Inspection · 2025-02-24
Licensing Inspector
D'Nae Goodwin
(757) 404-3063
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
20 Access to minor?s records
22.1 Early Childhood Care and Education
63.2 Child Abuse and 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 and completed on 2/24/25. The on-site inspection began at 12:30pm and ended at 2:30pm. The inspector reviewed compliance in the areas listed above. There were 12 children present and four staff. The inspector reviewed three children?s records and three staff records on-site. This inspection included document review, a 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 3/7/25. A POC submitted after this date will not appear on the public website.
Standard 22.1-289.011-F
The license and any other documents required by the Superintendent shall be posted in a conspicuous place on the licensed premises.
The results of the most recent inspection were not posted, which is required.
Plan of Correction: I will post inspection report as soon as received.
Standard 22.1-289.035-A
Centers are required to obtain a five-year repeat check for all required background checks.
The record for Staff #3 (employed for four years) did not contain a repeat criminal history search. Staff #3 was observed working on the day of the inspection.
Plan of Correction: Criminal history submitted and awaiting results. I will begin to do a monthly check of files to make sure we maintain compliance. I will make sure to add to my calendar a reminder to check monthly.
Standard 22.1-289.057-A
The program is required to submit to VDH and implement a plan to test potable water for lead. The program did not have evidence of a testing plan submitted to VDH and/or the program did not have evidence of the implementation of the required testing plan.
Plan of Correction: Center is working on plan now.
Standard 8VAC20-780-130-E
The center shall obtain documentation of additional immunizations once every six months for children under the age of two years.
The record for Child #2 (enrolled for two years) did not include documentation for additional immunizations for when the child was under the age of two.
Plan of Correction: I asked mom again for a copy of current immunizations. I will make sure to check all children's files monthly to make sure all records are up to date.
Standard 8VAC20-780-160-C
A tuberculosis (TB) screening is required every two years from the last screening.
The records for Staff #2 and Staff #3 (both employed for four years) did not contain a follow-up TB screening, which is required.
Plan of Correction: Staff have been given tb questionnaire to be filled out by doctor. I will make sure to check records monthly to make sure we have necessary testing done.
Standard 8VAC20-780-245-A
Staff shall complete annually a minimum of 16 hours of training appropriate to the age of children in care.
The records for Staff #1, Staff #2, and Staff #3 were missing documentation that 16 hours of training was completed in 2024.
Plan of Correction: All staff will be doing training in the upcoming month towards their yearly training amounts. I will begin to have staff complete monthly training to keep in compliance with training hours needed.
Standard 8VAC20-780-440-G
Cribs shall be used for children under 12 months of age. There was one child in an infant room over the age of 12 months that has a crib designated for sleeping.
Plan of Correction: I will make sure that there will be at least two cots available for children over 1. I will also make sure that staff know any child over 12 months needs a cot.
Standard 8VAC20-780-550-F
Lockdown procedures shall be practiced at least annually.
There was no documentation to show that the center completed a lockdown drill in 2024.
Plan of Correction: I reprinted lockdown procedures and printed out new drill log so all can be documented on the same form.
Standard 8VAC20-780-60-A
Repeat Violation
Each center shall maintain and keep at the center a separate record for each child enrolled that contains all the required information.
The record for Child #1 was missing documentation of viewing proof of the child's identity and age, the child?s first day of attendance, and the work phone number of one parent.
Plan of Correction: I obtained birth letter from dad. I also got dad to fill in phone information. As stated earlier I will start doing a monthly file check, so I do not get behind and all records kept up to date. I will also be sure to verify paperwork filled out completely on day of enrollment.
Standard 8VAC20-780-70
Staff records shall be kept for each staff person and contain all required information.
The records for Staff #1, Staff #2, and Staff #3 did not include documentation of name, address, and verification of age requirement.
Plan of Correction: I obtained a copy of each staff members driver's license or identification. I will make sure that I get a copy of identification upon receiving application for employment.