Inspection · 2025-05-05
Licensing Inspector
Angela Dudek
(804) 629-8167
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
22.1 Religious Exempt; Background Checks Code; Carbon Monoxide
32.1 Report by person other than physician
54.1 Must be MAT Certified.
63.2 Child abuse and neglect
8VAC20-770 Background Checks
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 code compliance inspection was initiated and completed on 5-5-25. The on-site inspection began at 11:30am and ended at 12:55pm. The inspector reviewed compliance in the areas listed above. There were 86 children present with 20 staff. The inspector reviewed 5 children?s records and 5 staff records on-site. This inspection included document review, tour of the facility, interviews, and observations. Information gathered during the inspection determined non-compliance(s) with applicable code sections, 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 5/14/25. A POC submitted after this date will not appear on the public website.
Standard 22.1-289.035-B-1
The Center is required to obtain documentation of a completed Sworn Disclosure Statement prior to date of hire.
The record for Staff #1 contained a sworn disclosure statement completed 3 weeks after hire.
Plan of Correction: The Center acknowledges the delay in obtaining the completed Sworn Disclosure Statement for Staff #1. To ensure compliance, effective immediately, all sworn disclosure statements will be completed, signed, and dated prior to the employee's start date. Additionally, Central Registry checks will be requested and documented prior to hire as required. Administrative procedures have been revised, and staff responsible for onboarding have been retrained to prevent recurrence,
Standard 22.1-289.035-B-2
The Center is required to obtain documentation of the results of a national fingerprint background check prior to date of hire.
The record for Staff #1 contained a fingerprint background check completed over 2 years after hire, and the record for Staff #2 contained a fingerprint background check completed a month after hire.
Plan of Correction: The Center acknowledges the oversight in obtaining timely fingerprint background checks for Staff #1 and Staff #2. Moving forward, all fingerprint background checks will be completed and documented prior to each new staff member's start date. Effective immediately, the hiring process has been updated to ensure that no staff member begins employment without verification of completed background check results. Administrative staff have been retrained on this requirement to ensure full compliance.
Standard 22.1-289.035-B-3
For staff hired after 7/1/24, the Provider is required to request a Central Registry check prior to employment.
1)The record for Staff #3 contained a Central Registry check that was sent 10 days after hire.
2)The record for Staff #1 did not contain documentation that a central registry search was completed within 30 days of employment.
Plan of Correction: The Center acknowledges the failure to request and document Central Registry checks within the required timeframes for Staff #1 and Staff #3, Moving forward, all Central Registry checks will be requested and documented prior to the start date for all new hires, as required for staff hired after 7 /1/24. In addition, a tracking system has been implemented to monitor the timely submission and receipt of Central Registry checks. Administrative staff have been retrained on these requirements to ensure full compliance with licensing regulations.