Inspection · 2025-05-29
Date
2025-05-29
Complaint Related
No
Licensing Inspector
Kimberly Weaver
(571) 596-3662
(571) 596-3662
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
8VAC20-800 Administration
8VAC20-800 Personnel
8VAC20-800 Household Members
8VAC20-800 Physical Health of Caregivers and Household members
8VAC20-800 Caregiver Training
8VAC20-800 Physical Equipment and Environment
8VAC20-800 Care of Children
8VAC20-800 Preventing the Spread of Disease
8VAC20-800 Medication Administration
8VAC20-800 Emergencies
8VAC20-800 Nutrition
8VAC20-820 THE LICENSE
8VAC20-770 Background Checks
20 Access to minor?s records
22.1 Background Checks Code, Carbon Monoxide
22.1 Potable Water Lead Testing
54.1 Provider must be MAT certified to administer prescription medication.
63.2 Child abuse and neglect
During the inspection, the inspector reviewed the areas listed above. 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 conducted 5/29/2025 from 11:55am - 1:20pm. There were 6 children and 3 caregivers present during the time of the inspection; totaling 13 points. The inspector reviewed 3 child records and 4 caregiver/household records onsite. The inspection included document review, interviews, observations, and a tour of the facility.
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 deficient practice will be or has been corrected. Submit your POC within five (5) business days from today, which will be the close of business on 6/9/2025. A POC submitted after this date will not appear on the public website.
Violations
13Standard 22.1-289.035-A
All caregivers shall undergo a background check in accordance with subsection B of the Code of Virginia every 5 years.
At the time of the inspection, the subsequent Central Registry check (CPS) and Sworn Statement for Caregiver #3 was overdue by 4 months.
At the time of the inspection, the subsequent Central Registry check (CPS) and Sworn Statement for Caregiver #3 was overdue by 4 months.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 22.1-289.035-B-1
The Family Day Home is required to obtain a completed sworn statement prior to a caregivers first day of employment.
Caregiver #1, employed for 4 months, and Caregiver #2, employed for almost 6 months, did not have a sworn statement.
Caregiver #1, employed for 4 months, and Caregiver #2, employed for almost 6 months, did not have a sworn statement.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 22.1-289.036-A
All adult household members shall undergo a background check in accordance with subsection B of the Code of Virginia every 5 years.
At the time of the inspection, the subsequent Central Registry check (CPS) and Sworn Statement for Household Member #1 was overdue by 4 months.
At the time of the inspection, the subsequent Central Registry check (CPS) and Sworn Statement for Household Member #1 was overdue by 4 months.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-800-120-B
Assistants records shall contain all required information.
The record for Caregiver #1, employeed for 4 months, and Caregiver #2, employed for almost 6 months, did not contain an address, verification of age, an emergency contact, and two reference checks.
The record for Caregiver #1, employeed for 4 months, and Caregiver #2, employed for almost 6 months, did not contain an address, verification of age, an emergency contact, and two reference checks.
Plan of Correction: All missing information for Caregiver #1 and #2 will be obtained and updated in their personnel files immediately. Files will be reviewed by the provider to ensure they are complete and in compliance. To prevent future occurrences, a staff file checklist has been implemented to be used during onboarding. No caregiver will be permitted to begin working with children until all required documentation has been received, verified, and filed. Quarterly audits of all straff records will be conducted.
Standard 8VAC20-800-170-A
Providers must obtain a current tuberculosis screening from a caregier at the time of hire and prior to coming into contact with children.
Caregiver #2 was employed and working for almost 3 months before a TB screening/test was obtained.
Caregiver #2 was employed and working for almost 3 months before a TB screening/test was obtained.
Plan of Correction: The provider acknowledges the oversight and confirms that a current TB screening has now been obtained and filed for Caregiver #2. Effective immediately, no caregiver shall be permitted to work or have contact with children until a valid TB dated within the required timeframe is submitted and verified. A revised hiring checklist has been implemented to include TB screening. The checklist must be completed and reviewed by the provider before a new caregiver begins. The provider will conduct a full review of all staff medical records to ensure TB documentation is current and compliant for every individual in the home. The provider understands the health and safety implications of this requirement and is committed to full and ongoing compliance.
Standard 8VAC20-800-170-B
The provider must obtain from each caregiver at the time of hire a current Report of Tuberculosis (TB) Screening form. The report shall have been completed within the last 30 days and be signed by a physician.
Caregiver #1 had a TB report dated 12 months prior to date of hire.
Caregiver #1 had a TB report dated 12 months prior to date of hire.
Plan of Correction: The provider acknowledges the oversight and confirms a new, valid TB screening dated within the required 30-day window has been obtained for Caregiver #1. Effective immediately, the provider will ensure that all new caregivers submit a TB screening dated withing the past 30 days before hire and coming into contact with children. The requirement is now included as a mandatory item on the updated Staff Hiring Checklist. The provider understands the importance of TB screening in maintaining a safe and healthy environment for children and staff.
Standard 8VAC20-800-200-B
The provider must orient assistants by the end of their first week of assuming job responsibilities to include all policies and procedures of the Family Day Home.
The provider did not have documentation of orientation for Caregiver #1, employed for 4 months, and Caregiver #2, employed for almost 6 months.
The provider did not have documentation of orientation for Caregiver #1, employed for 4 months, and Caregiver #2, employed for almost 6 months.
Plan of Correction: Orientation sessions covering all policies and procedures of the Family Day Home were conducted immediately for both Caregiver #1 and #2. Both caregivers have now signed and dated the Assistant Orientation form which has been placed in their files. Going forward, al new assistants will receive complete orientation during their first week of employment. To ensure compliance, the provider has created a hiring checklist that includes orientation as required before regular work duties begin.
Standard 8VAC20-800-280
Potentially poisonous substances and materials shall be stored in an area inaccessible to children.
The bathrooom used by children contained cleaning products on top of the counter and underneath the sink in an unlocked cabinet, making them accessible to children. A block of ant bait was on the floor underneath the bathroom cabinet and had leaked onto the floor next to the step stool used by children.
The bathrooom used by children contained cleaning products on top of the counter and underneath the sink in an unlocked cabinet, making them accessible to children. A block of ant bait was on the floor underneath the bathroom cabinet and had leaked onto the floor next to the step stool used by children.
Plan of Correction: All potentially hazardous substances have been immeidately removed from the childrens bathroom. Cleaning products are now stored in a locked cabinet outside of their reach. The unlocked cabinet under the bathroom sink has been secured with a child safety lock. The ant bait and remaining residue on the floor has been removed and thoroughly cleanted. No pest control substances will be used or stored in areas accessible to children moving forward. A monthly safety check will now be conducted by the provider to ensure continued compliance. All caregivers have been reminded of the policy and importance of maintaining a safe and toxin-free environment.
Standard 8VAC20-800-510-C
Occupied cribs, cots, and rest mats shall be at least 12 inches from each other.
Three children were observed sleeping on cots that were less than 12 inches from each other with parts of the pillows and bedding touching.
Three children were observed sleeping on cots that were less than 12 inches from each other with parts of the pillows and bedding touching.
Plan of Correction: Effective immediately, all cribs, cots, and rest mats will be arranged to maintain a minimum of 12 inches of space between each occupied sleep area. The nap area has been reorganized to ensure proper spacing and floor markers have been added to indicate approved cot placement. The provider and assistants have been retrained on nap setup to ensure spacing is verified before children are laid down to rest. A daily nap checklist has been implemented. If space becomes limited due to the number of children present, nap areas will be split into separate rooms without compromising safety.
Standard 8VAC20-800-590-A
Infants shall be placed on their backs when sleeping or napping unless otherwise ordered by a written statement signed by the childs physician.
The provider stated Child #4, age 4 months, is placed on their stomach to sleep. Child #4 is still practicing tummy time and cannot roll over.
The provider stated Child #4, age 4 months, is placed on their stomach to sleep. Child #4 is still practicing tummy time and cannot roll over.
Plan of Correction: Effective immediately, all infants will be placed on their backs for all sleep and nap times as required by Virginia regulations. No infant will be placed on their stomachs unless a written and signed statement from the child's physician is provided explicityly authorizing this position.
All staff members have been reminded of the safe sleep policy and importance of adherence. A written policy review and safe sleep refresher training will be completd by all caregivers by 6/9/2025. Documentation of training completion will be maintained in staff records. Compliance will be monitored daily by the provider.
All staff members have been reminded of the safe sleep policy and importance of adherence. A written policy review and safe sleep refresher training will be completd by all caregivers by 6/9/2025. Documentation of training completion will be maintained in staff records. Compliance will be monitored daily by the provider.
Standard 8VAC20-800-70-A
REPEAT VIOLATION
Before the child's first day of attendance, parents shall be provided required information in writing.
The record for Child #1, #2, and #3 did not contain the requirements for ill child pick up and communicable disease reporting. The record for Child #3 did not contain the policy for the administration of medication or liability insurance.
Before the child's first day of attendance, parents shall be provided required information in writing.
The record for Child #1, #2, and #3 did not contain the requirements for ill child pick up and communicable disease reporting. The record for Child #3 did not contain the policy for the administration of medication or liability insurance.
Plan of Correction: Immediately upon discovering the omission, the provider updated and reissued the Parent Information packet for Child #1, #2, and #3. The parents signed an acknowledgement form confirming receipt of required information. The acknowledgements have been placed in each childs file. To prevent recurrence, a revised Enrollment Checklist is now in place. Current children records are being audited to confirm complete compliance and all families will be reissued the updated policies.
Standard 8VAC20-800-800-A
The provider shall have a written emergency preparedness and response plan that includes but is not limited to emergency evacuation, relocation, and shelter-in-place procedures.
The provider did not have an emergency preparedness and response plan to review.
The provider did not have an emergency preparedness and response plan to review.
Plan of Correction: A comprehensive written Emergnecy Preparedness and Response plan has now been developed and completed in accordance with state regulations. The plan was reviewed and signed by all caregivers. A copy of the plan is now kept in an easily accessible location for quick reference during emergencies and will be reviewed with new staff upong hiring. Moving forward, the plan will be reviewed and updated annually, or sooner if needed. A copy of the completed plan will be shared with parents as part of the enrollment packet.
Standard 8VAC20-800-830-A
REPEAT VIOLATION
The emergency evacuation procedures shall be practiced montly with all caregivers and children in care.
An evacuation drill was not practiced December 2024 through April 2025.
The emergency evacuation procedures shall be practiced montly with all caregivers and children in care.
An evacuation drill was not practiced December 2024 through April 2025.
Plan of Correction: Effective immediately, monthly emergency evacuation drills will be conducted and documented consistently, without exception. A drill was completed for May 2025, and a schedule has been created for the remainder of the year to ensure compliance moving forward. A reminder has been added to the monthly calendar to ensure drills are not missed. All caregivers have been informed of the requirement and will participate in each shceduled drill. The provider will oversee and document each practice to ensure proper procedure is followed.