Inspection · 2025-05-21
Licensing Inspector
Anita Drewry
(757) 404-5261
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.
8VAC20-770 BACKGROUND CHECKS
8VAC20-820 THE LICENSE.
22.1 BACKGROUND CHECKS CODE; CARBON MONOXIDE
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 May 21, 2025 and completed on May 23, 2025. The on-site inspection began at 1:45 pm and ended at 3:05 pm. The inspector reviewed compliance in the areas listed above. There were 17 children present and 2 staff at the onset of inspection. The inspector reviewed 5 children?s records and 5 staff records electronically on May 22, 2025 and May 23, 2025. This inspection included document review, 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
6/4/2025. A POC submitted after this date will not appear on the public website.
Standard 22.1-289.035-B-3
(Repeat Violation) The center must request a search of the central registry prior to the employee's first day of employment. Staff #1, who had been employed for three months, and Staff #4, who had been employed for a year, did not have a central registry search. Staff #1 and Staff #4 were working alone with children.
Plan of Correction: Director will review all forms and it's appropriate timing for licensing guidelines.
Standard 22.1-289.057-B
The program is required to submit results of potable water testing to VDH. The program did not have evidence of submitting test results to VDH.
Plan of Correction: Director has submitted a copy to said party but was unable to retrieve through email.
Standard 8VAC20-780-160-A
(Repeat Violation) Each staff member shall submit documentation of a negative tuberculosis screening at the time of employment and shall have been completed within the last 30 calendars days of the date of employment. The screening for Staff #1, employed for three months, did not have documentation of negative results. The screening for Staff #2, employed for four months, was completed eleven months prior to beginning employment. The record for Staff #4, employed for a year, was completed nine months prior to beginning employment. The record for Staff #5, employed for two years, did not have a negative tuberculosis screening.
Plan of Correction: Director will make sure that TB results are given within the licensing guidelines of 30 days of the date of employment to secure safety protocol.
Standard 8VAC20-780-240-B
Staff shall complete orientation training prior to the staff member working alone with children and no later than seven days after the date of assuming job responsibilities. The record for Staff #2 had documentation of orientation training completed one month after beginning employment.
Plan of Correction: Director will make sure that proper training are completed within licensing guidelines within 7 days of assuming responsibilities.
Standard 8VAC20-780-340-F
Children under 10 years of age shall always be within actual sight and sound supervision of staff. During the inspection, three classrooms were observed at times with no staff supervision. Staff #4 was observed walking back and forth between the classrooms to check on the children. Children were not in sight supervision of staff for approximately 2 - 4 minutes while the staff member was in a different room. Children ranged in age from infants through preschool age.
Plan of Correction: Director will make sure that all supervision requirements are met due to licensing guidelines for sight and sound.
Standard 8VAC20-780-440-L
Filled comforters shall not be used by children under two years of age. Child #1, age 10 months, was observed sleeping in a crib with a filled comforter.
Plan of Correction: Director has already removed comforter and alerted parents as well.
Standard 8VAC20-780-500-B
The diapering surface shall be a nonabsorbent surface. Staff were observed in the infant room and toddler room changing children's diapers. The children were changed on a cloth pad that was absorbent.
Plan of Correction: Director has already removed item.
Standard 8VAC20-780-550-E
Shelter in place procedures shall be practiced a minimum of twice per year. There was not documentation of shelter in place drills completed in 2024.
Plan of Correction: Director will practice shelter procedures guidelines twice a year.
Standard 8VAC20-780-550-F
Lockdown procedures shall be practiced at least annually. There was not documentation of a lockdown drill completed in 2024.
Plan of Correction: Director will adhere to all lockdown procedures and review annually.
Standard 8VAC20-780-60-A
Each center shall maintain and keep at the center a separate record for each child enrolled that contains all of the required information. The record for Child #1, present during inspection, was missing the first date of attendance, physician name and physician phone number. The record for Child #2, enrolled for 11 months, was missing results of a physical examination. The record for Child #5, enrolled for a month, was missing the address for the second emergency contact.
Plan of Correction: Director will carefully review all vital documents to comply with licensing rules and guidelines.
Standard 8VAC20-780-70
Staff records shall be kept for each staff person and contain all required information. The record for Staff #1, employed for three months, was missing verification of age requirement, emergency contact information and documentation to demonstrate the individual possesses the education required by the job position. The record for Staff #2, employed for four months, was missing job title, verification of age requirement and documentation to demonstrate the individual possesses the education and training required by the job position. The record for Staff #3, employed for two months, was missing verification of age requirement, emergency contact information and documentation to demonstrate the individual possesses the education and training required by the job position. The record for Staff #4, employed for one year, was missing verification of age requirement and documentation to demonstrate the individual possesses the education and training required by the job position. The record for Staff #5, employed for two years, was missing verification of age requirement, emergency contact information and documentation to demonstrate the individual possesses the education required by the job position
Plan of Correction: Director will thoroughly review all items required by licensing guidelines to ensure that qualifications are met to fulfill his/her position with proper documentation.