Inspection · 2025-12-03
Date
2025-12-03
Complaint Related
No
Licensing Inspector
Beth Velke
(804) 629-8302
(804) 629-8302
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
5Standard 8VAC20-780-160-C
A tuberculosis (TB) screening is required every
two years from the last screening.
Evidence: The tuberculosis screening for Staff #2 was expired for five weeks before the results of the subsequent screening was completed.
two years from the last screening.
Evidence: The tuberculosis screening for Staff #2 was expired for five weeks before the results of the subsequent screening was completed.
Plan of Correction: 1. Compliance Tracking:
The director has updated the personnel health tracking system to ensure all staff TB screening expiration dates are logged and monitored.
2. A 30-day advance alert will be set for all staff to prevent future lapses.
3. Staff Notification Process:
All staff have been reminded of the two-year TB screening requirement and the expectation to complete renewal screenings before the expiration date.
4. Staff will receive written reminders and follow-up confirmation as expiration dates approach.
5. Administration will conduct monthly personnel record audits to verify that all required health documents TB screenings, physicals, and annual updates remain compliant.
The director has updated the personnel health tracking system to ensure all staff TB screening expiration dates are logged and monitored.
2. A 30-day advance alert will be set for all staff to prevent future lapses.
3. Staff Notification Process:
All staff have been reminded of the two-year TB screening requirement and the expectation to complete renewal screenings before the expiration date.
4. Staff will receive written reminders and follow-up confirmation as expiration dates approach.
5. Administration will conduct monthly personnel record audits to verify that all required health documents TB screenings, physicals, and annual updates remain compliant.
Standard 8VAC20-780-270-C
In inside areas occupied by children, the temperature shall be maintained no lower than 68?F.
Evidence: In the infant classroom, ages six weeks to 12 months, the thermostat located in the classroom indicated that it was 64 degrees.
Evidence: In the infant classroom, ages six weeks to 12 months, the thermostat located in the classroom indicated that it was 64 degrees.
Plan of Correction: 1.Infants were moved immediately during the Licensing Inspector?s visit to a temperature-compliant room to ensure safety and comfort.
2.They remained in this compliant room until all heating repairs were completed on 12/10/25.
3.HVAC Repair: A service call was placed promptly, and CB Lucas completed the heating unit repair on 12/10/25.
4.Temperature Monitoring and Prevention:
The director and/or admin support staff will conduct temperature checks upon arrival and hourly thereafter indefinitely to ensure ongoing compliance.
5.Classroom staff will monitor and report any temperature concerns immediately to the Director and Admin support staff so appropriate actions can be taken.
6.CB Lucas will continue to complete routine HVAC checks as they already are doing to prevent future issues.
7.Infant Care Practices:Infant teachers will ensure that infants are dressed appropriately, including wearing socks and shoes as needed, to maintain comfort and warmth at all times.
8.Staff Communication and Protocol Review: Staff have been reminded of temperature requirements and immediate reporting procedures.
9.The relocation protocol and maintenance request process have been reviewed with the infant , toddler team and all support staff.
2.They remained in this compliant room until all heating repairs were completed on 12/10/25.
3.HVAC Repair: A service call was placed promptly, and CB Lucas completed the heating unit repair on 12/10/25.
4.Temperature Monitoring and Prevention:
The director and/or admin support staff will conduct temperature checks upon arrival and hourly thereafter indefinitely to ensure ongoing compliance.
5.Classroom staff will monitor and report any temperature concerns immediately to the Director and Admin support staff so appropriate actions can be taken.
6.CB Lucas will continue to complete routine HVAC checks as they already are doing to prevent future issues.
7.Infant Care Practices:Infant teachers will ensure that infants are dressed appropriately, including wearing socks and shoes as needed, to maintain comfort and warmth at all times.
8.Staff Communication and Protocol Review: Staff have been reminded of temperature requirements and immediate reporting procedures.
9.The relocation protocol and maintenance request process have been reviewed with the infant , toddler team and all support staff.
Standard 8VAC20-780-340-F
Children under 10 years of age always shall be within actual sight and sound supervision of staff
Evidence: During the inspection the LI observed a four-year-old child leaving their class and enter the shared bathroom located in the hallway to wash their hands. The teacher was inside their classroom with seven other children conducting class and the child was not within actual sight and sound supervision. The shared hallway bathroom is too far from the classroom door for the teacher to hear the child and was not close enough to provide immediate intervention if needed. Staff confirmed that sometimes children are sent to the hallway bathroom while the teacher remains in the class.
Evidence: During the inspection the LI observed a four-year-old child leaving their class and enter the shared bathroom located in the hallway to wash their hands. The teacher was inside their classroom with seven other children conducting class and the child was not within actual sight and sound supervision. The shared hallway bathroom is too far from the classroom door for the teacher to hear the child and was not close enough to provide immediate intervention if needed. Staff confirmed that sometimes children are sent to the hallway bathroom while the teacher remains in the class.
Plan of Correction: 1.Staff Retraining:The classroom teacher has been retrained on Virginia?s supervision requirements, with emphasis on maintaining actual sight and sound supervision for all children under 10 years of age.
2.The teacher has completed the Better Kid Care ?Supervision: Sight and Sound? training module. A certificate of completion will be submitted to administration and kept on file.
3.Updated Bathroom Procedures:
Children will no longer access the hallway bathroom without direct staff supervision.The staff have been trained to take all children to the bathroom at scheduled intervals to reduce unsupervised individual bathroom requests.
4.A floater teacher will be used to support as-needed bathroom visits between group bathroom breaks, ensuring all children remain within sight and sound at all times and a staff member will accompany any child who requires the hallway
bathroom at all times.
5.The classroom door will remain closed at all times
6.Monitoring and Accountability:
Hallway cameras will be reviewed regularly to ensure compliance with sight and sound expectations and verify that no child is out of view.
7.Administration will conduct periodic supervision checks throughout the day.
8.Ongoing Prevention:
Supervision expectations and bathroom procedures have been reviewed with all staff to ensure consistency.
9.These procedures will be included in classroom routines
and reviewed during team meetings to prevent recurrence.
2.The teacher has completed the Better Kid Care ?Supervision: Sight and Sound? training module. A certificate of completion will be submitted to administration and kept on file.
3.Updated Bathroom Procedures:
Children will no longer access the hallway bathroom without direct staff supervision.The staff have been trained to take all children to the bathroom at scheduled intervals to reduce unsupervised individual bathroom requests.
4.A floater teacher will be used to support as-needed bathroom visits between group bathroom breaks, ensuring all children remain within sight and sound at all times and a staff member will accompany any child who requires the hallway
bathroom at all times.
5.The classroom door will remain closed at all times
6.Monitoring and Accountability:
Hallway cameras will be reviewed regularly to ensure compliance with sight and sound expectations and verify that no child is out of view.
7.Administration will conduct periodic supervision checks throughout the day.
8.Ongoing Prevention:
Supervision expectations and bathroom procedures have been reviewed with all staff to ensure consistency.
9.These procedures will be included in classroom routines
and reviewed during team meetings to prevent recurrence.
Standard 8VAC20-780-500-B
The diapering surface shall be used only for diapering or cleaning children, and it shall be cleaned with soap and at least room temperature water and
sanitized after each use.
Evidence: In the two-year class the Licensing Inspector (LI) observed wrinkled paper and a small plastic piece that appeared to be the barrier that is pulled off when opening up a new baby wipe container. Staff stated that prior to going to the Gym they had a child on the diaper surface to see if they had soiled their diaper. The class was in the Gym for 30 minutes.
sanitized after each use.
Evidence: In the two-year class the Licensing Inspector (LI) observed wrinkled paper and a small plastic piece that appeared to be the barrier that is pulled off when opening up a new baby wipe container. Staff stated that prior to going to the Gym they had a child on the diaper surface to see if they had soiled their diaper. The class was in the Gym for 30 minutes.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-80-A
For each group of children, the center shall maintain a written record of daily attendance that documents the arrival and departure of each child in care as it occurs.
Evidence: In the four-year class, eight children were present the written record reflected there were three.
Evidence: In the four-year class, eight children were present the written record reflected there were three.
Plan of Correction: 1. Staff was retrained on the same day as the licensing visit on proper daily attendance
documentation, including recording accurate arrival and departure times for each child as they occur.
2. Monitoring and Verification:
The director and administrative support team will conduct attendance checks at center opening and every 30 minutes until peak drop-off ends at 9:00 a.m.
3. During these checks, paper attendance records will be verified for time of arrival and accuracy.
4. The director will conduct name-to-face head counts during attendance checks, transitions to the playground, and any transitions to different areas of the school to ensure accuracy.
5. Ongoing Compliance:
Attendance procedures have been reviewed with all staff to reinforce the importance of accurate, realtime documentation.
6. Staff will be held accountable for maintaining correct records, and errors will be addressed immediately.
documentation, including recording accurate arrival and departure times for each child as they occur.
2. Monitoring and Verification:
The director and administrative support team will conduct attendance checks at center opening and every 30 minutes until peak drop-off ends at 9:00 a.m.
3. During these checks, paper attendance records will be verified for time of arrival and accuracy.
4. The director will conduct name-to-face head counts during attendance checks, transitions to the playground, and any transitions to different areas of the school to ensure accuracy.
5. Ongoing Compliance:
Attendance procedures have been reviewed with all staff to reinforce the importance of accurate, realtime documentation.
6. Staff will be held accountable for maintaining correct records, and errors will be addressed immediately.