Inspection · 2025-06-17
Licensing Inspector
Susan Ellington-Sconiers
(804) 588-2368
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.
8VAC20-780 Special Services.
8VAC20-820 THE LICENSE.
8VAC20-820 THE LICENSING PROCESS.
8VAC20-770 Background Checks (8VAC20-770)
20 Access to minors records
22.1 Background Checks Code, Carbon Monoxide
22.1 Early Childhood Care and Education
Inspector Notes
An unannounced, on-site renewal inspection was completed on 06/17/2025. The on-site inspection began at 10:12 a.m. and ended at 4:30 p.m. The inspector reviewed compliance in the areas listed above. There were 100 children present and 22 staff. The inspector reviewed 10 children?s records and 10 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 06/27/2025. A POC submitted after this date will not appear on the public website.
Standard 8VAC20-780-140-A
Physical examinations completed by a physician shall be obtained prior to the first day of attendance or within 30 days after the first day of attendance. The physical examination for C7 was not conducted within the required timeframe. The examination was four days out of compliance with enrollment date.
Plan of Correction: Moving forward, the enrollment checklist has been updated to include a verification step for tracking the 30-day deadline. Administrative staff will conduct weekly audits of new enrollments to ensure all required documentation is submitted within the required period.
Standard 8VAC20-780-160-C
Repeat violation
A tuberculosis (TB) screening is required every two years from the last screening. S7 updated screening was completed 40 days late.
Plan of Correction: The updated TB screening for S7 has now been completed and is on file. To prevent future occurrences, an electronic tracking system has been implemented to monitor TB screening due dates for all staff. Notifications will be sent to staff and supervisors 60 days, 30 days, and one week before the due date to ensure timely compliance.
Standard 8VAC20-780-240-D
Prior to working alone and within seven days of the first day of employment, staff shall be provided in writing with the center?s information listed in 8VAC20-780-420-A. The staff records for S1and S4 did not contain page 3 of the orientation form that documents staff training regarding written Parent Policies
Plan of Correction: To prevent future occurrences, administration will implement a checklist to ensure all pages of the orientation from are completed and filed within the first seven days of employment. The checklist will be reviewed and signed by both the new staff member and a supervisor upon completion.
Standard 8VAC20-780-420-E-3
Staff shall request at least annually parent confirmation that the required information in the
child's record is up to date. The information in the record of C9 had not been updated since 04/2024.
Plan of Correction: To ensure ongoing compliance, a tracking system has been implemented to monitor annual update due dates, and reminders will be sent to families 30 days prior to the anniversary of enrollment.
Standard 8VAC20-780-450-A
Cots used by children shall have linens consisting of a top cover and bottom cover. A child was observed sleeping on a cot in the Pre-School 1 classroom without a bottom cover.
Plan of Correction: All classroom staff have been reminded of the requirement that each cot must have both a top and bottom cover. Moving forward, classroom teachers will complete a daily nap-time checklist to ensure all children have the required linens before rest time begins.
Standard 8VAC20-780-70
Staff records shall include information about any health problems that may interfere with staff fulfilling the job responsibilities. The staff records for S1, S2, S3, S4, S5, S6, S7, S8, S9 and S10 did not include this information.
Plan of Correction: Moving forward, the staff hiring and onboarding checklist has been updated to ensure this documentation is obtained and filed during the initial orientation process. Administrative staff will audit new hire files within the first week of employment to verify compliance.