Inspection · 2025-10-07
Date
2025-10-07
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 monitoring inspection was initiated on 10/07/2025 and completed on 10/17/2025, as a part of licensure period. The on-site inspection began at 10:13 AM and ended at 11:00 AM. The inspectors reviewed compliance in the areas listed above. There were 4 children present and 1 caregiver; the point total was 9. The inspectors reviewed 4 children?s records and 2 caregiver 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 business days from today, which will be the close of business on 10/24/2025. A POC submitted after this date will not appear on the public website.
Amended report:12/10/2025. Inspection Summary comments were updated to correct the dates the inspection was initiated and completed.
Violations
15Standard 22.1-289.011-F
Repeat Violation
The license and any other documents required shall be posted in a conspicuous place on the licensed premises
The most recently issued license was not posted. (Modified license: issued 8/29/25)
The most findings from the most recent inspection were not posted (Inspection date: 7/30/2025)
The license and any other documents required shall be posted in a conspicuous place on the licensed premises
The most recently issued license was not posted. (Modified license: issued 8/29/25)
The most findings from the most recent inspection were not posted (Inspection date: 7/30/2025)
Plan of Correction: The license will be posted.
Standard 22.1-289.035-A
Repeat Violation
The provider is required to have employees undergo a background check every five years.
Caregiver B's background searches had not been repeated.
Caregiver B's repeat central registry check for was overdue by 10 months.
Caregiver B's repeat national criminal background check was overdue by 11 months.
The provider is required to have employees undergo a background check every five years.
Caregiver B's background searches had not been repeated.
Caregiver B's repeat central registry check for was overdue by 10 months.
Caregiver B's repeat national criminal background check was overdue by 11 months.
Plan of Correction: Caregiver B's repeat background checks have been submitted for processing. The provider will ensure all background checks are completed before the expiration date by maintaining a tracking log and reviewing records quarterly to prevent future delays.
Standard 8VAC20-800-100-A
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 #3's record did not contain documentation of a completed physical. exam The physical was overdue by 13 months.
Child #3's record did not contain documentation of a completed physical. exam The physical was overdue by 13 months.
Plan of Correction: The parent was asked to provide updated documentation of the child's physical examination. Once received, it will be added to the child's file. The provider will review all records quarterly to ensure physicals are obtained within 30 days of enrollment or as required.
Standard 8VAC20-800-120-B
Assistants' and substitute providers' records shall contain the following: name, address and telephone number of a person to be notified in an emergency.
There was no emergency contact documented for Caregiver B.
There was no emergency contact documented for Caregiver B.
Plan of Correction: The assistant's record has been updated to include emergency contact information. The provider will verify that all staff and substitute files contain current emergency contact details and will review records annually for accuracy
Standard 8VAC20-800-130
Caregivers shall be able to speak, read, and write in English as necessary to carry out
assigned job responsibilities, and communicate effectively with emergency responders. Caregivers shall meet the requirements for background checks.
At 10:13AM Caregiver B was working alone supervising children and does not speak English.
Inspector used translation services to communicate with the caregiver.
Caregiver B did not have current background check results on file.
assigned job responsibilities, and communicate effectively with emergency responders. Caregivers shall meet the requirements for background checks.
At 10:13AM Caregiver B was working alone supervising children and does not speak English.
Inspector used translation services to communicate with the caregiver.
Caregiver B did not have current background check results on file.
Plan of Correction: The caregiver communicates effectively in English and has no issues interacting with parents. At the time of inspection, there were only four children present. A new assistant will be hired in the near future. Caregiver A was absent due to a scheduled doctor's appointment.
Standard 8VAC20-800-200-C
Documentation of the orientation shall be signed and dated by the provider and substitute provider or by the provider and assistant.
Orientation for Caregiver B was not signed by the caregiver.
Orientation for Caregiver B was not signed by the caregiver.
Plan of Correction: The orientation form for Caregiver B has been signed and dated by both the provider and the caregiver. Going forward, the provider will ensure all orientation documents are properly completed and signed immediately after training to maintain compliance.
Standard 8VAC20-800-280
Potentially poisonous substances, materials and supplies such as, but not limited to, cleaning agents shall be stored away from food in areas inaccessible to children.
Dish soap and glass cleaner were stored in a cabinet under the sink that was not inaccessible to children.
Dish soap and glass cleaner were stored in a cabinet under the sink that was not inaccessible to children.
Plan of Correction: The cabinet was accidently left unlocked at the time of inspection. All cleaning supplies and scissors were immediately moved to a locked cabinet out of children's reach. The provider will double-check daily to ensure all potentially hazardous materials remain securely stored and inaccessible to children.
Standard 8VAC20-800-340-C
The bathroom shall be kept clean and contain a working toilet and sink, toilet tissue, liquid soap, and paper towels.
There were no paper towels in the bathroom.
There were no paper towels in the bathroom.
Plan of Correction: Paper towels will be in the bathroom.
Standard 8VAC20-800-60-B
Repeat Violation
Systemic Deficiency
Children's records did not contain all required information.
Missing information included:
Child #1: Child's first date of attendance, second emergency contact's address, verification of viewing proof of birth documentation, authorization for emergency care and medical insurance policy number.
Child #2: parent phone number and 2 emergency contact's addresses.
Child #4: Verification of viewing proof of birth documentation.
Systemic Deficiency
Children's records did not contain all required information.
Missing information included:
Child #1: Child's first date of attendance, second emergency contact's address, verification of viewing proof of birth documentation, authorization for emergency care and medical insurance policy number.
Child #2: parent phone number and 2 emergency contact's addresses.
Child #4: Verification of viewing proof of birth documentation.
Plan of Correction: All children's records have been updated to include the missing information. Parents were contacted to provide the required details and documentation. The provider will review each child's file monthly to ensure all records remain complete and up to date.
Standard 8VAC20-800-70-B
Repeat Violation
Systemic Deficiency
Before the child's first day of attendance the provider shall obtain the parent's written acknowledgment of the receipt of the information regarding family day home operations and administration.
Four child records were reviewed.
Missing acknowledgments for Child #1:
Signed acknowledgement of all policies and procedures, Acknowledgment of the decision to administer medication and Acknowledgment of the declaration of liability insurance.
Missing acknowledgment for Child #2:
Acknowledgmen of the provisions of the emergency preparedness plan.
Missing acknowledgment for Child #4:
Acknowledgment of the provisions of the emergency preparedness plan.
Systemic Deficiency
Before the child's first day of attendance the provider shall obtain the parent's written acknowledgment of the receipt of the information regarding family day home operations and administration.
Four child records were reviewed.
Missing acknowledgments for Child #1:
Signed acknowledgement of all policies and procedures, Acknowledgment of the decision to administer medication and Acknowledgment of the declaration of liability insurance.
Missing acknowledgment for Child #2:
Acknowledgmen of the provisions of the emergency preparedness plan.
Missing acknowledgment for Child #4:
Acknowledgment of the provisions of the emergency preparedness plan.
Plan of Correction: Parents were asked to review and sign all missing acknowledgment forms, including policies, medication decisions, liability insurance, and emergency preparedness plan. All updated documents have been placed in the children's files. The provider will ensure acknowledgments are signed before a child's first day of attendance moving forward.
Standard 8VAC20-800-780-B
Repeat Violation
Systemic Deficiency
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 31months.
Child #3's information update was overdue by 2 months.
Child #4's information update was overdue by 33 months.
Systemic Deficiency
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 31months.
Child #3's information update was overdue by 2 months.
Child #4's information update was overdue by 33 months.
Plan of Correction: All children's emergency contact information has been reviewed and updated. Parents of the affected children were asked to verify and sign the updated forms. The provider will conduct annual reviews each January to ensure all emergency contact information remains current and compliant.
Standard 8VAC20-800-830-A
The emergency evacuation procedures shall be practiced monthly with all caregivers and children in care during all shifts that children are in care.
There was no documentation of emergency evacuation drills having been practiced monthly for April, May, June, July and August 2025.
There was no documentation of emergency evacuation drills having been practiced monthly for April, May, June, July and August 2025.
Plan of Correction: All required emergency and safety drills will be conducted monthly. Documentation of each drills will be completed and kept on file for review.
Standard 8VAC20-800-90-A
Before attendance, documentation of immunizations is to be obtained for each child.
Child #3 did not have an immunization record on file. The record w as overdue by 14 months.
Child #3 did not have an immunization record on file. The record w as overdue by 14 months.
Plan of Correction: The parent was asked to provide the child's updated immunization record. Once received, it will be placed in the child's file. The provider will review all records quarterly to ensure immunization documentation is obtained and kept current for every child before attendance.
Standard 8VAC20-800-90-C
Repeat Violation
Documentation of additional immunizations is required once every six months for children under the age of two years.
Child #4, currently 35 months old, had no immunization updates documented every six months for the past 2 years.
Documentation of additional immunizations is required once every six months for children under the age of two years.
Child #4, currently 35 months old, had no immunization updates documented every six months for the past 2 years.
Plan of Correction: Parents were asked to provide updated immunization records to ensure all files remain current and complaint. The provide will follow up until all documentation is received, and will review records quarterly to maintain accuracy.
Standard 8VAC20-800-920
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 was not for the current one-week period. The menu was dated March 21, 2025.
The menu posted was not for the current one-week period. The menu was dated March 21, 2025.
Plan of Correction: The menu will be posted every Monday.