Inspection · 2025-01-14
Date
2025-01-14
Complaint Related
No
Licensing Inspector
Heather Harrell
(757) 334-4329
(757) 334-4329
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
8VAC20-770 Background Checks
8VAC20-790 Introduction
8VAC20-790 Administration
8VAC20-790 Physical Plant
8VAC20-790 Staff Qualifications & Training
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
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 with applicable standards or law, and violations were documented on the violation notice issued to the facility.
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 2/13/25. A POC submitted after this date will not appear on the public website.
Violations
27Standard 22.1-289.035-A
The center is required to have employees undergo a background check every 5 years.
The sworn statement or affirmation for staff 4 is overdue by 2 years and 2 months. There is no updated national criminal background check result in the record for staff 4.
The national criminal background check for staff 5 is overdue by 1 year and 5 months.
The sworn statement or affirmation for staff 4 is overdue by 2 years and 2 months. There is no updated national criminal background check result in the record for staff 4.
The national criminal background check for staff 5 is overdue by 1 year and 5 months.
Plan of Correction: The vendor responded with the following: The center will implement an automated notification system for background check renewals, ensuring compliance with the 5-year requirement. Updated results will be recorded in employee files and tracked in the compliance log.
Staff 4: completed results have been placed in their employee file.
Staff 5: scheduled to complete on 2/13/2025.
Staff 4: completed results have been placed in their employee file.
Staff 5: scheduled to complete on 2/13/2025.
Standard 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 sworn statement for Staff 3 is dated four months after their first day of employment.
The sworn statement for Staff 3 is dated four months after their first day of employment.
Plan of Correction: The vendor responded with the following: The center will ensure all staff records are reviewed and up to date. The center has implemented a new hiring protocol that includes mandatory review of all employee files to ensure that all required documents have been completed. The center will also check staff files every three months to ensure no required updates are needed and or missing.
The sworn statement for Staff 3 was placed in her employee file on 1/15/2025. Staff 3 previously completed before her first day however, this was not placed in her employee file.
The sworn statement for Staff 3 was placed in her employee file on 1/15/2025. Staff 3 previously completed before her first day however, this was not placed in her employee file.
Standard 22.1-289.035-B-2
The center must obtain a completed national criminal background check prior to the employee's first day of employment.
The record for staff 3, who has been employed for 11 months and has been working alone with children, does not contain documentation of a completed national criminal background check.
The record for staff 3, who has been employed for 11 months and has been working alone with children, does not contain documentation of a completed national criminal background check.
Plan of Correction: The vendor responded with the following: The center will ensure all staff records are reviewed and up to date. The center has implemented a new hiring protocol that includes a mandatory review of all employee files to ensure that all required documents have been completed and are placed in the employee file. Staff 3's background check was completed before the inspection, however, was never placed in her file. The background check was placed in Staff 3's file on 1/14/2025.
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.
The record for staff 1, who has been employed for four months, does not contain a central registry search result. Staff 1 was working alone with children.
The record for staff 1, who has been employed for four months, does not contain a central registry search result. Staff 1 was working alone with children.
Plan of Correction: The vendor responded with the following: The center will ensure all staff records are up to date. Staff 1 Central Registry has been resent. The center will also continue to follow up with OBI as it has done in the past to get updates on the central registry search. Last contact was made on 2/9/25.
Standard 8VAC20-790-520-C
The center shall not exceed the capacity of children cared for as allowed by law or regulation.
The Certificate of Occupancy issued by the local zoning authority allows for no more than 5 children under the age of 2 1/2 years to be in care at any one time. There were 9 children under the age of 2 1/2 years in care during the inspection.
The Certificate of Occupancy issued by the local zoning authority allows for no more than 5 children under the age of 2 1/2 years to be in care at any one time. There were 9 children under the age of 2 1/2 years in care during the inspection.
Plan of Correction: The vendor responded with the following: The center promptly informed parents about the policy and its importance for the safety and well-being of their children, especially by limiting the number of children under 2 1/2 years old. Staggered
half-day drop-offs were implemented, and a staff meeting emphasized the need for compliance with regulations. The center will also stablish a tracking system to monitor the number of children in each age group, featuring daily headcounts and regular internal audits to ensure capacity limits are maintained.
half-day drop-offs were implemented, and a staff meeting emphasized the need for compliance with regulations. The center will also stablish a tracking system to monitor the number of children in each age group, featuring daily headcounts and regular internal audits to ensure capacity limits are maintained.
Standard 8VAC20-790-520-F
The vendor shall maintain a current written list of all children's allergies, sensitivities and dietary restrictions.
The most recent written children's allergies, sensitivities and dietary restrictions list was dated 6/13/23.
The most recent written children's allergies, sensitivities and dietary restrictions list was dated 6/13/23.
Plan of Correction: The vendor responded with the following: The center will review the current medical records and parental communication logs to identify any changes or new allergies,
sensitivities, or dietary restrictions for each child. An updated allergy list was posted in each classroom effective January 15, 2025.
sensitivities, or dietary restrictions for each child. An updated allergy list was posted in each classroom effective January 15, 2025.
Standard 8VAC20-790-530-B
For each grouping 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.
There was no written attendance record of the children in care for 1/14/25.
There was no written attendance record of the children in care for 1/14/25.
Plan of Correction: The vendor responded with the following: Staff have been reminded to document attendance for each child during arrival and departure, and attendance procedures have been reviewed to ensure clarity and compliance. For the missing records from 1/14/25, we have corrected.
Standard 8VAC20-790-540-B
Children's records should include all the required elements.
The record for child 1, enrolled for over two years, does not contain the name, address and telephone number of at least one emergency contact person.
The record for child 2, enrolled for three months, does not contain the name, home address and telephone number for one parent or the employment information for either parent.
The record for child 3, enrolled for eleven months, does not contain the employment information for one parent.
The record for child 4, enrolled for over three months, does not contain the name, home address, telephone number or employment information for one parent or the work number for the other parent.
The record for child 1, enrolled for over two years, does not contain the name, address and telephone number of at least one emergency contact person.
The record for child 2, enrolled for three months, does not contain the name, home address and telephone number for one parent or the employment information for either parent.
The record for child 3, enrolled for eleven months, does not contain the employment information for one parent.
The record for child 4, enrolled for over three months, does not contain the name, home address, telephone number or employment information for one parent or the work number for the other parent.
Plan of Correction: The vendor responded with the following: The center will ensure all records are updated ensuring all forms are filled out completely. The center will also ensure a mandatory review of all children's files are checked prior to enrollment and every 3-6 months thereafter.
Standard 8VAC20-790-550-1
Staff records shall contain the date of employment.
The record for staff 1 does not contain the date of employment.
The record for staff 1 does not contain the date of employment.
Plan of Correction: The vendor responded with the following: The center will ensure all staff records are up to date. The center has implemented a hiring protocol that includes a mandatory review of all employee files to ensure that all required documents have been completed.
Standard 8VAC20-790-560-A
Staff shall be evaluated by a health professional and be issued a statement that the individual is determined to be free of communicable tuberculosis (TB). Documentation of the screening shall be submitted at the time of employment and prior to coming into contact with children. The documentation shall have been completed within the last 30 calendar days of the date of employment and be signed by a physician, physician's designee, or an official of the local health department.
There was no TB screening on file for staff 2, who has been employed and working with children for over one week.
The TB screening for staff 3 was completed 21 days after their first day of employment.
There was no TB screening on file for staff 2, who has been employed and working with children for over one week.
The TB screening for staff 3 was completed 21 days after their first day of employment.
Plan of Correction: The vendor responded with the following: The center will ensure all staff have completed their TB and Health Statements prior to starting.
Standard 8VAC20-790-560-B
Subsequent TB screenings are required at least every two years from the date of the initial screening.
An updated TB screening for staff 4 was not completed and was overdue by two years and three months.
An updated TB screening for staff 4 was not completed and was overdue by two years and three months.
Plan of Correction: The vendor responded with the following: The center will ensure all staff files remain up to date. The center will implement an automated notification system for TB renewals, ensuring compliance with the 2 year requirement. Updated results will be recorded in employee files and tracked in the compliance log.
Standard 8VAC20-790-580-B
Documentation of additional immunizations shall be obtained once every six months for children less than two years of age.
An updated immunization record for child 5, under 2 years of age, is overdue by two months.
An updated immunization record for child 5, under 2 years of age, is overdue by two months.
Plan of Correction: The vendor responded with the following: The center will ensure all children have updated immunizations on file.
Standard 8VAC20-790-600-D-1
All staff who work directly with children shall have current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care. The training shall include an in-person competency demonstration.
Staff 3's CPR certification training does not include an in-person competency demonstration.
The records for staff 5 and staff 6 do not contain documentation of current CPR certification.
Staff 3's CPR certification training does not include an in-person competency demonstration.
The records for staff 5 and staff 6 do not contain documentation of current CPR certification.
Plan of Correction: The vendor responded with the following: The center will ensure all staff working with children have completed CPR/First Aid, including the in-person hands-on training.
Standard 8VAC20-790-600-D-2
All staff who work directly with children shall have current certification in first aid appropriate to the ages of children in care.
The records for staff 3, staff 5 and staff 6 do not contain documentation of current certification in first aid.
The records for staff 3, staff 5 and staff 6 do not contain documentation of current certification in first aid.
Plan of Correction: The vendor responded with the following: The center will ensure all staff working with children have completed CPR/First Aid before starting.
Standard 8VAC20-790-600-F
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.
Staff 3 has completed only 3 of the required 16 hours of annual training for 2024.
Staff 5 has completed only 9 of the required 16 hours of annual training for 2024.
There is no documentation that staff 6 has completed the annual subsidy health and safety update course for 2024.
Staff 3 has completed only 3 of the required 16 hours of annual training for 2024.
Staff 5 has completed only 9 of the required 16 hours of annual training for 2024.
There is no documentation that staff 6 has completed the annual subsidy health and safety update course for 2024.
Plan of Correction: The vendor responded with the following: The center will ensure all staff have completed 16 hours of training and staff development. Staff 3, the required hours were previously completed and have been added to their employee file.
Staff 5, the required hours were previously completed and have been added to their employee file.
Staff 6 health and safety training was previously completed and have been added to their employee file.
Staff 5, the required hours were previously completed and have been added to their employee file.
Staff 6 health and safety training was previously completed and have been added to their employee file.
Standard 8VAC20-790-600-I
There shall be at least one staff on duty who has obtained within the last three years instruction in performing a daily health observation of children.
The record provided for all current staff did not include documentation that any of the staff have obtained instruction in performing daily health observation of children.
The record provided for all current staff did not include documentation that any of the staff have obtained instruction in performing daily health observation of children.
Plan of Correction: The vendor responded with the following: The center will ensure at least one member of staff on duty has completed daily health observation. The center has implemented this training for all staff.
Standard 8VAC20-790-630-A
Areas and equipment of the center shall be maintained in a safe condition.
There is a 3 foot high shelf in the toddler room that is unsecured and unstable. The shelf has numerous items and equipment, including a lamp, DVD player and scissors, sitting on top. The shelf sways from side to side when touched, creating a toppling hazard to children in care.
There is a 3 foot high shelf in the toddler room that is unsecured and unstable. The shelf has numerous items and equipment, including a lamp, DVD player and scissors, sitting on top. The shelf sways from side to side when touched, creating a toppling hazard to children in care.
Plan of Correction: The vendor responded with the following: The center will ensure all furniture is safe and securely bolted to the wall if necessary. The shelf has been removed from the classroom, effective same day.
Standard 8VAC20-790-630-C-2
Electrical outlets shall have protective covers that are of a size that cannot be swallowed by children.
There were numerous uncovered electrical outlets in the large multi-purpose room, accessible to children in care, that lacked protective covers.
There were numerous uncovered electrical outlets in the large multi-purpose room, accessible to children in care, that lacked protective covers.
Plan of Correction: The vendor responded with the following: The center will ensure all outlets are covered at all times. In the event one is missing, all staff have been given a maintenance sheet to fill out.
Standard 8VAC20-790-640-A
Hazardous substances such as cleaning materials shall be kept in a locked place using a safe locking method that prevents access by children.
There was an unlocked spray bottle of bleach water next to the sink in the infant classroom. A spray bottle of bleach water, a can of Raid, a spray bottle of Windex, a mold and mildew with bleach spray and a pet odor and stain eliminator spray was also found in an unlocked cabinet below the bathroom sink in the preschool classroom.
There was an unlocked spray bottle of bleach water next to the sink in the infant classroom. A spray bottle of bleach water, a can of Raid, a spray bottle of Windex, a mold and mildew with bleach spray and a pet odor and stain eliminator spray was also found in an unlocked cabinet below the bathroom sink in the preschool classroom.
Plan of Correction: The vendor responded with the following: The center will ensure all hazardous substances are safe and securely locked away. A lock has been placed on the cabinet. The center will only keep bleach/water and soap/water in the classroom. All other substances have been removed. A staff meeting was held on 1/17/2025 where all staff were made aware of the policies, procedures, and standards of hazardous substances.
Standard 8VAC20-790-670-C-1
Facilities operated by, or under the auspices of, a religious institution and exempt from license shall ensure the following ratio requirements are maintained:
1. One staff member to 4 children from ages zero to 16 months;
2. One staff member to 5 children from ages 16 months to 24 months;
3. One staff member to 8 children from ages 24 months to 36 months;
4. One staff member to 10 children from ages 36 months to 5 years.
When a group of children receiving care includes children from different age brackets, the age of the youngest child in the group shall be used to determine the staff-to-children ratio that applies to that group.
Upon the licensing inspectors arrival to the center at 9:25am, staff 3 and staff 5 were observed supervising 14 children, ages 7 months - 4 years, in the multi-purpose room. The number and ages of the children required 4 staff to be present. A third staff person arrived to the center at 10:05am and a fourth staff person arrived at 10:40am.
1. One staff member to 4 children from ages zero to 16 months;
2. One staff member to 5 children from ages 16 months to 24 months;
3. One staff member to 8 children from ages 24 months to 36 months;
4. One staff member to 10 children from ages 36 months to 5 years.
When a group of children receiving care includes children from different age brackets, the age of the youngest child in the group shall be used to determine the staff-to-children ratio that applies to that group.
Upon the licensing inspectors arrival to the center at 9:25am, staff 3 and staff 5 were observed supervising 14 children, ages 7 months - 4 years, in the multi-purpose room. The number and ages of the children required 4 staff to be present. A third staff person arrived to the center at 10:05am and a fourth staff person arrived at 10:40am.
Plan of Correction: The vendor responded with the following: A staff meeting was conducted to emphasize the importance of maintaining appropriate staff-to-child ratios, especially during transitions and when mixing age groups. The meeting included a review of licensing standards and the procedures for notifying parents when children cannot be accepted due to low staffing. The center has also revamped its staff scheduling system to handle unexpected changes in availability and attendance. Additionally, a new manual system for monitoring and documenting staff-to--child ratios has been implemented by all staff throughout the day. Staff training was completed on the day of the violation. The new staff scheduling and arrival procedures were put in place starting January 16, 2025. The new ratio monitoring system was implemented and fully operational on January 21, 2025.
Standard 8VAC20-790-710-1
The following actions or threats thereof are forbidden: roughly handling a child.
On 1/14/25, the licensing inspector observed staff 1 lift child 6 off the floor by the upper arm to have the child stand up. Staff 1 walked the child across the room holding their upper arm and sat the child down in a chair. Child 6's feet lifted up off the floor twice, once as staff 1 lifted the child off of the floor by the arm and a second time as staff 1 walked the child across the room while holding their arm.
On 1/14/25, the licensing inspector observed staff 1 lift child 6 off the floor by the upper arm to have the child stand up. Staff 1 walked the child across the room holding their upper arm and sat the child down in a chair. Child 6's feet lifted up off the floor twice, once as staff 1 lifted the child off of the floor by the arm and a second time as staff 1 walked the child across the room while holding their arm.
Plan of Correction: The vendor responded with the following: Staff 1 received coaching and was required to complete additional training hours on Guiding Big Emotions and Self-Regulation for Adults and Children and Guiding Behavior. Staff 1 will also receive one-on-one coaching and guidance on appropriate methods for interacting with children. She has been placed on A 90-day probation to ensure that the corrected behaviors are being practiced. The center notified the parent/guardian of child 6 the same day about the incident and the corrective measures being taken to prevent future occurrences.
Standard 8VAC20-790-760-B-3-c
A nonabsorbent surface for diapering or changing shall by used.
The diaper changing pad in the infant classroom had two tears on the surface of the pad.
The diaper changing pad in the infant classroom had two tears on the surface of the pad.
Plan of Correction: The vendor responded with the following: The center will ensure a nonabsorbent surface for diapering or changing is used at all times. The center has removed the old one and replaced it with a new one.
Standard 8VAC20-790-770-B-2
The vendor may administer over-the-counter or nonprescription medication to a child with written permission from the parent, provided the medication is labeled with the child's name.
There were two over-the-counter medications for child 7 in the infant room that were not labeled with the child's name.
There were two over-the-counter medications for child 7 in the infant room that were not labeled with the child's name.
Plan of Correction: The vendor responded with the following: The center will ensure all over-the- counter medication or nonprescription medication is labeled. The center will also ensure that written permission from the parent is on file. The medication was sent home.
Standard 8VAC20-790-770-D
Medication shall be kept in a locked place using a safe locking method that prevents access by children.
There were two over-the-counter medications in an open plastic basket sitting on a counter in the infant room.
There were two over-the-counter medications in an open plastic basket sitting on a counter in the infant room.
Plan of Correction: The vendor responded with the following: The center will ensure all medication is kept locked.
Standard 8VAC20-790-780-C-2
One working, battery-operated radio is required.
The center had no batteries for the battery-operated radio.
The center had no batteries for the battery-operated radio.
Plan of Correction: The vendor responded with the following: The center will ensure they have a battery-operated radio and batteries all times and that all staff are aware of the location.
Standard 8VAC20-790-800-B
The vendor shall maintain a record of the dates of the practice drills for one year.
The emergency drill log for the facility lacked documentation of the two required shelter-in-place practice drills and the one required lockdown drill for 2024.
The emergency drill log for the facility lacked documentation of the two required shelter-in-place practice drills and the one required lockdown drill for 2024.
Plan of Correction: The vendor responded with the following: The center will ensure records for practice drills have been updated. A shelter-in-place drill was completed on January 21, 2025.
Standard 8VAC20-790-810-C-1
When food is brought from home, the food container shall be clearly labeled in a way that identifies the owner.
There was a can of powdered baby formula for child 7 that was not labeled with the child's name.
There was a can of powdered baby formula for child 7 that was not labeled with the child's name.
Plan of Correction: The vendor responded with the following: The center will ensure all children's items are labeled. The center will also ensure staff are labeling items as they come in.