Inspection · 2025-05-16
Date
2025-05-16
Complaint Related
No
Licensing Inspector
Brandie Viscayda
(757) 636-3427
(757) 636-3427
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
8VAC20-770 Background Checks (8VAC20-770)
20 Access to minor?s records
22.1 Background Checks Code, Carbon Monoxide
63.2 Child Abuse & Neglect
Inspector Notes
An unannounced, on-site monitoring inspection was initiated on May 16, 2025 and completed on May 16, 2025. The on-site inspection began at 7:55am and ended at 10:50. The inspector reviewed compliance in the areas listed above. There were 25 children present and 2 staff. The inspector reviewed 8 children?s records and 8 staff records on site. This 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.
Please complete the plan of correction (POC) and date to be corrected sections for each violation cited on the violation notice. Specify how the deficient practice will be or has been corrected. Submit your POC within five (5) business days from today, which will be the close of business on 7/7/25. A POC submitted after this date will not appear on the public website.
Violations
20Standard 22.1-289.035-B-1
The center is required to obtain a completed sworn statement prior to the employee's first day of employment. The record for staff #4 and #7 did not have documentation of a sworn statement.
Plan of Correction: Staff #7 have been immediately required to complete and submit sworn statements. Staff 4 is no longer employed. All current staff files have been reviewed and any missing sworn statements have been rectified.
Standard 22.1-289.035-B-2
Providers must obtain a completed national criminal background check prior to the employee's first day of employment. Staff #7, who had been employed for approximately a month, did not have a completed national criminal background check. Staff #7 was working with children alone.
Plan of Correction: Staff was removed from unsupervised contact with children until the completed background check was received and verified.
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 #4 who had been employed for approximately a year and staff #7, who had been employed for approximately a month, did not have a central registry search requested. Staff #7 was working alone with children.
Plan of Correction: Staff #7 has had their central registry requested. Administrative audits will be conducted bi-weekly by the director to ensure pre employment documentation is completed to start date.
Standard 8VAC20-780-140-A
Each child shall have a physical examination by or under the direction of a physician before the child's attendance or within 30 days after the first day of attendance. The record for child #5 did not have documentation of a completed physical. The child has been in care for approximately four months.
Plan of Correction: The parent of the child has been contacted and given written notice to provide documentation of completed physical. A temporary exclusion policy has been put in place. children without valid physical examination documentation within 30 days of enrollment will not be permitted to continue care until proper documentation is submitted.
Standard 8VAC20-780-160-A
Each staff member shall submit documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with children. The record for staff #3, staff #5, and staff #7 did not have documentation of a completed tuberculosis screening.
Plan of Correction: TB screening for all staff have scheduled and completed. All documentation has been places in their files. The director will perform quarterly audits of all staff health records to ensure TB screening remains up to date and renewed as required by licensing standards
Standard 8VAC20-780-160-C
At least every two years from the date of the initial screening or testing staff members shall obtain and submit the results of a follow-up tuberculosis screening. The last tuberculosis screening documented for staff #1 was completed in 2023 and the last tuberculosis screening was completed for staff #6 in 2022.
Plan of Correction: All staff records have been audited in updated to ensure compliance with TB screen requirements. A mass compliance calendar has been implemented to try expiration dates of all required to have screenings. Alert will be sent out to the director 30 days before any health screening is due. All staff are required to maintain current to continue active employment.
Standard 8VAC20-780-210-A
Program leaders shall have fulfilled a high school program completion or the equivalent. The record for staff #3 and staff #7 did not have documentation of a high school completion program or the equivalent.
Plan of Correction: All affected have been instructed to submit value proof of high school completion or GED within five business days. The documentation is reviewed, they will not be counted as leads. A new hiring checklist has been able to verify our credentials requirements are fulfilled prior to employment. Staff files will be reviewed monthly to assure continued compliance.
Standard 8VAC20-780-245-A
Staff shall complete annually a minimum of 16 hours of training appropriate to the age of children in care. The record for staff #, staff #4, staff #5 and staff #6, who have all been working at the center for over a year did not have documentation of annual training.
Plan of Correction: At least two additional staff members are currently being enrolled in Matt certification to ensure full coverage at all times. Until their certification is complete, the current mat certified staff schedule has been adjusted to ensure that they are present doing all hours when children with emergency medication are in care. A list of children requiring emergency medications have been posted discreetly in the front office and staff lunch and daily schedules are being crossed. Check to confirm a mat certified staff is always on site. In addition, all emergency boxes will be logged a check daily to assure compliance, and staff readiness.
Standard 8VAC20-780-245-J
Any child for whom emergency medications (such as albuterol, glucagon, and
epinephrine auto injector) have been prescribed shall always be in the care of a
staff member or independent contractor who meets the requirements in Medication Administration Training (MAT). The medication box had the medications listed above and there is only one staff member who is MAT certified and they were not present at the time of the inspection.
epinephrine auto injector) have been prescribed shall always be in the care of a
staff member or independent contractor who meets the requirements in Medication Administration Training (MAT). The medication box had the medications listed above and there is only one staff member who is MAT certified and they were not present at the time of the inspection.
Plan of Correction: At least two additional staff members are currently being enrolled in Matt certification to ensure full coverage at all times. Until their certification is complete, the current mat certified staff schedule has been adjusted to ensure that they are present doing all hours when children with emergency medication are in care. A list of children requiring emergency medications have been posted discreetly in the front office and staff lunch and daily schedules are being crossed. Check to confirm a mat certified staff is always on site. In addition, all emergency boxes will be logged a check daily to assure compliance, and staff readiness.
Standard 8VAC20-780-270-A
REPEAT VIOLATION
Areas and equipment of the center, inside and outside, shall be maintained in a safe condition. There was an extension cord on a shelf in the school age room and a power cord with multiple plugs on a changing table in the infant room. Both areas were accessible to children.
Areas and equipment of the center, inside and outside, shall be maintained in a safe condition. There was an extension cord on a shelf in the school age room and a power cord with multiple plugs on a changing table in the infant room. Both areas were accessible to children.
Plan of Correction: All extension cords and power stripes were immediately removed from child- accessible areas upon identification. A facility- wide safety audit will be conducted weekly to ensure all equipment and cords are secured and inaccessible to children. Staff have been retrained on environmental safety and the importance of maintaining hazard- free classrooms.
Standard 8VAC20-780-280-B
REPEAT VIOLATION
Hazardous substances shall be kept in a locked place using a safe locking method that prevents access by children. There was an unlocked cabinet in the toddler room with a can of disinfectant spray with the label ?keep out if reach of children? accessible to children.
Hazardous substances shall be kept in a locked place using a safe locking method that prevents access by children. There was an unlocked cabinet in the toddler room with a can of disinfectant spray with the label ?keep out if reach of children? accessible to children.
Plan of Correction: All hazardous substance have been removed from unlocked areas and place that secure, lock storage. Staff have been retrained on the proper storage of cleaning and hazardous material. A daily end of day safety check is now required for each classroom, with a designated staff member responsible for verifying all hazard items have been locked. Random safety audit will be conducted weekly by management to assure continued compliance.
Standard 8VAC20-780-350-B-1
The staff-to-children ratio for children ages birth to 16 months is one staff for every four children and are required whenever children are in care. The ratio for the infant room was one staff and twelve children for approximately two hours.
Plan of Correction: We will ensure that the infant room maintains a strict staff-to-child ratio of 1:4. An additional two staff members have been assigned to the infant classroom to ensure appropriate coverage at all times. A floating staff schedule has also been implemented to provide immediate coverage in the event of staff absence or emergency. The director will conduct routine ratio checks throughout the day.
Standard 8VAC20-780-350-B-4
The staff-to-children ratio for children ages three years old to school age eligible is one staff for every ten children and are required whenever children are in care. The ratio for the pre-k room was one staff and thirteen children for approximately two hours.
Plan of Correction: To correct this violation, an additional staff member has been added to the pre-k classroom to meet the required ratio. Going forward, classroom assignments will be double checked each morning before children arrive to ensure proper staffing is in place. Daily attendance and staff placement will be monitored through our electronic system and verified by the director or assistant director. In the event of a staff absence, a designated floater or on-call staff will be deployed immediately.
Standard 8VAC20-780-500-A
Children's hands shall be washed with soap and running water or disposable wipes before and after eating meals or snacks. Four infant?s hands were not washed before eating.
Plan of Correction: A revised hand hygiene protocol has been implemented. All in room staff have been retrained on the requirement to wash and wipe each child's hands before and after every meal or snap. A visual step-by-step reminder is now posted near the feeding area. Staff will log hygiene tasks in a daily care sheet to assure accountabilityThe director or designated will randomly observe me times weekly to verify compliance and address any concerns promptly.
Standard 8VAC20-780-510-G
Medication shall be labeled with the child's name, the name of the medication, the dosage amount, and the time or times to be given. Prescriptive medications were observed loosely in the medication box that were not in the original container.
Plan of Correction: All medications were removed and returned to parents immediately with instructions to provide proper label medication in its original container as required by licensing regulations. The center medication policy has been updated to state that only properly labeled medications in their original containers will be accepted. A medication intake form will be implemented, requiring administrative verification prior to accepting medication into the facility. All staff will be retrained on medication storage and administration procedures with annual refreshers scheduled moving forward.
Standard 8VAC20-780-520-C
Diaper ointment or cream shall be labeled with the child's name. In the infant room, 7 tubes of diaper cream were unlabeled with no child?s name.
Plan of Correction: All unlabeled diaper creams were immediately removed from the infant room. Parents were notified to properly label diaper creams with their child's name before returning to the center. Diaper cream are not permitted back into the classroom unless clearly labeled as required by licensing standards. A new diaper cream in procedure was implemented with staff. Must verify label upon receipt of any diaper creak or ointment. A designated supply log is not maintained in the room with the staff signature verifying all diapers are labeled and checked weekly.
Standard 8VAC20-780-560-G
When food is brought from home, the food container shall be clearly dated and labeled in a way that identifies the owner. In the infant room refrigerator, there were 2 baby bottles with milk that had no names or dates to identify the owner.
Plan of Correction: All parents have been reinforced, baited by the requirement to label all bottles and food items with both the child's full name and date upon arrival. All reminder signs have been placed on a refrigerator door in the in room. Additionally, a designated staff member will be responsible each morning for checking all bottles upon arrival and labeling any missing information used and providing waterproof labels and markers.Any unlabeled bottles would be returned to the parent immediately before being a store. This policy was reviewed with the staff and parents and will be enforced daily without exceptions.
Standard 8VAC20-780-570-A
When a child is placed in an infant seat or high chair, the protective belt shall be fastened securely. In the infant room, 2 of 4 children at the infant feeding table did not have the protective belt fastened securely.
Plan of Correction: All staff working in the inform room have been retrained on the importance of securely fastened and protective belts. Anytime, a child is placed in a highchair or infancy. A laminated visual has been posted above the infant feeding area to reinforce this safety protocol. Daily safety checks will be conducted by the lead teacher and verified by the assistant director to ensure full compliance. Any staff who fails to follow this policy will receive a disciplinary action. We Are committed to maintaining the height of safety for all children..
Standard 8VAC20-780-60-A
REPEAT VIOLATION
Each center shall maintain and keep at the center a separate record for each child enrolled which shall contain all required information.
The record for child #1, child #4 and child # 6 did not have documentation of work information for both parents and child #2 did not have the work information for one parent.
The record for child #1 and child #5 did not have documentation of the contact information of two emergency contacts.
The record for child #3 did not have the first day of attendance documented.
Each center shall maintain and keep at the center a separate record for each child enrolled which shall contain all required information.
The record for child #1, child #4 and child # 6 did not have documentation of work information for both parents and child #2 did not have the work information for one parent.
The record for child #1 and child #5 did not have documentation of the contact information of two emergency contacts.
The record for child #3 did not have the first day of attendance documented.
Plan of Correction: All three children's files were reviewed and parents were contacted to submit all missing documentation. Monthly, child files audit will be conducted by the director to ensure compliance. Any missing items will be flagged and parents will be given no more than 48 hours to comply before exclusion.
Standard 8VAC20-780-70
Documentation of at least two references to character, reputation, and competency are to be checked prior to employment. Staff #3, staff #4, and staff #7 did not have completed reference verifications on file. The record for staff #5 only had one reference in their file.
Plan of Correction: All missing reference sheets for staff have been completed and added to their personnel files. A revised hiring checklist has been created to assure no staff may begin working without verified references. A second layer of review by the director or Assistant director is not required before finalizing anystaff on boarding. HR records will be out monthly for compliance.