Inspection · 2026-02-25
Licensing Inspector
Cindy Horne
(804) 297-4469
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.
Yes
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
8VAC20-790 Introduction
8VAC20-790 Administration
8VAC20-790 Staff Qualifications & Training
8VAC20-790 Physical Plant
8VAC20-790 Staffing & Supervision
8VAC20-790 Programs
8VAC20-790 Special Care Provisions & Emergencies
8VAC20-790 Special Services
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 on 2/25/2026 and completed on 2/26/2026. The on-site inspection on 2/25/2026 began at 12:00 p.m. and ended at 4:00 p.m. The on-site inspection on 2/26/2026 began at 11:00 a.m. and ended at 12:20 p.m. The inspector reviewed compliance in the areas listed above. There were 17 children present at nap time on 2/25/26 with four staff and two volunteers. The inspector reviewed five children?s records and seven staff records on-site on 2/25/2026. This inspection included document review (i.e. emergency drill logs, annual food, health and fire inspections background checks, physical examinations and immunizations), tour of the facility, interviews, and observations.
A subsidy health and safety inspection (SHSI) was conducted in conjunction with the code compliance inspection. Subsidy standards that are not covered in Code were reviewed during this SHSI.
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 business days from today, which will be the close of business on 3/18/2026. A POC submitted after this date will not appear on the public website.
Standard 22.1-289.031-A-3-d
(Systemic deficiency) The center shall ensure that the ratio requirement of one staff member to 10 children from ages 36 months to five years is maintained. Volunteer #1 was observed alone in a classroom with 12 children ages three to five years on 2/25/26. Staff #4 later came back into the room with Volunteer #1. The period of time that the children were alone with Volunteer #1 is unknown.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 22.1-289.031-A-9
(Systemic deficiency) The child day center shall comply with all safe sleep guidelines recommended by the American Academy of Pediatrics. The guidelines require that soft objects, such as pillows, pillow-like toys, quilts, comforters, mattress toppers, fur-like materials, and loose bedding, such as blankets and nonfitted sheets, be kept away from the infant?s sleep area to reduce the risk of SIDS, suffocation, entrapment/wedging, and strangulation.' Three infants were observed sleeping in their cribs at nap time with fleece blankets.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 22.1-289.031-B-5
The child day center shall establish and implement procedures for ensuring that all areas of the premises accessible to children are free of obvious injury hazards. The pad on the changing table in the infant room was cracked in several places with exposed foam. Peeling paint was observed in the toddler?s classroom and in the boys? and girls? bathrooms. There was a cord to a portable heater that was within reach of children in the classroom with preschool children, ages two and three, that could entangle them or cause them to pull the heater down on themselves.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 22.1-289.035-A
(Repeat Violation systemic deficiency) The center is required to have employees undergo a background check every five years. The most recent national criminal background check for staff #1, who works directly with children, was overdue by a year and three months.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 22.1-289.035-B-1
(Systemic deficiency) The center is required to obtain a completed sworn statement prior to the employee's first day of employment. There was no sworn statement for Volunteer #1, who was observed on 2/25/26, directly supervising children when she was not in sight and sound supervision of a staff member and was counted in the staff-to-children ratio.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 22.1-289.035-B-2
(Repeat Violation/systemic deficiency) Providers must obtain a completed national criminal background check prior to the employee's first day of employment. Staff #3, who had been employed for over two years, did not have a completed national criminal background check.
There was no national criminal background check for Volunteer #1, who was observed on 2/25/26, directly supervising children when she was not in sight and sound supervision of a staff member and was counted in the staff-to-children ratio.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 22.1-289.057-A
The program is required to submit to VDH and implement a plan to test potable water for lead. The program did not have evidence of a testing plan submitted to VDH and/or the program did not have evidence of the implementation of the required testing plan.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-770-40-D-2
(Repeat Violation/systemic deficiency) For staff hired before July 1, 2024, providers must obtain the results of a central registry search for an employee, within 30 days of service.
There were no central registry search results in the record of Staff #1, who works directly with children and has been employed at the center for over five years.
There were no central registry search results in the records of Staff #2 and Staff #4, who work directly with children and have both been employed at the center for two years.
There were no central registry search results in the record of Staff #5, who works directly with children and who has been employed at the center for more than 4 years and 5 months.
There were no central registry search results for Volunteer #1, who was observed on 2/25/26, directly supervising children when she was not in sight and sound supervision of a staff member and was counted in the staff-to-children ratio.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-790-530-B
For each group of children, the vendor shall maintain a written hard copy record of daily
attendance that documents the arrival and departure of each child in care as it occurs. The attendance record for the classroom of Staff #3 was observed to be blank at approximately 12:30 p.m. on 2/25/2026 even though three children from that classroom were present.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-790-540-B-16
Children?s records shall include a written statement that the vendor will notify the parent when the child becomes ill and that the parent will arrange to have the child picked up as soon as possible if so requested by the vendor. This statement was not in the records for Child #1,#2,#3,#4, or #5.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-790-560-A
(Repeat Violation/systemic deficiency) The center is required to obtain documentation of a negative tuberculosis (TB) screening at the time of employment and prior to coming into contact with children. Staff #3 and Staff #4 have been working at the center for two years. There were no TB screenings in their records.
There was no TB screening for Volunteer #1, who was observed on 2/25/26, directly supervising children when she was not in sight and sound supervision of a staff member and was counted in the staff-to-children ratio.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-790-560-B
(Systemic deficiency) A subsequent tuberculosis (TB) screening is required every two years from the date of the initial screening. The screening for Staff #2 was due more than five years ago.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-790-600-B
(Repeat Violation/systemic deficiency) Within the first 90 days of employment all staff who work directly with children shall complete Virginia Preservice Training for Child Care Staff. There was no record of Virginia Preservice Training for Staff #3, who has been working at the center for two years.
There was no record of Virginia Preservice Training for Volunteer #1, who was observed on 2/25/26, directly supervising children when she was not in sight and sound supervision of a staff member and was counted in the staff-to-children ratio.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-790-600-C
(Repeat Violation/systemic deficiency) Orientation training for staff shall be completed on required facility specific topics within seven days of their employment and prior to working alone with children. There was no documentation of orientation training in the records of Staff #1, #2, #3, #4, #5, who have all been working for more than seven days.
There was no documentation of orientation training for Volunteer #1, who was observed working alone with children on 2/25/26.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-790-600-D-1
(Repeat Violation/systemic deficiency) All staff who work directly with children shall have within 90 days of the date of employment current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care. Staff #6 is overdue for certification in cardiopulmonary resuscitation (CPR) by more than two months.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-790-600-D-2
(Repeat Violation /systemic deficiency) All staff who work directly with children shall have within 90 days of the date of employment current certification in first aid appropriate to the ages of children in care. Staff #6 is overdue for certification in first aid by more than two months.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-790-600-F
(Repeat Violation/systemic deficiency) Staff who work directly with children shall annually attend at least 16 hours of training and staff development activities, to include the department's health and safety update course.
There was no documentation of completion of the department's health and safety update course for Staff #3, and Staff #5. Staff #3 has been working at the center for two years. Staff #5 has been working at the center for more than 4 years and 5 months.
There was no documentation of completion of the department's health and safety update course for Volunteer #1, who was observed on 2/25/26, directly supervising children when she was not in sight and sound supervision of a staff member and was counted in the staff-to-children ratio.
Completion of the department's health and safety update course for Staff #2 was overdue by more than 2 years and 5 months.
Completion of the department's health and safety update course for Staff #4 was overdue by more than 2 years and 2 months.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-790-730-F-2
(Systemic deficiency) Cots, rest mats, or beds shall be provided for children older than 12 months of age. Child #5 and Child #6 (age 18 months) were observed sleeping on the floor during nap time on large U shaped pillows.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-790-760-C-2
(Systemic deficiency) Toilet chairs shall be emptied promptly and cleaned and sanitized after each use. Staff #3 reported that she uses wipes to sanitize the toilet chairs rather than sanitizing them by spraying or dipping them into sanitizing solution and then allowing them to air dry for a minimum of two minutes or according to the sanitizing solution instructions.
Plan of Correction: Not available online. Contact Inspector for more information.