Inspection · 2025-09-16
(804) 629-8302
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
8VAC20-780 Special Services.
8VAC20-820 THE LICENSE.
8VAC20-820 THE LICENSING PROCESS.
8VAC20-820 HEARINGS PROCEDURES.
8VAC20-770 Background Checks
20 Access to minor?s records
22.1 Early Childhood Care and Education
63.2 Child Abuse & Neglect
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 monitoring inspection was initiated on 9/16/25 and completed on 9/16/25. The on-site inspection began at 10:25 a.m. and ended at 12:50 p.m. The inspector reviewed compliance in the areas listed above. There were 36 children present and nine staff. The inspector reviewed five children?s records and five 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 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 10/2/25. A POC submitted after this date will not appear on the public website.
Violations
6Evidence: The record for Staff #4 did not contain documentation of a repeat central registry background check. The background check expired one year ago.
background check. Documentation will be maintained in the staff record. To prevent recurrence, as directors, we will implement a tracking system to monitor the expiration of all staff background checks. Staff files will be reviewed quarterly
to ensure compliance with the
5-year renewal requirement.
Evidence: The record for Staff #1 did not contain the results of an out-of-state central registry background check, out-of-state criminal record check, and out-of-state sex offender registry search. The out-of-state background checks were overdue by two years.
1. Immediate Correction:
? The center has reviewed all current staff files to identify any missing out-of-state background check documentation.
? Any incomplete files are being updated immediately, and the necessary background checks have been requested from the appropriate state agencies. Documentation of requests will be maintained in each staff file until results are received.
Evidence: The record for Staff #2, Staff #4, and Staff #5 did not contain documentation of a repeat tuberculosis screening every two years. The records for Staff #2 had a tuberculosis screening that expired for one year before obtaining a new screening, Staff #4 had a tuberculosis screening that expired for nine months before obtaining a new screening, and Staff #5 had a tuberculosis screening that expired 14 months ago.
? Staff with outdated screenings have been notified and scheduled to obtain updated TB results. Documentation will be placed in personnel files once received.
? A tracking system has been created to log TB screening dates and automatically flag staff due for renewal at least 30 days in advance.
? Staff will not be permitted to continue working past their TB expiration date without current documentation on file.
Evidence:
1. In the Noah?s Ark room, ages 6 weeks to 16 months-old, a mini fridge with a box fan sitting on top of it was observed. Upon further inspection it was discovered that the mini fridge was missing one of the leveling feet causing it to be unstable and posing an entrapment hazard.
2. In the Gift of the Spirit room, ages 16 months to two-years-old, children were observed playing on a carpet that had several large wrinkles, posing a trip hazard.
? In the Gift of the Spirit room, the carpet with large wrinkles has been removed/re-secured to eliminate trip hazards before children re-entered the space.
? A monthly classroom safety inspection checklist has been implemented to identify and correct hazards promptly.
? Any equipment found to be damaged or unstable will be immediately repaired or replaced before being used around children.
? The director will conduct weekly walkthroughs of all classrooms to ensure safe and operable conditions are consistently maintained.
When staff are supervising children, they shall always ensure their care, protection, and guidance.
Evidence: In the infant room, Child #1, six-months-old, was observed sleeping in a crib with loose fitting sheets.
For each group of children, the center shall maintain a written record of attendance that documents the arrival and departure of each child in care as it occurs.
Evidence: In the Songbirds class, ages three and four-years-old, seven children were present, the written record reflected there were eight
? Teachers have been instructed to complete the attendance record at the time each child arrives and again at departure.
The Songbirds class attendance record has been corrected to reflect the accurate number of children present.
? Staff were immediately reminded that attendance must be updated in real time as children arrive and depart.
? Teachers will take attendance at arrival, after transitions (e.g., playground, lunch, nap), and at departure to ensure accuracy throughout the day.
? A second staff member in each classroom will verify the attendance count at least twice daily.
? Staff have been retrained on the importance of accurate documentation and the safety risks associated with inaccurate attendance records.
? The director or designee will review attendance sheets daily to ensure accuracy and compliance.