Inspection · 2025-03-05
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 monitoring inspection was completed on 03/05/2025. The on-site inspection began at 12:00 p.m. and ended at 5:30 p.m. The inspector reviewed compliance in the areas listed above. There were 42 children present and 13 staff. The inspector reviewed 7 children?s records and 6 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 03/21/2025. A POC submitted after this date will not appear on the public website.
Standard 22.1-289.035-B-2
Providers must obtain a completed national criminal background check prior to the employee's first day of employment. S5, who had been employed for 13 days, did not have a completed national criminal background check.
Plan of Correction: New staff will not be allowed to start trainings at home before the background check has been received. as this is considered "employed"
Standard 8VAC20-780-150-B
Immunization records are required to be signed and dated by a physician, his designee, or an official of the local health department. The immunization record for C2 was not dated.
Plan of Correction: C2's immunization record was sent home for parent to have date added by physician. Record has been dated and returned.
Standard 8VAC20-780-160-A
Repeat Violation
Documentation of a negative tuberculosis (TB) screening must be submitted at the time of employment, before coming into contact with children, and shall have been completed within the last 30 days of the date of employment. S1 had been employed for 34 days.
Plan of Correction: S1 was employed and working through online trainings, but was not in contact with children. Orientation process has been updated to require the TB test to be submitted within 30 days Of employment.
Standard 8VAC20-780-240-C
Staff orientation shall include all required facility specific topics. Orientation documentation for S2 and S5 did not include training regarding prevention of sudden infant death syndrome, use of safe sleep practice, prevention of shaken baby syndrome, and abusive head trauma.
Plan of Correction: S2 and SS have received sudden infant death syndrome, use of safe sleep practice, prevention of shaken baby syndrome. and abusive head trauma training on 3/21/2025
This training has been added to our staff process as well.
Standard 8VAC20-780-240-E
Repeat Violation
Staff are to complete within 30 days of the first date of employment orientation training in first aid and cardiopulmonary resuscitation (CPR). S2 employed for seven months has not completed this orientation.
Plan of Correction: The staff orientation process has been updated to included an ?initial? first aid and CPR orientation on tho first day of employment. Also. all new staff will be required to complete first aid and CPR training within 30 days of employment.
S2 has been scheduled to take first aid and CPR training on 4/12/2025
Standard 8VAC20-780-550-D
8VAC20-780-550.D
The center shall implement a monthly practice evacuation drill. Drills were not conducted in April 2024 and October 2024.
Plan of Correction: The Program Manager has added monthly appointments on her digital calendar to remind them of each months drills.
Standard 8VAC20-780-550-P
The center shall maintain written records of children?s injuries that contains all of the required information. Injury reports dated 09/16/2024, 09/26/2024, 10/01/2024, 12/11/2024, and 03/04/2025 did not document the time of parental notification of the injury. Injury reports dated 09/13/2024, 10/01/2024, 11/14/2024, 12/11/2024, and 02/04/2025 did not document any future action to prevent recurrence of the injury.
Plan of Correction: Staff have been retrained in the documentation of injury reports to include documenting the time the parent is notified on the injury report. Staff created a spreadsheet to help analyze patterns of injuries. The Program Manager, Curriculum Specialist and Admin Assistant have reviewed all 2024 injury reports and created an action plan. This process will be conducted semi-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 C3, enrolled for six months, was missing documentation of viewing proof of the child?s identity and age.
Plan of Correction: C3's parent brought in the birth certificate. It has been viewed and documented in C3s file.