Inspection · 2022-09-28
Date
2022-09-28
Complaint Related
No
Licensing Inspector
Stacy Doyle
(571) 835-0386
(571) 835-0386
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 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)
22.1 Background Checks Code, Carbon Monoxide
63.2 Child Abuse & Neglect
Inspector Notes
An unannounced monitoring inspection was conducted on 9/28/2022 from 9:49am to 12:25pm. At the time of entrance, 50 children were in care with 12 staff members present. Children were observed doing the following: painting, circle time counting and talking about the weather, writing their names, washing hands, tasting different colored apples, music time dancing, looking at the doctor themed toys in circle time and listening to the teacher read a book. Interactions between the children and staff were positive. The site was organized and contained an abundant supply of developmentally appropriate materials. A selection of staff and children records, medications, the physical space, evacuation drills, emergency supplies and attendance records were reviewed. Areas of non-compliance are identified in the violation notice. Please contact me if you have any questions at Stacy.Doyle@doe.virginia.gov or 571-835-0386.
Violations
18Standard 8VAC20-770-60-C-2
Based on review of staff records, the center did not obtain the central registry findings for a staff member within 30 days of employment.
Evidence:
1. Staff #1 (Date of hire 8/22/2022) had documentation that a request was sent 8/22/2022, but the center did not have the findings in the record and did not follow up within 30 days.
Evidence:
1. Staff #1 (Date of hire 8/22/2022) had documentation that a request was sent 8/22/2022, but the center did not have the findings in the record and did not follow up within 30 days.
Plan of Correction: Will set a calendar reminder with all new hires to follow up with Central
Registry to resend request if we do not hear back before 30 days
Registry to resend request if we do not hear back before 30 days
Standard 8VAC20-780-140-A
Based on review of children's records, the center did not obtain a physical examination for a child within 30 days of the child's start date.
Evidence:
1. Child #4's file (start date 7/06/2022) did not have a copy of the child's physical examination.
Evidence:
1. Child #4's file (start date 7/06/2022) did not have a copy of the child's physical examination.
Plan of Correction: Will set weekly reminder for all new students that the School Health
Entrance forms (physical examination) to be completed before
the child finishes their first 30 days in the center.
Entrance forms (physical examination) to be completed before
the child finishes their first 30 days in the center.
Standard 8VAC20-780-150-B
Based on review of children's records, the center did not have reports of a physical examination and immunization signed by a physician, his designee, or an official of a local health department and was not dated.
Evidence:
1. Child #4's file (start date 7/06/2022) had an immunization record, but it was not signed and did not have the child's physical signed.
Evidence:
1. Child #4's file (start date 7/06/2022) had an immunization record, but it was not signed and did not have the child's physical signed.
Plan of Correction: All new students School Health Entrance forms will be check by the
Director and Regional Director to make sure a physician's signature is
present and dated.
Director and Regional Director to make sure a physician's signature is
present and dated.
Standard 8VAC20-780-240-A
Based on training review, three staff did not complete the Virginia Department of Education-sponsored orientation course within 90 calendar days of employment.
Evidence:
1. Staff #5(12/15/2021 hire date), Staff #6 (3/17/2022 hire date) and Staff #7 (5/26/2022 hire date) did not complete the 10 hour Virginia Department of Education-sponsored orientation course within 90 calendar days of employment.
Evidence:
1. Staff #5(12/15/2021 hire date), Staff #6 (3/17/2022 hire date) and Staff #7 (5/26/2022 hire date) did not complete the 10 hour Virginia Department of Education-sponsored orientation course within 90 calendar days of employment.
Plan of Correction: We are using our floaters to cover the classroom so the teachers can
complete their required 10-hour training . Will set calender
reminders to remind the directors to makes sure staff finishes required
training within 90 days of start of employment.
complete their required 10-hour training . Will set calender
reminders to remind the directors to makes sure staff finishes required
training within 90 days of start of employment.
Standard 8VAC20-780-240-E
Based on review of staff training, one staff member did not complete orientation training in first aid.
Evidence:
1. Staff #1 (date of hire 8/22/2022) completed cardiopulmonary resuscitation (CPR) training on 9/20/2022, but did not complete training in First Aid.
2. Staff #6 (date of hire 3/17/2022) and Staff #7 (date of hire 5/26/2022) did not compete orientation training in first aid and CPR within 30 days of the first day of employment.
Evidence:
1. Staff #1 (date of hire 8/22/2022) completed cardiopulmonary resuscitation (CPR) training on 9/20/2022, but did not complete training in First Aid.
2. Staff #6 (date of hire 3/17/2022) and Staff #7 (date of hire 5/26/2022) did not compete orientation training in first aid and CPR within 30 days of the first day of employment.
Plan of Correction: If new hire hire does not First Aid and CPR at the time of hire, Director
will arrange a First Aid/CPR course for the new employee within 30
days.
will arrange a First Aid/CPR course for the new employee within 30
days.
Standard 8VAC20-780-270-A
Based on observation, Areas and equipment of the center outside were not maintained in a safe and operable condition.
Evidence:
1. A blue riding toy was missing a piece on the back.
2. The splash pad blue carpet had approximately 15 areas of missing carpet.
3. A stake around the tree that holds the black border was protruding.
4. Rust was visible on two steps to the purple and green slide.
5. The swing set had one broken swing that was in two pieces.
6. The large play structure had a step that was peeling.
Evidence:
1. A blue riding toy was missing a piece on the back.
2. The splash pad blue carpet had approximately 15 areas of missing carpet.
3. A stake around the tree that holds the black border was protruding.
4. Rust was visible on two steps to the purple and green slide.
5. The swing set had one broken swing that was in two pieces.
6. The large play structure had a step that was peeling.
Plan of Correction: 1. Blue riding toy has been thrown away.
2. Splash pad is closed until spring. New carpet isscheduled to be replace
before spring.
3. A rubber mallet will bepurchased and a director will inspect weekly.
4. Director will sand down the rusted area and will apply a new rubber coat to
the surface.
5. Broken swing will be taken down.
6. A new rubber sealant coat will be applied to structure.
2. Splash pad is closed until spring. New carpet isscheduled to be replace
before spring.
3. A rubber mallet will bepurchased and a director will inspect weekly.
4. Director will sand down the rusted area and will apply a new rubber coat to
the surface.
5. Broken swing will be taken down.
6. A new rubber sealant coat will be applied to structure.
Standard 8VAC20-780-40-G
Based on review, the center did not obtain proof of child identity and age within 7 days of attendance for two children.
Evidence:
1. Child #1 (start date 6/01/2022) and Child #4 (start date 7/06/2022) did not have documentation of proof of child identity.
Evidence:
1. Child #1 (start date 6/01/2022) and Child #4 (start date 7/06/2022) did not have documentation of proof of child identity.
Plan of Correction: The Regional Director and Director will review all required forms that are
completely filled out properly within 7 days of the child's first day at the
center.
completely filled out properly within 7 days of the child's first day at the
center.
Standard 8VAC20-780-40-M
Based on observation and interview, the center did not maintain a current dated written list of all children's allergies, sensitivities, and dietary restrictions and did not keep it in each room or area where children are present.
Evidence:
1. The center did not have a current written list of all children's allergies, sensitivities, and dietary restrictions. Rm. 6 classroom had a list, but it was dated 2/01/2022 and was not up to date.
Evidence:
1. The center did not have a current written list of all children's allergies, sensitivities, and dietary restrictions. Rm. 6 classroom had a list, but it was dated 2/01/2022 and was not up to date.
Plan of Correction: Allergy forms will be updated each time a new student is enrolled and
when there is expired medication is replaced. All classrooms will have a complete
schoolwide list of students with allergies, sensitivities, and dietary
restrictions posted and kept confidential. A weekly check will be
performed by the director.
when there is expired medication is replaced. All classrooms will have a complete
schoolwide list of students with allergies, sensitivities, and dietary
restrictions posted and kept confidential. A weekly check will be
performed by the director.
Standard 8VAC20-780-420-E-3
Based on review, the center did not obtain parent confirmation that the required information in the child's record is up to date.
Evidence:
1. Child #1 (Start date 6/01/2021) did not have documentation that the required information in the child's record is up to date.
2. Child #3 (Start date 4/26/2021) did not have documentation that the required information in the child's record is up to date. The last allergy action plan was dated 4/26/2021.
Evidence:
1. Child #1 (Start date 6/01/2021) did not have documentation that the required information in the child's record is up to date.
2. Child #3 (Start date 4/26/2021) did not have documentation that the required information in the child's record is up to date. The last allergy action plan was dated 4/26/2021.
Plan of Correction: Director will check weekly that all immunizations are up to date for each student.
All documentation will be reviewed by the director weekly to ensure required information is up to date.
The director will go through all children with listed allergies to
update any expired action plan. Director will perform a monthly check
and will add updates to the class allergies each time there is a new
student or if a plan has changed.
All documentation will be reviewed by the director weekly to ensure required information is up to date.
The director will go through all children with listed allergies to
update any expired action plan. Director will perform a monthly check
and will add updates to the class allergies each time there is a new
student or if a plan has changed.
Standard 8VAC20-780-50-A
Based on observation, children's records were not treated confidentially.
Evidence:
1. In the Pre-K classroom, three children's allergies and dietary restrictions/preferences were posted on the wall in the classroom and were not kept confidential.
Evidence:
1. In the Pre-K classroom, three children's allergies and dietary restrictions/preferences were posted on the wall in the classroom and were not kept confidential.
Plan of Correction: A cover sheet will be placed over the posted allergy plans in each
classroom or allergy plans will be kept in a classroom binder out of
sight from parents.
classroom or allergy plans will be kept in a classroom binder out of
sight from parents.
Standard 8VAC20-780-500-B
Based on observation, the center did not meet all requirements for diapering.
Evidence:
1. Classroom #3 had a diaper changing pad that had a 2 inch (approximately) crack on the surface and was considered absorbent. The diapering surface also had a cup of children's milk on the table.
2. Classroom #4 had a trash can in the bathroom with diapers in it. It was not foot operated. The lid was under the trashcan and not connected.
3. Classroom 7 had a foot operated trashcan, but it was broke and not connected on one side.
Evidence:
1. Classroom #3 had a diaper changing pad that had a 2 inch (approximately) crack on the surface and was considered absorbent. The diapering surface also had a cup of children's milk on the table.
2. Classroom #4 had a trash can in the bathroom with diapers in it. It was not foot operated. The lid was under the trashcan and not connected.
3. Classroom 7 had a foot operated trashcan, but it was broke and not connected on one side.
Plan of Correction: Diaper pads will be checked by the Director on a weekly basis and has
instructed teachers to immediately notify a director if there is a cut in the
changing pad. Director has notified all staff that the changing pad station can only beused for changing diapers and no other items can be placed on it.
Trash cans will be inspected by a director on a weekly basis. A new
trash can has been rendered for classroom 7
instructed teachers to immediately notify a director if there is a cut in the
changing pad. Director has notified all staff that the changing pad station can only beused for changing diapers and no other items can be placed on it.
Trash cans will be inspected by a director on a weekly basis. A new
trash can has been rendered for classroom 7
Standard 8VAC20-780-510-P
Based on review of medication, the center did not dispose of medication within 14 days when a parent did not pick up medication that had an expired authorization.
Evidence:
1. Child #5 had two medications with authorizations dated 3/17/2022 and the center did not dispose of them. The medications had also expired in August 2022.
2. Child #6 had two medications with authorizations dated 7/23/2022 and the center did not dispose of them.
Evidence:
1. Child #5 had two medications with authorizations dated 3/17/2022 and the center did not dispose of them. The medications had also expired in August 2022.
2. Child #6 had two medications with authorizations dated 7/23/2022 and the center did not dispose of them.
Plan of Correction: Will enter all medications expiration dates into the calendar as a
reminder that will be checked daily. We will give parents 2 weeks notice
that the medications are about to expire and will return to parents on
the day of expiration or before if requested by parents.
reminder that will be checked daily. We will give parents 2 weeks notice
that the medications are about to expire and will return to parents on
the day of expiration or before if requested by parents.
Standard 8VAC20-780-520-B
Based on observation, the center did not meet all requirements when using sunscreen.
Evidence:
1. Classroom #3 had 2 sunscreens in bins in the classroom and were within reach of children.
Evidence:
1. Classroom #3 had 2 sunscreens in bins in the classroom and were within reach of children.
Plan of Correction: Morning Director will do a morning walk through to make sure all
sunscreens and bug sprays are out of reach of children and locked up in
a cabinet.
sunscreens and bug sprays are out of reach of children and locked up in
a cabinet.
Standard 8VAC20-780-520-C
Based on observation, the center did not meet all requirements when using diaper ointment or cream.
Evidence:
1. Classroom 4 had 5 diaper creams in low bins in the bathroom children use and were within reach of children.
Evidence:
1. Classroom 4 had 5 diaper creams in low bins in the bathroom children use and were within reach of children.
Plan of Correction: Diaper creams have been removed to a cabinet that is locked. The
director reminded all teachers that diapers creams must be placed out
of reach from children.
director reminded all teachers that diapers creams must be placed out
of reach from children.
Standard 8VAC20-780-60-A
Based on record review, children's records did not have complete information.
Evidence:
1. Child #1 (start date 6/01/2021) did not have an annual update or proof of birth documented in the record.
2. Child #3 (start date 11/30/2020) did not have the parent's place of employment, work address, work phone number, two emergency contact addresses and the annual update.
3. Child #4 (start date 7/06/2022) did not have proof of birth documented, documentation of immunizations and physical signed by a physician, his designee or local health department.
4. Child #5 (start date ?) did not have the parent's address, work information, one emergency contact address and one emergency contact name, address and telephone number, previous schools attended and the parent agreement.
Evidence:
1. Child #1 (start date 6/01/2021) did not have an annual update or proof of birth documented in the record.
2. Child #3 (start date 11/30/2020) did not have the parent's place of employment, work address, work phone number, two emergency contact addresses and the annual update.
3. Child #4 (start date 7/06/2022) did not have proof of birth documented, documentation of immunizations and physical signed by a physician, his designee or local health department.
4. Child #5 (start date ?) did not have the parent's address, work information, one emergency contact address and one emergency contact name, address and telephone number, previous schools attended and the parent agreement.
Plan of Correction: Director will go through all files of children with allergies and complete
missing information.Will no longer ask for Social Security cards as a proof of birth. We request the parents provide a copy of proof of identity from the list
provided by the licensing inspector. The director will check each new
student forms to make sure parentsprovide place or employment, work
address, work phone number and 2 emergency contacts and previous
schools. Will also check that all immunizations are signed by
physicians.
missing information.Will no longer ask for Social Security cards as a proof of birth. We request the parents provide a copy of proof of identity from the list
provided by the licensing inspector. The director will check each new
student forms to make sure parentsprovide place or employment, work
address, work phone number and 2 emergency contacts and previous
schools. Will also check that all immunizations are signed by
physicians.
Standard 8VAC20-780-60-A-8
Based on review of children with allergies, the center did not obtain a written care plan for each child with a diagnosed food allergy, to include instructions from a physician regarding the food to which the child is allergic and the steps to be taken in the event of a suspected or confirmed allergic reaction.
Evidence:
1. Child #2, Child #4 and Child #5 had a diagnosed food allergy and the center did not have a written care plan for each child with instructions from a physician..
Evidence:
1. Child #2, Child #4 and Child #5 had a diagnosed food allergy and the center did not have a written care plan for each child with instructions from a physician..
Plan of Correction: A care plan will be typed up for each child and will ask parents to provide
instructions from a physician the steps to be taken if there are
suspected or confirmed allergic reactions.
instructions from a physician the steps to be taken if there are
suspected or confirmed allergic reactions.
Standard 8VAC20-780-70
Based on record review, staff records did not include all required information.
Evidence:
1. Staff #1, Staff #2, Staff #3 and Staff #4 did not have the address of a person to be notified in an emergency at the center.
2. Staff #1 (date of hire 8/22/2022) and Staff #3 (date of hire 9/05/2022) were missing two references. Staff #2 (date of hire 8/24/2022) and Staff #4 (date of hire 9/07/2022) were missing one reference.
Evidence:
1. Staff #1, Staff #2, Staff #3 and Staff #4 did not have the address of a person to be notified in an emergency at the center.
2. Staff #1 (date of hire 8/22/2022) and Staff #3 (date of hire 9/05/2022) were missing two references. Staff #2 (date of hire 8/24/2022) and Staff #4 (date of hire 9/07/2022) were missing one reference.
Plan of Correction: Regional Director and Director will review all new hire paperwork on
their first day to make sure all required information is complete.
Proof of references will be added to the employee file before start date
by the Regional Director.
their first day to make sure all required information is complete.
Proof of references will be added to the employee file before start date
by the Regional Director.
Standard 8VAC20-820-120-E-2
Based on observation, the findings of the most recent inspection of the facility was not posted.
Evidence;
1. The 1st page of the violation report from the inspection dated 3/15/2022 was not posted on the bulletin board.
Evidence;
1. The 1st page of the violation report from the inspection dated 3/15/2022 was not posted on the bulletin board.
Plan of Correction: Director will make sure all pages are posted when violation reports are
provided to the facility.
provided to the facility.