Inspection · 2025-05-28
Licensing Inspector
Michelle Argenbright
(540) 848-4123
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.
8VAC20-820 HEARINGS PROCEDURES.
8VAC20-770 Background Checks
20 Access to minor?s records
22.1 Background Checks Code, Carbon Monoxide
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 May 28, 2025 and completed on May 28, 2025. The on-site inspection began at 10:30 a.m. and ended at 1:25 p.m. The inspector reviewed compliance in the areas listed above. There were 82 children present and 15 staff. The inspector reviewed eight children?s records and eight staff records on-site. This inspection included tour of facility, record review, observations, and interviews.
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 business days from today, which will be the close of business on June 9, 2025. A POC submitted after this date will not appear on the public website.
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 center did not have a sworn statement for Staff #2, who is currently working.
Plan of Correction: This individual is a volunteer used in ratio. Volunteers will no longer be utilized as "Willow Tree staff member." They will simply be utilized as a volunteer, as an extra set of hands to help where needed.
Standard 22.1-289.035-B-4
The center is required to obtain background checks from any state in which the individual has resided in the preceding five years. Staff #2, employed for one months, did not have documentation of a search of the sex offender registry search from a different state.
Plan of Correction: The administrator has learned how to obtain the correct documentation for out of state background checks; and the staff who was missing their background, we have now completed the correct documentation.
Standard 8VAC20-780-240-B
Staff shall complete orientation training in subsection C of this section prior to the staff member working alone with children and no later than seven days of the date of assuming job responsibilities. The staff record did not contain documentation of staff 2 completing orientation training. The administrator verified staff 2 did not complete orientation. Staff 2 has been working with children at the facility for one month.
Plan of Correction: This individual is a volunteer used in ratio. Volunteers will no longer be utilized as "Willow Tree staff member." They will simply be utilized as a volunteer, as an extra set of hands to help where needed.
Standard 8VAC20-780-280-B
REPEAT VIOLATION/SYSTEMIC DEFICIENCY Hazardous substances such as cleaning materials, insecticides, and pesticides shall be kept in a locked place using a safe locking method that prevents access by children.
Gallons of paint, Zep glass cleaner, Pledge, Murphy Oil and other hazardous substances were on the floor and shelves in the hall closet. The closet was unlocked.
Plan of Correction: Owner replaced the door handle that can now only be used with a key; only select staff have access to this key. This will maintain that this closet is kept always locked.
Standard 8VAC20-780-70
Staff records shall be kept for each staff person and contain documentation that two or more references as to character and reputation as well as competency were checked before employment or volunteering. The record for staff 2, who has worked at the facility one month, did not have references.
Plan of Correction: This individual is a volunteer used in ratio. Volunteers will no longer be utilized as "Willow Tree staff member." They will simply be utilized as a volunteer, as an extra set of hands to help where needed.