Inspection · 2025-06-25
(757) 404-5261
Areas Reviewed
22.1 Religious Exempt; Background Checks Code; Carbon Monoxide
32.1 Report by person other than physician
8VAC20-770 Background Checks
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 focused monitoring inspection was initiated on June 25, 2025 and completed on June 25, 2025. The on-site inspection began at 11:15 and ended at 12:40. The inspector reviewed compliance in the areas listed above. The Department issued a Notice of Intent to Revoke Exemption Granted Under Authority of Section 22.1-289.031 of the Code of Virginia on October 29, 2024 as a result of high-risk violations. There were twenty-three children present with six staff. The inspector reviewed two staff records on-site. This inspection included document review, tour of the facility, interviews and observations.
Information gathered during the inspection determined non-compliance(s) with applicable code sections, 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 July 3, 2025. A POC submitted after this date will not appear on the public website.
Violations
2A staff member had completed the required paperwork, but the sworn statement was not found in their personnel file. The issue was discovered during a routine file review conducted by the center's compliance designee.
Corrective Actions Taken:
* The employee was immediately asked to complete a new sworn statement.
* The document was completed and placed in the file before the end of their shift that same day.
* The internal review system was evaluated and updated to ensure documentation is tracked more efficient.
Preventive Measures Moving Forward:
* All sworn statements will now be completed during the in-person interview process or on the day of the Central Registry being initiated.
* Weekly compliance audits in regard to staff paperwork will continue to verify that all files remain complete and updated.
* A meeting was held with the business consultant to review and discuss the online maintenance of staff paperwork.
* After this employee was hired, another employee was hired and the sworn statement was completed during her interview per the compliance agreement. The issue was corrected immediately and not repeated for the next employee hired.
An employee was permitted to be in the classroom with another teacher before her fingerprint background results were returned. Although her Central Registry results were complete, her fingerprint background check was still pending until the following day. This oversight occurred due to urgent need to cover a classroom, as the lead teacher was going to be absent due to being near her due date. The employee was allowed to be with that teacher to shadow just to see the flow of the classroom with an experienced individual.
Correction Actions Taken:
* The situation was identified and promptly addressed by the management team.
* A team meeting was held to review and improved onboarding and background checks procedures.
* The Assistant Director is now required to be involved in the collection and verification of all hiring paperwork from start to finish.
* Background check submissions are now initiated immediately upon interview selection to prevent delays.
Preventive Measures Moving Forward:
* The Director and Assistant Director will jointly review all hiring documents before onboarding.
* Monthly compliance reports will be conducted at a minimum to verify the status and completeness of all documentation in staff files.
* The center's email is being cleaned and reorganized to improve tracking of background check submissions and returns. This will hep maintain yearly and 5-year update requirements as well.
* All background check results will be printed and filed promptly to ensure timely processing, expedite hiring , and maintain compliance with state and center policies.