Inspection · 2025-05-06
Date
2025-05-06
Complaint Related
No
Licensing Inspector
Rebecca Forestier
(540) 309-2835
(540) 309-2835
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
22.1 BACKGROUND CHECKS, CODE, CARBON MONOXIDE
Inspector Notes
An unannounced, on-site monitoring inspection was initiated and completed on 05/06/2025. The on-site inspection began at 9:30 am and ended at 1:15 pm. The inspector reviewed compliance in the areas listed above. There were 51 children present and 8 staff. The inspector reviewed 5 children?s records and 5 staff records on-site.
The 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.
Violations
15Standard 22.1-289.035-B-2
Providers must obtain a completed national criminal background check prior to the employee?s first day of employment.
The national criminal background check for Staff 4 was obtained 2 weeks after the first day of employment.
The national criminal background check for Staff 4 was obtained 2 weeks after the first day of employment.
Plan of Correction: Will get prior to hire.
Standard 22.1-289.035-B-3
REPEAT VIOLATION
The center must request a search of the central registry prior to the employee?s first day of employment.
Staff 2, who has been employed for more than 9 months, did not have a central registry request. Staff 3, who has been employed for more than one month, did not have a central registry request. Staff 4, who has been employed for more than 8 months, did not have a central registry request. Staff 5, who has been employed for more than one week, did not have a central registry request.
The center must request a search of the central registry prior to the employee?s first day of employment.
Staff 2, who has been employed for more than 9 months, did not have a central registry request. Staff 3, who has been employed for more than one month, did not have a central registry request. Staff 4, who has been employed for more than 8 months, did not have a central registry request. Staff 5, who has been employed for more than one week, did not have a central registry request.
Plan of Correction: Will work on requesting these this week.
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.
The center did not request the criminal record check and child abuse and neglect registry check from one state that Staff 3 has resided in within the preceding 5 years; Staff 3 has been employed for more than 1 month.
The center did not request the criminal record check and child abuse and neglect registry check from one state that Staff 3 has resided in within the preceding 5 years; Staff 3 has been employed for more than 1 month.
Plan of Correction: Will work on getting these requested this week.
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 2, who has been attending for more than 1 month, did not have documentation of an immunization record on file.
Child 2, who has been attending for more than 1 month, did not have documentation of an immunization record on file.
Plan of Correction: Will ask the parent.
Standard 8VAC20-780-160-A
REPEAT VIOLATION
The center is required to obtain documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with children.
The record for Staff 3, who has been working with children and has been employed for more than one month, does not contain documentation of a negative tuberculosis screening. The record for Staff 4, who has been working with children and has been employed for more than eight months, does not contain documentation of a negative tuberculosis screening. The record for Staff 5, who has been working with children and has been employed for more than one week, does not contain documentation of a negative tuberculosis screening.
The center is required to obtain documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with children.
The record for Staff 3, who has been working with children and has been employed for more than one month, does not contain documentation of a negative tuberculosis screening. The record for Staff 4, who has been working with children and has been employed for more than eight months, does not contain documentation of a negative tuberculosis screening. The record for Staff 5, who has been working with children and has been employed for more than one week, does not contain documentation of a negative tuberculosis screening.
Plan of Correction: Will have the staff get them.
Standard 8VAC20-780-240-A
Staff are to complete the VDOE sponsored online orientation course within 90 days of hire.
Staff 4, who has been employed for more than eight months, has not completed the course.
Staff 4, who has been employed for more than eight months, has not completed the course.
Plan of Correction: Will ask the staff to complete.
Standard 8VAC20-780-280-B
Hazardous substances must be in a locked place that prevents access by children.
There were two containers of insecticides unlocked on top of a cabinet in Room 6.
There were two containers of insecticides unlocked on top of a cabinet in Room 6.
Plan of Correction: Will lock in a separate storage closet.
Standard 8VAC20-780-280-C
Pesticides or insecticides shall not be stored in areas used by children or in areas used for food preparation or storage.
There were two containers of insecticides on top of a cabinet in Room 6; Room 6 is used to store the children?s belongings and is used to store food.
There were two containers of insecticides on top of a cabinet in Room 6; Room 6 is used to store the children?s belongings and is used to store food.
Plan of Correction: Will lock in a separate storage closet.
Standard 8VAC20-780-350-C
When children are in ongoing mixed age groups, the staff-to-children ratio applicable to the youngest child in the group shall apply.
On 05/06/2025, there were 2 staff supervising 9 children, ages 3 months- 2 years, in Room 1. The staff-to-child ratio for children from birth to 16 months (1 staff:4 children) was applicable to this group of children. Three staff were required for this group.
On 05/06/2025, there were 2 staff supervising 9 children, ages 3 months- 2 years, in Room 1. The staff-to-child ratio for children from birth to 16 months (1 staff:4 children) was applicable to this group of children. Three staff were required for this group.
Plan of Correction: There were 2 staff out today; will adjust as necessary.
Standard 8VAC20-780-370-1
When an infant is placed in their crib, they shall be placed on their back.
Child 2, Child 3 and Child 5 were placed on their stomachs in their cribs.
Child 2, Child 3 and Child 5 were placed on their stomachs in their cribs.
Plan of Correction: Will remind all staff and will post safe sleep procedures.
Standard 8VAC20-780-40-K
The center shall develop written procedures for prevention of shaken baby syndrome or abusive head trauma, including coping with crying babies, safe sleeping practices, and sudden infant death syndrome awareness.
The written procedures were not available for review.
The written procedures were not available for review.
Plan of Correction: If the original cannot be located a new one will be created.
Standard 8VAC20-780-550-G
Documentation shall be maintained of emergency evacuation, shelter-in-place and lockdown drills.
The emergency evacuation drill conducted in April 2025 was not documented.
The emergency evacuation drill conducted in April 2025 was not documented.
Plan of Correction: Will document all drills when they are done.
Standard 8VAC20-780-60-A
REPEAT VIOLATION
The center shall maintain a separate record for each child enrolled that contains all of the required information.
The records for Child 2, Child 4 and Child 5 were missing information required by the standards.
The center shall maintain a separate record for each child enrolled that contains all of the required information.
The records for Child 2, Child 4 and Child 5 were missing information required by the standards.
Plan of Correction: Will get the information today.
Standard 8VAC20-780-70
Documentation of at least 2 references to character, reputation, and competency are to be checked prior to employment.
Staff 2, who has been working at the center for one month, did not have any completed reference verifications on file. Staff 5, who has been working at the center for one week, did not have any completed reference verifications on file.
Staff 2, who has been working at the center for one month, did not have any completed reference verifications on file. Staff 5, who has been working at the center for one week, did not have any completed reference verifications on file.
Plan of Correction: Will get the references.
Standard 8VAC20-780-80-A
REPEAT VIOLATION
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.
On 05/06/2025, there were 10 children present in Room 2, but only 9 were marked present on the attendance record. There were 15 children present in Room 3 and 16 marked present on the attendance record. There were 8 children present in Room 4, but only 7 children were marked present on the attendance record.
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.
On 05/06/2025, there were 10 children present in Room 2, but only 9 were marked present on the attendance record. There were 15 children present in Room 3 and 16 marked present on the attendance record. There were 8 children present in Room 4, but only 7 children were marked present on the attendance record.
Plan of Correction: Will adjust the attendance record.