Inspection · 2025-12-07
Date
2025-12-07
Complaint Related
No
Licensing Inspector
Susan Ellington-Sconiers
(804) 588-2368
(804) 588-2368
SHSIA monitoring inspection of an approved subsidy vendor to determine compliance with current subsidy requirements regarding the health and safety of children and to promote quality standards for the children in their care.
No
Violations
12Standard 22.1-289.035-B-2
Providers must obtain a completed national criminal background check prior to the employee's first day of employment. S6, who had been employed for 16 days, did not have a completed national criminal background check.
Plan of Correction: Effective immediately, the school has reinforced its hiring procedures to ensure that all components of the background check process?including the national criminal background check?are fully completed and documented prior to an employee?s first day of work, regardless of role or level of child contact.
Standard 22.1-289.035-B-3
The center must request a search of the central registry prior to the employee's first day of employment. S1, who had been employed for 15 days, did not have a central registry search requested.
Plan of Correction: Effective immediately, the school has reinforced its hiring procedures to ensure that all components of the background check process?including the national criminal background check?are fully completed and documented prior to an employee?s first day of work, regardless of role or level of child contact.
Standard 22.1-289.035-B-4
The center is required to obtain background checks from any state in which the individual has resided in the preceding five years. S7, employed for more than 15 months, did not have documentation of requesting a central registry check or criminal history check from one state.
Plan of Correction: At the time of the licensing visit, the required national criminal background check for the staff member had been completed prior to the employee?s first day of employment; however, the documentation was not present in the employee?s physical file.
Immediately upon discovery, the national criminal background check was re-submitted and completed, and the updated documentation was placed in the employee?s file to ensure the record was complete, current, and accessible.
Immediately upon discovery, the national criminal background check was re-submitted and completed, and the updated documentation was placed in the employee?s file to ensure the record was complete, current, and accessible.
Standard 8VAC20-780-150-B
Immunization records are required to be signed and dated by a physician, his designee, or an official of the local health department. The immunization record dated 08/13/2025 for C4 was not signed. The immunization record for C6 was not dated.
Plan of Correction: Upon identification of this issue, the children?s health records were reviewed. It was confirmed that both immunization records were submitted as part of a complete health form packet that was signed and dated by a physician; however, the individual immunization record pages within the packets did not contain separate signatures and/or dates. The center has reinforced its health record review procedures to ensure that each required immunization record page contains the appropriate signature and date, even when included as part of a larger health form packet.
Standard 8VAC20-780-160-A
Each staff member shall submit documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with the children. The screening for S3 was completed 3 days after hire and the screening for S6 was completed 4 days after hire.
Plan of Correction: Upon identification of this issue, hiring and onboarding procedures were reviewed to ensure tuberculosis screening documentation is received prior to a new staff member having contact with children.
Standard 8VAC20-780-240-A
Staff are to complete the VDOE sponsored online orientation course within 90 days of hire. S7 completed the course 53 days late. The record for S4 did not contain documentation of course completion due 12/2/2025. The record for S9 did not contain documentation of VDOE online orientation course since employment in 01/2023.
Plan of Correction: A review of training records was conducted for all staff identified.
? S7: The VDOE-sponsored online orientation course had been completed; however, it was not completed within the required 90-day timeframe.
? S4: Staff member S4 had been on a leave of absence beginning 11/21/2025 and has since separated from employment with the center.
? S9: Staff member S9 had completed the VDOE-sponsored online orientation course on 11/19/2023; however, documentation was not present in the employee file. The documentation has since been obtained and placed in the file.
? S7: The VDOE-sponsored online orientation course had been completed; however, it was not completed within the required 90-day timeframe.
? S4: Staff member S4 had been on a leave of absence beginning 11/21/2025 and has since separated from employment with the center.
? S9: Staff member S9 had completed the VDOE-sponsored online orientation course on 11/19/2023; however, documentation was not present in the employee file. The documentation has since been obtained and placed in the file.
Standard 8VAC20-780-245-A
Repeat Violation
Staff shall complete a minimum of 16 hours of training annually, appropriate to the age of children in care. S7 obtained 3 of the 16 required hours between 08/2024 ? 08/2025.
Staff shall complete a minimum of 16 hours of training annually, appropriate to the age of children in care. S7 obtained 3 of the 16 required hours between 08/2024 ? 08/2025.
Plan of Correction: Upon identification of this issue, a review of staff member S7?s training record was conducted. It was determined that the shortfall in required annual training hours was related to a recent clarification that the VDOE-sponsored online orientation course and its annual update do not count toward the 16-hour annual training requirement. Going forward, we will continue to ensure proper training hours of all staff members.
Standard 8VAC20-780-260-B
The center shall provide for review the annual approval from the health department. The last inspection available for review was dated 08/28/2024.
Plan of Correction: At the time of the licensing visit on 12/3/2025, the most recent annual health department inspection approval available for review was dated 08/28/2024. The center?s next scheduled health department inspection was subsequently completed on 12/7/2025, with no violations noted.
Standard 8VAC20-780-440-E
There shall be at least 12 inches of space between occupied cots, beds, or rest mats. Licensing inspector observed the 2-year-old room during nap time and multiple occupied cots were not 12 inches apart.
Plan of Correction: The center has reviewed and reinforced nap-time setup procedures to ensure appropriate spacing is maintained consistently in all classrooms using mats. Classroom layouts have been adjusted as needed to allow for proper spacing, and staff have been instructed to verify spacing prior to children lying down for rest time.
Standard 8VAC20-780-560-J
Tables shall be sanitized before and after each use for feeding. Licensing inspector observed staff clean tables in Pre-school 2 room, but not sanitizing before the children ate their lunch.
Plan of Correction: The Director reviewed proper sanitizing procedures with the classroom staff and reinforced expectations during staff follow-up. This requirement has also been reiterated with all teaching staff to ensure understanding and consistent implementation. Classroom practices will be monitored to ensure continued compliance.
Standard 8VAC20-780-60-A
Each center shall maintain and keep at the center a separate record for each child enrolled that contains all of the required information. The record for C4, enrolled for over 3 months, and C 8, enrolled for 1 month was missing the name, address, and phone number for second designated person to call in an emergency if a parent cannot be reached.
Plan of Correction: Upon identification of this issue, updated emergency contact information was obtained for both children the following day. The additional emergency contact documentation has been placed in each child?s file and is now complete. The center has reinforced enrollment and record-review procedures to ensure that all required child record information, including a minimum of two emergency contacts, is completed and verified upon enrollment.
Standard 8VAC20-780-70
Documentation of at least 2 references to character, reputation, and competency are to be checked prior to employment. S6, who has been actively working at the center for more than 2 months, did not have any completed reference verifications on file.
Plan of Correction: Upon identification of this issue, a review of staff member S5?s personnel file was conducted. It was confirmed that staff member S5 met the qualifications for the Lead Teacher position, as her application indicates she had been serving in a Lead Teacher role at another preschool since August 2024, prior to her employment with the center beginning in June 2025.