Inspection · 2025-06-05
Licensing Inspector
Pamela Sneed
(804) 629-2691
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
Inspector Notes
An unannounced, on-site monitoring inspection was conducted on 6/5/25. The on-site inspection began at 10:28am and ended at 3:58pm. The inspector reviewed compliance in the areas listed above. There were 134 children present and 44 staff. The inspector reviewed 10 children?s records and 12 staff records while on-site. This inspection included document review, tour of the facility and interviews. 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 6/18/25. A POC submitted after this date will not appear on the public website.
Standard 8VAC20-780-130-E
The center shall obtain documentation of additional immunizations once every 6 months for children under the age of 2 years.
Immunizations on-file for Child #3 were dated as completed in May 2023, when the child was 15 months old.
Plan of Correction: The missing immunization update for Child #3 has been obtained and documented in their file. Reinforcement of Policy- All children under 2 years old must have updated immunization records every six months, per Virginia licensing requirements. Immunization records must include: Date of immunization Type of vaccine administered Provider?s name and signature Corrective Measures - Records missing updates will be flagged for immediate correction. Monitoring & Follow-Up - Monthly audits of immunization records will be conducted. Pre-inspection compliance reviews will verify that all records meet licensing standards.
Standard 8VAC20-780-270-A
Areas and equipment of the center, inside and outside, shall be maintained in a safe and operable condition.
The rubber resilient surfacing tiles are buckling, not level and presenting as trip hazards on both outdoor play areas.
Safety straps were missing in the seats of a feeding table and feeding chairs in a older infant/toddler classroom serving children over 12 months of age.
Plan of Correction: Feeding Table Safety- The missing safety straps in the two infant classrooms were ordered and replaced. The missing safety traps for the younger toddler classrooms were ordered and will be replaced upon arrival. Replacement safety belts were ordered and installed in the infant classrooms. The replacement safety straps for the young toddler classrooms were ordered and will be installed upon arrival by the office/facilities manager or maintenance personnel. Staff must verify that all safety straps are properly secured before seating children. Staff will alert administration if straps break or go missing. Monthly Safety Audits- Leadership will conduct monthly playground and equipment inspections to ensure compliance.
Playground Upgrade- The center was awarded a grant for playground improvements. Once the funds are deposited, the school will schedule the installation of a pour-in-place foundation or astro-turf, permanently eliminating trip hazards caused by the buckling tiles. Until the new surfacing is installed, teachers and staff will conduct daily visual inspections before outdoor play begins and report any hazards immediately. The TCS Admin Team and Board are monitoring the grant deposit timeline and will provide updates to licensing officials as scheduling is finalized.
Standard 8VAC20-780-280-B
Repeat violation.
Hazardous substances such as cleaning materials shall be kept in a locked place using a safe locking method that prevents access by children.
In 4 of 6 classrooms observed by the inspector, hazardous substances such as cleaning supplies were not kept in a locked place preventing access by the children. Spray and aerosol cleaning products and household cleaning wipes were found to be in unlocked cabinets (upper and lower level cabinets), in unlocked lower level drawers and on counter tops and tables.
Plan of Correction: On June 12, 2025, leadership held two staff meetings at 1:30PM and 2:30PM, where Executive Director Erin Hindes provided a PowerPoint presentation reinforcing clear expectation for hazardous substance storage. Staff were reminded that all cleaning wipes, aerosol sprays, spray solutions, bleach mixtures, and other hazardous materials must be stored in locked cabinets or drawers at all times unless actively in use. Given that this is a repeat violation, the importance of compliance was strongly emphasized. Leadership will conduct random audits throughout the week to confirm adherence to the policy. To maintain accountability, weekly inspections will be conducted to ensure continued
compliance. Any staff members found to be violating the policy will receive written warnings, and repeated offenses will result in corrective action. All steps taken to address this violation will be documented for licensing review to demonstrate compliance improvements.
Standard 8VAC20-780-40-I
The center shall develop written procedures for injury prevention.
The written injury prevention procedures provided to the inspector for review were limited to the outdoor playground safety procedures and did not include general injury prevention at the center.
Plan of Correction: A comprehensive written injury prevention policy was drafted to meet licensing requirements. Reinforcement of Policy - The updated injury prevention procedures now cover: Classroom safety (furniture placement, trip hazards, safe handling of materials) Hallway and common area safety (clear walkways, emergency exits, supervision protocols) Outdoor and playground safety (fall prevention, equipment checks, supervision ratios) Emergency response to injuries (first aid procedures, incident reporting, staff responsibilities) Corrective Measures -Formal Documentation: The new injury prevention policy was added to the center?s operational handbook. Staff were provided with written copies of the updated procedures. Implementation & Training: Staff will receive mandatory training on the expanded injury prevention procedures. Annual review of injury prevention procedures to ensure they remain up to date. The Admin Team will present monthly incident and accident reports, monitor and adjust prevention strategies accordingly.
Standard 8VAC20-780-440-J
There shall be at least 30" of space between service sides of occupied cribs and other furniture.
A crib in one classroom was placed in the corner of the nap room with walls on 2 sides and another unoccupied crib was measured to be 16" away on the service side of the crib.
Plan of Correction: The crib previously placed in the corner of the nap room has been repositioned to meet spacing requirements. The unoccupied crib that was 16 inches away has been adjusted to maintain proper clearance. Mandatory refresher training on crib placement and infant safety was conducted on June 11th, ensuring all staff understand and adhere to spacing guidelines. All cribs must maintain at least 30 inches of space between their sides and other furniture. Cribs cannot be placed too close to a corner wall. They must have at least 30 inches of clearance.
Crib spacing will be checked during monthly compliance walkthroughs.
Standard 8VAC20-780-510-E
The center's procedures for administering medication shall include parent and physician written authorization for long-term medications and be consistent with the manufacturer's instructions for non-prescription medicine.
Staff did not follow the center's procedures for obtaining written authorization for long-term medications on-site for Child #6. No written authorizations were on-file.
According to the manufacturer's instructions for a medication on-site for Child #1, it is to be administered to children ages 2 years of age and older. Child #1 is 13 months old.
Plan of Correction: The Administrative team reached out to the parents of Child #6 and have received the long term medication form. Parents of Child #1 have been notified that documentation is required before administration. The parent has provided the long-term medication form and medication to The Children?s School. Staff were reminded at the June 11th staff meeting that they must not accept medication directly from families. All medication must be processed through the office before approval. A reminder was also given that all medication must be stored in a locked medication box at all times.
Standard 8VAC20-780-520-A
All nonprescription over-the-counter skin products shall be used in accordance with the manufacturer's recommendations.
There was no documentation of when the product should be administered, which child the product belonged too and if administration was consistent with manufacture's recommendations.
Plan of Correction: Staff were reminded during the June 11th meeting that all sunscreen must be labeled with the child?s first and last name and placed in individual bags with the completed Topical Cream/Lotion/Sunscreen/Bug Spray Parental Consent Form.
Sunscreen and topical products must be stored in a locked cabinet, ensuring they are not placed on top of cubbies. Ziploc bags were provided to ensure topical product forms are stored with the child?s sunscreen for easy reference. Staff were instructed that all over-the-counter topical forms must be completed and stored with the sunscreen. Sunscreen must be applied following manufacturer recommendations and only with written parent authorization. Daily compliance checks will be conducted by lead teachers. Monthly audits of sunscreen logs and storage practices will be reviewed by administration to ensure consistency.
Standard 8VAC20-780-550-D
The center shall implement a monthly practice evacuation drill.
There was no documentation of a monthly evacuation drill for March 2025 and staff stated a drill was not practiced that month.
Plan of Correction: The lapse in March 2025 has been acknowledged and steps have been taken to ensure this does not happen again. The monthly evacuation drill schedule will now be managed directly by Erin and Cavangaline to ensure consistency. A designated administrator will oversee drill documentation to prevent lapses. A centralized record will continue to be maintained, with drills logged immediately after completion. Emergency preparedness procedures have been reinforced within the admin team. Erin and Cavangaline will conduct quarterly internal reviews to verify drill documentation is complete.
Standard 8VAC20-780-550-P
The center shall maintain a written record of children's serious and minor injuries in which entries are made the day of occurrence. The record shall include how the parent was notified and the time the parent was notified.
2 of 10 written injury reports did not include the time the parent was notified, and 1 of 10 reports did not include how the parent was notified.
Plan of Correction: Staff were reminded at the June 11th staff meeting that injury reports must include both the time and method of parent notification. The two reports missing notification time were updated to reflect the exact time parents were informed. The one report missing method of notification was corrected to indicate whether the parent was notified by phone, email, or in person. Reinforcement of Policy - All injury reports must be completed on the same day as the incident using the existing accident report form, ensuring: Description of the injury Location of the incident Exact time the parent was notified Method of notification (phone, email, in person, etc.) Before submitting reports to the office, staff must confirm all required fields are completed. Corrective Measures/Staff Accountability -TCS Admin Team will review injury reports before filing to verify completeness. Missing information will be flagged for correction before final submission. Staff Training & Compliance Checks -Refresher training on injury documentation was conducted on June 11th.
Monitoring & Follow-Up -Monthly audits of injury records will be conducted to ensure compliance.
Standard 8VAC20-780-570-A
Feeding chairs and feeding table seats shall be used for children under 12 months who are not held while being fed. When a child is placed in an infant seat the protective belt shall be fastened securely.
Two feeding table seats in one classroom were missing the safety straps and when asked staff stated they place children in the seats without the safety straps.
Plan of Correction: During the June 12, 2025 staff meeting, Executive Director Erin Hindes clarified with all staff that all feeding table seats must have properly secured safety straps before use. All staff were reminded that waist and crotch straps must be fastened according to manufacturer instructions to ensure child safety. The missing safety straps in the two infant classrooms were ordered and replaced. The missing
safety traps for the younger toddler classrooms were ordered and will be replaced upon arrival. Replacement Straps Ordered- The necessary safety straps were ordered and have been installed in the infant classrooms by the office/facilities manager. The safety straps were ordered for the young toddler classrooms and will be installed when they arrive. Equipment Inspection- Classroom Teaching Teams will conduct daily checks to ensure all feeding table seats have properly secured straps before seating children. They will notify the administrative team if any equipment needs to be replaced. Monthly Safety Audits- Leadership will conduct routine inspections to ensure ongoing compliance.
Standard 8VAC20-780-570-E
Prepared infant formula shall be refrigerated, dated and labeled with the child's name.
A total of 12 bottles/bags of prepared infant formula were not dated and 1 did not have the name of the child it belonged to in one classroom. The milk formula that was not labeled with the child's name and date was sitting on a shelf in the refrigerator and was not in a labeled bin.
Plan of Correction: On June 12, 2025, during staff meetings at 1:30 and 2:30 PM, Executive Director Erin Hindes clearly instructed all staff that each bottle and cup must be labeled with the child?s name and date and placed in that child?s designated labeled bin inside the refrigerator. This expectation applies to both formula and breast milk, whether prepared on-site or brought from home. All new hires will be properly trained in infant classroom formula and milk labeling. This will include live demonstrations on proper labeling and bin use. The classroom teaching team will conduct daily visual checks of the refrigerator in each infant and toddler room to ensure ongoing compliance. If a bottle is not properly labeled by the family
at drop off, staff will alert the family and immediately correct it.
Standard 8VAC20-780-60-A
The center shall maintain and keep at the center a separate record for each child enrolled which shall contain documentation of viewing the child's proof of identity.
The record for Child #2 did not include documentation of viewing the child's proof of identity.
Plan of Correction: The TCS admin team obtained and reviewed documentation of Child #2?s proof of identity, ensuring compliance. Reinforcement of Policy - Within seven business days of a child?s first day of attendance, staff must verify and document proof of identity using one of the following: Certified birth certificate Birth registration card
Passport The method of verification must be recorded in the child?s file.
Corrective Measures - Standardized Documentation Process: The existing proof of identity verification form will continue to be used for all new enrollments. Records missing identity documentation will be flagged for immediate correction. Supervisors will review all new enrollment records to confirm proof of identity documentation is included. Monitoring & Follow-Up - Monthly audits of enrollment records will be conducted to ensure compliance.
Standard 8VAC20-780-70
Repeat violation.
The following staff records shall be kept for each staff person: Name, address, age, job title, date of employment, written reference checks, documentation of education and experience for the job position, First Aid/CPR, TB screening, health problems and background checks.
There was no staff record available for review for Staff #9 who was observed working in a Co-Lead Teacher role today.
Plan of Correction: Sara Shaw, the administrator for Integration Station, reached out to APS?s home office to request Staff #9?s record. APS confirmed receipt of the request but has not yet provided the required documentation or connected with Licensing Specialist. All APS staff hosted at The Children's School were asked to sign a release form allowing The Children's School to access their records. Staff #9 is employed under Integration Station, not The Children's School. Record keeping for Integration Station staff falls under APS?s jurisdiction, and TCS does not
manage or maintain these records. TCS is requesting Integration Station staff sign a release form to provide us with their documentation. Ongoing Follow-Up- Sara Shaw will continue to request updates from APS until Staff #9?s record
is provided. Licensing Communication- TCS leadership will keep Licensing Specialist up to date regarding progress obtaining documentation. Sara Shaw will track APS?s response and provide updates to Erin Hindes. Monitoring & Follow-Up -Documentation of Compliance Efforts- All communication will be maintained to show that TCS and Integration Station have made good-faith efforts to resolve the issue.