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Inspection · 2025-04-24

Date

2025-04-24

Complaint Related

Licensing Inspector

Angela Dudek
(804) 629-8167

Areas Reviewed

8VAC20-780 Administration
8VAC20-780 Staff Qualifications and Training.
8VAC20-780 Physical Plant.
8VAC20-780 Staffing and Supervision.
8VAC20-780 Programs.
8VAC20-780 Special Care Provisions and Emergencies
8VAC20-780 Special Services.
8VAC20-820 THE LICENSE.
8VAC20-820 THE LICENSING PROCESS.
8VAC20-820 HEARINGS PROCEDURES.
8VAC20-770 Background Checks
20 Access to minor?s records
22.1 Early Childhood Care and Education
63.2 Child Abuse & Neglect

During the inspection, the inspector reviewed the areas listed above to include standards found out of compliance during the previous inspection. Unless otherwise noted as a violation within this inspection report, the provider was in compliance with the standards reviewed. If there were any serious injuries or fatalities related to a violation, the details will be included in the description of the violation.

Inspector Notes

An unannounced, on-site monitoring inspection was initiated and completed on 4-24-25. The on-site inspection began at 1:45pm and ended at 3:45pm. The inspector reviewed compliance in the areas listed above. There were 37 children present and 11 staff. The inspector reviewed 5 children?s records and 5 staff records on-site. This inspection included document review, tour of the facility, interviews, observations, and measurements. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations are documented on the violation notice issued to the program.
Please complete the plan of correction (POC) and date to be corrected sections for each violation cited on the violation notice. Specify how the violation will be or has been corrected. Submit your POC within five (5) business days from today, which will be the close of business on 5-9-25. A POC submitted after this date will not appear on the public website.

Violations

Standard 22.1-289.035-B-2

(Repeat Violation) The Center is required to obtain documentation of the results of a national fingerprint background check prior to date of hire.

1)The record for Staff #1 did not contain documentation of a fingerprint background check completed prior to their date of hire which was 13 days ago.
2)The Fingerprint check for Staff #2 was completed 15 days after hire.

Plan of Correction: Admin discussed the change in procedure as it relates to new employee date of hire.

Standard 22.1-289.035-B-3

For staff hired after 7/1/24, the Provider is required to request a Central Registry check prior to employment.
The record for Staff #2 had documentation that the Central Registry check had been requested 10 days after hire.

Plan of Correction: Noted, adhere to new hire checklist.

Standard 8VAC20-780-160-A

(Repeat Violation) The Center is required to obtain documentation of a negative tuberculosis (TB) test or screening for staff at the time of employment and prior to contact with children and within 30 days prior to employment that is signed by a physician or a physician?s designee.

1)The file for Staff #1 contained a TB test or screening that was completed 6 days after hire.
2)The file for Staff #2 did not contain documentation of a negative TB test or screening within 30 days prior to employment.

Plan of Correction: Collect TB results

Standard 8VAC20-780-160-C

The Center is required to obtain documentation of a negative tuberculosis (TB) test or screening for staff every 2 years from the date of the initial screening or testing.

A TB test for Staff #3 was due over 7 months ago.

Plan of Correction: Collect TB results

Standard 8VAC20-780-240-A

(Repeat Violation) The Center is required to ensure that the Virginia Department of Education-sponsored orientation course was completed within 90 calendar days of employment.

Evidence: The record for Staff #2 did not contain documentation that the Virginia Department of Education-sponsored orientation course was completed within 90 calendar days of employment. The orientation was due 11 days ago.

Plan of Correction: Conduct orientation

Standard 8VAC20-780-240-E

The Center is required to ensure that staff complete a First Aid and CPR orientation appropriate to the age of the children in care within 30 days of the first day of employment.

Evidence: The file for Staff #2 did not contain documentation of a completed First Aid and CPR orientation within 30 days of employment. The orientation was due 2 months ago.

Plan of Correction: Schedule CPR training

Standard 8VAC20-780-240-I

The Center is required to ensure that orientation documentation was kept for each staff member.

Evidence:
The file for Staff #2 and Staff #4 did not contain documentation of an orientation.

Plan of Correction: Conduct orientation #2 collect checklist #4

Standard 8VAC20-780-330-B

The Center is required to ensure that the required resilient surfacing surrounding playground equipment with moving parts or climbing apparatus created a sufficient fall zone.
1)The playground has a swingset with wood chips measuring at less than 1 inch in depth directly under the right side swing. The required depth of wood chips in this area should be 6 inches.
2)The playground has dome shaped climbing structure at 54 inches in height at the center with wood chips measuring at 1 inch under the center of the dome.

Plan of Correction: Order and spread new mulch

Standard 8VAC20-780-340-F

(Repeat Violation) The Center is required to ensure that children under 10 years of age always be within actual sight and sound supervision of staff.
1)During inspection in the Yellow and Blue classroom, a child walked out of the classroom to the outside patio area to retrieve an item that had been left there. There was no staff member present with the child outdoors leaving them out of sight and sound supervision.
2)During inspection in the Extended day classroom where children were napping, a child was placed behind a toy shelf to take a nap and could not be seen by either staff member based on their positioning while the child was laying on their mat.

Plan of Correction: Position nappers in open or space or space staff with vantage point.

Standard 8VAC20-780-530-A

The Center is required to have at least one staff member in each classroom or area where children are present that has obtained CPR and first aid training.

The files for Staff #1 and Staff #2 did not contain documentation for completion of CPR and first aid training and these staff members were the only 2 staff members present in the Extended day classroom.

Plan of Correction: Schedule CPR training

Standard 8VAC20-780-60-A

The Center is required to maintain and keep at the center a separate record for each child enrolled.
There was no record on site for Child #1.

Plan of Correction: Complete file

Standard 8VAC20-780-70

The Center is required to maintain documentation for staff records including two or more references as to character and reputation as well as competency were checked before employment.

The center did not have two or more signed references for Staff #1.

Plan of Correction: Collect reference

Standard 8VAC20-780-80-A

(Repeat Violation) The Center is required to keep a written record of daily attendance for each group of children documenting the arrival and departure of each child in care as it occurs.

1)During inspection in the Toddler classroom, there were 3 children present, but the written record had not been completed for the day.
2)During inspection in the Yellow and Blue classroom, there were 16 children present, but the written record reflected there were 17 children present.
3)The Green classroom and the Yellow and Blue classroom did not document departure for any of the children for the current week of attendance.

Plan of Correction: Admin will check and enforce attendance capture every day by 9:15am

View original record on Virginia Department of Social Services