Inspection · 2025-07-14
Date
2025-07-14
Complaint Related
No
Licensing Inspector
Maria Robles-Lopez
(703) 397-3827
(703) 397-3827
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
8VAC20-780 Administration.
8VAC20-780 Staff Qualifications and Training.
8VAC20-780 Physical Plant.
8VAC20-780 Staffing and Supervision.
8VAC20-780 Programs.
8VAC20-780 Special Care Provisions and Emergencies
8VAC20-780 Special Services.
8VAC20-820 THE LICENSE.
8VAC20-820 THE LICENSING PROCESS.
8VAC20-820 HEARINGS PROCEDURES.
8VAC20-770 Background Checks
20 Access to minor?s records
22.1 Early Childhood Care and Education
63.2 Child Abuse & 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 07/14/2025, as part of the licensure period.
The on-site inspection began at 10:50 am and ended at 1:30 pm. The inspector reviewed compliance in the areas listed above.
There were 55 children present and 9 staff. The inspector reviewed 4 children?s records and 15 staff records on-site.
Information gathered during the inspection determined non-compliance with applicable standards or law and violations were 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 5 business days from today, which will be the close of business on 07/24/2025. A POC submitted after this date will not appear on the public website.
Violations
15Standard 22.1-289.035-B-2
*REPEAT VIOLATION*
Employees must obtain a completed national criminal background check prior to the employee's first day of employment.
The record for Staff #4 (employed for six weeks) did not contain a fingerprint test result.
Employees must obtain a completed national criminal background check prior to the employee's first day of employment.
The record for Staff #4 (employed for six weeks) did not contain a fingerprint test result.
Plan of Correction: Will request background check for #4.
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.
Staff #3 (employed for one month), Staff #4 (employed for six weeks), Staff #5 (employed for four months), Staff #7 (employed for one year), Staff #8 (employed for one month), and Staff #9 (employed for four months) did not have a central registry search requested.
Staff #3 (employed for one month), Staff #4 (employed for six weeks), Staff #5 (employed for four months), Staff #7 (employed for one year), Staff #8 (employed for one month), and Staff #9 (employed for four months) did not have a central registry search requested.
Plan of Correction: Will request CRS for #3, #5, #7 and #8.
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.
Staff #3 and Staff #8 (employed for one month each), and Staff #9 (employed for four months) did not have documentation of requesting a central registry check from one state and no documentation of requesting a central registry check, and sex offender registry search for states other than Virginia.
Staff #3 and Staff #8 (employed for one month each), and Staff #9 (employed for four months) did not have documentation of requesting a central registry check from one state and no documentation of requesting a central registry check, and sex offender registry search for states other than Virginia.
Plan of Correction: Will request background checks for Staff #3, #8 and #9.
Standard 8VAC20-780-130-A
The center shall obtain documentation that each child has received the immunizations required by the State Board of Health before the child can attend the center.
Child #1, who had been attending for one month; and Child #2, who had been attending for one week, did not have documentation of an immunization record on file.
Child #1, who had been attending for one month; and Child #2, who had been attending for one week, did not have documentation of an immunization record on file.
Plan of Correction: Will connect with parents to submit all forms.
Standard 8VAC20-780-140-A
Physical examinations completed by a physician shall be obtained prior to the first day of attendance or within 30 days after the first day of attendance.
There was no physical examination in the record of Child #1, who had been enrolled for one month; and Child #2, who had been enrolled for one week.
There was no physical examination in the record of Child #1, who had been enrolled for one month; and Child #2, who had been enrolled for one week.
Plan of Correction: Will connect with parents to get physicals for #1 and #2.
Standard 8VAC20-780-160-A
Each staff member shall submit documentation of a negative tuberculosis (Tb) screening at the time of employment and prior to coming into contact with children.
*The records for Staff #5(employed for four months) and #9 (employed for four months) did not contain documentation of a negative Tb screening.
*The Tb screening in the records for Staff #7 was dated seventeen days after hire, and for Staff #4 was dated ten days after hire.
*The records for Staff #5(employed for four months) and #9 (employed for four months) did not contain documentation of a negative Tb screening.
*The Tb screening in the records for Staff #7 was dated seventeen days after hire, and for Staff #4 was dated ten days after hire.
Plan of Correction: Will update files with up to date Tb for #5, #7, #9 and #4.
Standard 8VAC20-780-160-C
*REPEAT VIOLATION*
At least every two years from the date of the first initial screening or testing, staff members
shall obtain and submit the results of a follow up tuberculosis screening.
The tuberculosis screening in the records for Staff #14 and Staff #15 were overdue by six
weeks each, and for Staff #11 was overdue by two weeks.
At least every two years from the date of the first initial screening or testing, staff members
shall obtain and submit the results of a follow up tuberculosis screening.
The tuberculosis screening in the records for Staff #14 and Staff #15 were overdue by six
weeks each, and for Staff #11 was overdue by two weeks.
Plan of Correction: Will update Tb in file for #14 and #15.
Standard 8VAC20-780-190-A
Program directors shall be at least 21 years of age and shall meet the required qualifications.
The record for Staff #9 did not contain documentation to verify that they possess the required qualifications of a program director.
The record for Staff #9 did not contain documentation to verify that they possess the required qualifications of a program director.
Plan of Correction: #9 will update file to keep program director qualifications in there.
Standard 8VAC20-780-240-A
Staff are to complete the VDOE sponsored online orientation course within 90 days of hire.
*The records for Staff #5 and Staff #9 (employed for four months each) did not have documentation of having completed the orientation course.
*The records for Staff #5 and Staff #9 (employed for four months each) did not have documentation of having completed the orientation course.
Plan of Correction: Will complete VDOE for #5 and #9.
Standard 8VAC20-780-240-B
*REPEAT VIOLATION*
Orientation training shall be appropriate to the age of the children in care prior to the staff member working alone with children and no later than seven days of the date of assuming job responsibilities, and include all of the required facility specific topics.
*The records for Staff #3 (employed for four weeks) , Staff #4 (employed for six weeks), Staff #5 (employed for four months), Staff #8 (employed for four weeks), and Staff #9 (employed for four months) did not have documentation of having completed the orientation training.
*The records for Staff #7 (employed for two months), Staff #10 (employed for fourteen months), Staff #13 (employed for two years), Staff #14 (employed for three years), and Staff #15 (employed for two years) did not have documentation of having completed orientation training in the following areas:
*Prevention of sudden infant death syndrome, and
*Prevention of shaken baby syndrome and
abusive head trauma.
Orientation training shall be appropriate to the age of the children in care prior to the staff member working alone with children and no later than seven days of the date of assuming job responsibilities, and include all of the required facility specific topics.
*The records for Staff #3 (employed for four weeks) , Staff #4 (employed for six weeks), Staff #5 (employed for four months), Staff #8 (employed for four weeks), and Staff #9 (employed for four months) did not have documentation of having completed the orientation training.
*The records for Staff #7 (employed for two months), Staff #10 (employed for fourteen months), Staff #13 (employed for two years), Staff #14 (employed for three years), and Staff #15 (employed for two years) did not have documentation of having completed orientation training in the following areas:
*Prevention of sudden infant death syndrome, and
*Prevention of shaken baby syndrome and
abusive head trauma.
Plan of Correction: Will update orientation fo #3, #4, #7, #13, #14 and #14.
Standard 8VAC20-780-240-D
*REPEAT VIOLATION*
Prior to working alone with children and within seven days of the first day of employment, staff
shall be provided in writing with the center's information listed in 8VAC20-780-420 A.
There is no documentation in the records for Staff #3 (employed for one month), Staff #4 (employed for six weeks), Staff #5 (employed for four months), Staff #6 (employed for two years), Staff #7 (employed for one year), Staff #8 (employed for one month), Staff #9 (employed for four months) of having received the required documentation.
Prior to working alone with children and within seven days of the first day of employment, staff
shall be provided in writing with the center's information listed in 8VAC20-780-420 A.
There is no documentation in the records for Staff #3 (employed for one month), Staff #4 (employed for six weeks), Staff #5 (employed for four months), Staff #6 (employed for two years), Staff #7 (employed for one year), Staff #8 (employed for one month), Staff #9 (employed for four months) of having received the required documentation.
Plan of Correction: Will update files with new orientation for #3, #4, #5, #6, #7, #8 and #9.
Standard 8VAC20-780-540-E
*REPEAT VIOLATION*
One working, battery-operated radio in each building is required.
A battery-operated radio was not available on the date of inspection.
One working, battery-operated radio in each building is required.
A battery-operated radio was not available on the date of inspection.
Plan of Correction: New radio arrived.
Standard 8VAC20-780-60-A
*REPEAT VIOLATION*
Each center shall maintain and keep at the center a separate record for each child enrolled that contains all of the required information.
Records for children were missing the following required components:
*For Child #1, enrolled for 1 month, was missing the address for one parent's place of employment; the address for two emergency contacts; and documentation of viewing proof of the child's identity and age.
*For Child #2, enrolled for one week, was missing the name, address and phone number of two emergency contacts other than the parents.
*For Child #3, enrolled for one month, was missing the address of two emergency contacts.
*For Child #4, enrolled for two years, was missing the annual update of the information in the child's record.
Each center shall maintain and keep at the center a separate record for each child enrolled that contains all of the required information.
Records for children were missing the following required components:
*For Child #1, enrolled for 1 month, was missing the address for one parent's place of employment; the address for two emergency contacts; and documentation of viewing proof of the child's identity and age.
*For Child #2, enrolled for one week, was missing the name, address and phone number of two emergency contacts other than the parents.
*For Child #3, enrolled for one month, was missing the address of two emergency contacts.
*For Child #4, enrolled for two years, was missing the annual update of the information in the child's record.
Plan of Correction: Will connect with parent to submit missing information.
Standard 8VAC20-780-70
*REPEAT VIOLATION*
For each staff person, verification of age requirement, date of employment, and documentation that two or more references as to character and reputation as well as competency were checked before employment shall be kept in their record.
*The records for Staff #3, #4, #5, #7, #8, #10 and #11 did not contain documentation that two or more references were checked before employment.
*The records for Staff #5, and #7 did not contain verification of age requirement.
For each staff person, verification of age requirement, date of employment, and documentation that two or more references as to character and reputation as well as competency were checked before employment shall be kept in their record.
*The records for Staff #3, #4, #5, #7, #8, #10 and #11 did not contain documentation that two or more references were checked before employment.
*The records for Staff #5, and #7 did not contain verification of age requirement.
Plan of Correction: Shall request reference checks and copies of ID for all staff.
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.
*The "Barracudas" group did not have a written record of attendance specific for the group.
*The general attendance that is recorded in the tablet was not accurate. There were two children that were present but not checked-in.
*The "Barracudas" group did not have a written record of attendance specific for the group.
*The general attendance that is recorded in the tablet was not accurate. There were two children that were present but not checked-in.
Plan of Correction: Will ensure all counselors have the most up to date list.