Inspection · 2025-03-28
Date
2025-03-28
Complaint Related
No
Licensing Inspector
Sarah Marbert
(703) 479-4678
(703) 479-4678
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
Areas Reviewed
8VAC20-800 Administration
8VAC20-800 Personnel
8VAC20-800 Household Members
8VAC20-800 Physical Health of Caregivers and Household members
8VAC20-800 Caregiver Training
8VAC20-800 Physical Equipment and Environment
8VAC20-800 Care of Children
8VAC20-800 Preventing the Spread of Disease
8VAC20-800 Medication Administration
8VAC20-800 Emergencies
8VAC20-800 Nutrition
8VAC20-770 Background Checks
20 Access to minor?s records
22.1 Early Childhood Care and Education
54.1 Provider must be MAT certified to administer prescription medication.
63.2 Child abuse and 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 renewal inspection was initiated and completed on 3/28/2025, as a part of the licensure period. The on-site inspection began at 12:26 PM and ended at 2:40 PM. The inspector reviewed compliance in the areas listed above. There were 5 children present and 2 caregivers; the point total was12. The inspector reviewed 5 children?s records and 4 caregiver and household member records on-site.
This inspection included: document review, tour of the facility, interviews and observations.
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 4/23/25. A POC submitted after this date will not appear on the public website.
AMENDED REPORT
Violations
20Standard 22.1-289.011-F
Repeat Violation
Any documents required by the Superintendent shall be posted in a conspicuous place on the licensed premises.
The inspection report posted was not the most recently issued report. The report posted was dated 12/4/23. The most recent report was issued 8/6/24.
Any documents required by the Superintendent shall be posted in a conspicuous place on the licensed premises.
The inspection report posted was not the most recently issued report. The report posted was dated 12/4/23. The most recent report was issued 8/6/24.
Plan of Correction: Reports have been posted and updated in the classroom.
Standard 8VAC20-800-100-A
Repeat Violation
The provider shall obtain documentation of a physical examination by or under the direction of a physician prior to a child's attendance or within 30 days after the first day of attendance.
Child #2's record did not contain a completed physical. The physical was overdue by 30 months.
Child #5's record contained an incomplete physical.
The provider shall obtain documentation of a physical examination by or under the direction of a physician prior to a child's attendance or within 30 days after the first day of attendance.
Child #2's record did not contain a completed physical. The physical was overdue by 30 months.
Child #5's record contained an incomplete physical.
Plan of Correction: The required physical examination documentation for both Child #2 and Child #5 has been requested from the parent s. I have reminded them of the importance of submitting completed and up- to-date records. I will follow up to ensure the documentation is received promptly and placed in each child 's file to maintain full
compliance.
compliance.
Standard 8VAC20-800-120-B
Assistants' record shall contain verification of age, date of employment , the name address and telephone number of a person to be notified in an emergency.
Caregiver B's record did not contain an emergency contact, verification of age, date of employment.
Caregiver B's record did not contain an emergency contact, verification of age, date of employment.
Plan of Correction: Information was requested and updated.
Standard 8VAC20-800-130
Caregivers shall be able to speak, read, and write in English as necessary to carry out assigned job responsibilities.
At 12:26 PM the caregiver working alone at the daycare, did not speak English. Inspector confirmed through translation services, that the caregiver did not speak English.
At 12:26 PM the caregiver working alone at the daycare, did not speak English. Inspector confirmed through translation services, that the caregiver did not speak English.
Plan of Correction: The caregiver felt intimidated by the inspector due to several rapid and repeated questions during the visit. Please note that this caregiver has been effectively communicating with parents for over five years without issue. To
ensure she feels more confident and prepared in future inspections, she will receive appropriate training and support.
ensure she feels more confident and prepared in future inspections, she will receive appropriate training and support.
Standard 8VAC20-800-200-C
Repeat Violation
Documentation of the orientation shall be signed and dated by the provider and assistant.
There was no documentation to verify that Caregiver B had orientation training.
Documentation of the orientation shall be signed and dated by the provider and assistant.
There was no documentation to verify that Caregiver B had orientation training.
Plan of Correction: The information is updated.
Standard 8VAC20-800-210-A
Repeat Violation
In addition to satisfactory completion of first aid training and CPR training, caregivers shall obtain a minimum of sixteen clock hours of training annually in areas relevant to their job responsibilities.
There is no documentation that Caregivers A and B completed any of the 16 required annual training hours.
In addition to satisfactory completion of first aid training and CPR training, caregivers shall obtain a minimum of sixteen clock hours of training annually in areas relevant to their job responsibilities.
There is no documentation that Caregivers A and B completed any of the 16 required annual training hours.
Plan of Correction: Caregiver A has completed 10 hours of training through the subsidy program. she will complete the remaining 16 hours this year. Caregiver B will update her training hours accordingly.
Standard 8VAC20-800-270-A
Firearms of every type and purpose shall be stored unloaded in a locked container.
A handgun case, used to store an unloaded weapon, did not have a lock on it.
A handgun case, used to store an unloaded weapon, did not have a lock on it.
Plan of Correction: The firearm was stored in the provider's private bedroom on the third floor, inside a cabinet and within a box. Children do not have access to any area of the home other than the basement, where care is provided. To ensure full compliance with regulations, the provider will purchase a lockable container specifically designed for firearm storage.
Standard 8VAC20-800-50-C
Information contained in a child's record shall be privileged and confidential. The provider shall not distribute or release information in a child's record to any unauthorized person without the written consent of the child's parent.
The provider stated that Adult C was given access to children's records to help organize information, on 3/24/25 and 3/25/25.
The provider stated that Adult C was given access to children's records to help organize information, on 3/24/25 and 3/25/25.
Plan of Correction: Adult c was assisting the provide with administrative tasks and was under direct supervision at all times. However, the provider acknowledges that Adult C was not an approved assistant or substitute with completed background checks and therefore should not have had access to children's records. To correct this and remain in compliance with 8VAC20-800-50.C, the provider has taken immediate
steps to ensure that only individuals who are approved by the Department of Social services, have passed background checks, and are listed as assistants or substitutes, will be all owed to assist with any part of the program-especially when it involves access to children's records.
steps to ensure that only individuals who are approved by the Department of Social services, have passed background checks, and are listed as assistants or substitutes, will be all owed to assist with any part of the program-especially when it involves access to children's records.
Standard 8VAC20-800-60-B
A child's record shall contain the following information; emergency contact information, authorization for emergency treatment, medical insurance policy number, and the first day of attendance.
Five records were reviewed.Records were missing;
*First day of attendance (Children #1,5)
*Emergency contact information (Children #1,5)
*Medical insurance policy number (Children #1,3)
*Written authorization for emergency care (Child 1)
Five records were reviewed.Records were missing;
*First day of attendance (Children #1,5)
*Emergency contact information (Children #1,5)
*Medical insurance policy number (Children #1,3)
*Written authorization for emergency care (Child 1)
Plan of Correction: Parents were notified about the missing information.
Standard 8VAC20-800-690-D
The diapering surface shall be nonabsorbent and cleaned and sanitized after each use.
The diaper changing pad surface has tears in it, exposing the absorbent sponge interior, and cannot be cleaned and sanitized.
The diaper changing pad surface has tears in it, exposing the absorbent sponge interior, and cannot be cleaned and sanitized.
Plan of Correction: The diaper changing pad has been replaced with a new one to ensure compliance with health and safety standards. The new pad is
nonabsorbent and can be properly cleaned and sanitized after each use.
nonabsorbent and can be properly cleaned and sanitized after each use.
Standard 8VAC20-800-70-B
The provider shall obtain the parent's written acknowledgement of the receipt of the required information.
Five child records were reviewed. Missing information included:
*Signed acknowledgement of all policies and procedures (Children #1,3) (Model form in use not signed or completed by provider)
*Acknowledgment of the decision to administer medication (Children #1,3)
*Acknowledgment of the provision of the emergency preparedness plan (Children #2,3,4,5)
*Acknowledgment of the declaration of liability insurance (Children #1,3)
Five child records were reviewed. Missing information included:
*Signed acknowledgement of all policies and procedures (Children #1,3) (Model form in use not signed or completed by provider)
*Acknowledgment of the decision to administer medication (Children #1,3)
*Acknowledgment of the provision of the emergency preparedness plan (Children #2,3,4,5)
*Acknowledgment of the declaration of liability insurance (Children #1,3)
Plan of Correction: Parents were notified about the missing information.
Standard 8VAC20-800-760-A-1
A first aid kit that contains at a minimum; two triangular bandages.
There were no triangular bandages in the first aid kit.
There were no triangular bandages in the first aid kit.
Plan of Correction: Bandages are in the aid kit.
Standard 8VAC20-800-770
A working portable battery-operated weather band radio, and extra batteries shall be kept in a designated area and be available to caregivers at all times.
There were no batteries in the weather band radio.
There were no batteries in the weather band radio.
Plan of Correction: Batteries were replaced.
Standard 8VAC20-800-780-B
Repeat Violation
Annually, the provider shall review with the parent the emergency contact information to ensure the information is correct, and obtain the parent's signed acknowledgment of the review.
Child #2's information update was overdue by 30 months.
Child #4's information update was overdue by 26 months.
Child #5's information update was overdue by 25 months.
Annually, the provider shall review with the parent the emergency contact information to ensure the information is correct, and obtain the parent's signed acknowledgment of the review.
Child #2's information update was overdue by 30 months.
Child #4's information update was overdue by 26 months.
Child #5's information update was overdue by 25 months.
Plan of Correction: Parents were notified about the missing information.
Standard 8VAC20-800-80-C
The provider shall document in the child's record the method of verification of the child's age and identity.
Five of five child records reviewed did not contain complete documentation that the provider viewed proof of birth documents. (Children #1,2,3, 4,5)
Five of five child records reviewed did not contain complete documentation that the provider viewed proof of birth documents. (Children #1,2,3, 4,5)
Plan of Correction: Parents were notified
Standard 8VAC20-800-800-A
The family day home shall have a written emergency preparedness and response plan that Includes emergency evacuation, emergency relocation, and shelter-in-place
procedures.
The provider stated the emergency plan was not available.
procedures.
The provider stated the emergency plan was not available.
Plan of Correction: The emergency preparedness and response plan has been updated and is now on file. It includes all required procedures and is available for review.
Standard 8VAC20-800-830-B
Repeat Violation
Shelter-in-place procedures shall be practiced a minimum of twice per year.
No shelter-in-place drills have been conducted in the previous year.
Shelter-in-place procedures shall be practiced a minimum of twice per year.
No shelter-in-place drills have been conducted in the previous year.
Plan of Correction: The Shelter will be held every year.
Standard 8VAC20-800-90-C
The family day home shall obtain documentation of additional immunizations for a child once every six months for children under the age of two years.
Child #2's record did not contain immunization updates since enrollment. Immunization updates were overdue by 30 months.
Child #3's record did not contain immunization updates. Updates were overdue by one month.
Child #2's record did not contain immunization updates since enrollment. Immunization updates were overdue by 30 months.
Child #3's record did not contain immunization updates. Updates were overdue by one month.
Plan of Correction: The information was required to the parents.
Standard 8VAC20-800-900-B
Children shall not be allowed to eat or drink while lying down.
Child #3 was observed asleep in their crib with a bottle of formula in their mouth.
Child #3 was observed asleep in their crib with a bottle of formula in their mouth.
Plan of Correction: Child #3 was not sleeping at the time the bottle was given. Moving forward, the child will be given her milk prior to being placed in the crib to ensure compliance with regulations. Children will not be allowed to drink while lying down.
Standard 8VAC20-800-920
Repeat Violation
When meals or snacks are provided by the family day home, the menu for the current one-week period shall be dated.
The menu posted is not for the current one-week period. The menu is dated 11/2021.
When meals or snacks are provided by the family day home, the menu for the current one-week period shall be dated.
The menu posted is not for the current one-week period. The menu is dated 11/2021.
Plan of Correction: Menus will be posted every week.