Inspection · 2025-05-22
Date
2025-05-22
Complaint Related
No
Licensing Inspector
Florence Martus
(804) 389-0157
(804) 389-0157
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.
8VAC20-770 Background Checks
20 Access to minor's records
22.1 Early Childhood Care and Education
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 05/22/25 and completed on 06/09/25, as a part of the licensure period. The on-site inspection began at 10:25am and ended at 12:55pm. The inspector reviewed compliance in the areas listed above. There were 55 children present and 11 staff. The inspector reviewed five children?s records and five staff records on-site. Additional documentation was reviewed electronically on 06/04/25 and 06/09/25. 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 business days from today, which will be the close of business on 06/27/25. A POC submitted after this date will not appear on the public website.
Violations
13Standard 22.1-289.011-F
The license and any other documents required shall be posted in a conspicuous place on the licensed premises.
The findings from the most recent inspection, dated 11/25/24, were not posted in a conspicuous place on the premises.
The findings from the most recent inspection, dated 11/25/24, were not posted in a conspicuous place on the premises.
Plan of Correction: Per the Center: "I recognize the critical importance of having our license and other documents posted. As the acting director, I have diligently reviewed all documents and posted them where they are visible to staff and parents.
An updated report has been posted and will be posted timely when each new report is received moving forward. "
An updated report has been posted and will be posted timely when each new report is received moving forward. "
Standard 22.1-289.035-B-4
(Repeat Violation) The center is required to obtain background checks from any state in which the individual has resided in the preceding five years.
Staff #1, employed for more than nine months, did not have documentation of requesting a sex offender registry check or a central registry check from one state.
Staff #1, employed for more than nine months, did not have documentation of requesting a sex offender registry check or a central registry check from one state.
Plan of Correction: Per the Center: "By auditing all the current staff files of each employee and all central registry search requests have been submitted, received and updated into the staff file.
-Moving forward, no staff member will begin their first day of employment without submitting all employment documentation and completing any necessary state training requirements. I will ensure this by meeting with all new hires prior to their first day to verify or reverify documentation.
-Staff #1 central registry has been requested
No staff member will be allowed to begin employment without the proper background checks submitted. Each new staff will attend a paperwork appointment prior to their first day of employment to ensure all necessary documents have been obtained and submitted."
-Moving forward, no staff member will begin their first day of employment without submitting all employment documentation and completing any necessary state training requirements. I will ensure this by meeting with all new hires prior to their first day to verify or reverify documentation.
-Staff #1 central registry has been requested
No staff member will be allowed to begin employment without the proper background checks submitted. Each new staff will attend a paperwork appointment prior to their first day of employment to ensure all necessary documents have been obtained and submitted."
Standard 22.1-289.058
Each building that was built before 2015 and that houses a child day program that is licensed that serves preschool-age children shall be equipped with at least one carbon monoxide detector.
There was no carbon monoxide available in the building during the inspection.
There was no carbon monoxide available in the building during the inspection.
Plan of Correction: Per the Center: "I recognize the critical importance of having a Carbon Monoxide detector in the center and will have a work order put in immediately.
A work order has been placed to have a new Carbon Monoxide detector installed. "
A work order has been placed to have a new Carbon Monoxide detector installed. "
Standard 8VAC20-780-130-A
The center shall obtain documentation that each child has received the immunizations required by the State Board of Health before the child can attend the center.
The immunizations in the record of Child #1 were obtained 21 days after their first day of attendance.
The immunizations in the record of Child #1 were obtained 21 days after their first day of attendance.
Plan of Correction: Per the Center: "I understand the seriousness of repeated violations and have made corrections.
Child #1 has records have been updated and put away in her file.
No child will be allowed to begin care without all necessary paperwork. An enrollment meeting will be held prior to the child?s first day of attendance to ensure all required documents have been obtained."
Child #1 has records have been updated and put away in her file.
No child will be allowed to begin care without all necessary paperwork. An enrollment meeting will be held prior to the child?s first day of attendance to ensure all required documents have been obtained."
Standard 8VAC20-780-140-A
(Repeat Violation) Physical examinations completed by a physician shall be obtained prior to the first day of attendance or within 30 days after the first day of attendance.
The physical examination in the record of Child #1 was completed more than a year and nine months after the first day of attendance.
The physical examination in the record of Child #1 was completed more than a year and nine months after the first day of attendance.
Plan of Correction: Per the Center: "No child will be allowed to begin care without all necessary paperwork. An enrollment meeting will be held prior to the child?s first day of attendance to ensure all required documents have been obtained."
Standard 8VAC20-780-280-B
(Repeat Violation) Hazardous substances such as cleaning materials shall be kept in a locked place using a safe locking method that prevents access by children.
In the Toddler classroom, the cleaning materials were observed in an unlocked cabinet, out of reach of children. In the Preschool classroom, the cleaning materials were in an unlocked cabinet under a sink used by children.
In the Toddler classroom, the cleaning materials were observed in an unlocked cabinet, out of reach of children. In the Preschool classroom, the cleaning materials were in an unlocked cabinet under a sink used by children.
Plan of Correction: Per the Center: "I understand the seriousness of repeated violations and have made corrections by having all staff lock all hazardous substances away in non-reachable areas.
All staff have been retrained on appropriate storage of chemicals and hazardous substances. A member of management will ensure compliance with daily checks. "
All staff have been retrained on appropriate storage of chemicals and hazardous substances. A member of management will ensure compliance with daily checks. "
Standard 8VAC20-780-340-A
(Repeat Violation) When staff are supervising children, they shall always ensure their care, protection, and guidance.
On 05/22/25, an emergency medication for Child #1 was reportedly on-site, but staff were not able to open the medication box during the inspection. Child #1 was present at center at the time of the inspection.
On 05/22/25, an emergency medication for Child #1 was reportedly on-site, but staff were not able to open the medication box during the inspection. Child #1 was present at center at the time of the inspection.
Plan of Correction: Per the Center: "I understand the seriousness of repeated violations and have been working diligently to correct and implement these changes as followed:
-I will continue to conduct regular staff meetings to reinforce trainings, address any emerging concerns, and ensure ongoing compliance with all licensing regulations.
I am committed to providing a safe and nurturing environment for all children in our care. Therefore, I am committed to maintain open and transparent communication with the licensing agency regarding our staffing and supervision practice and will promptly address any further concerns.
All managers have been informed on and trained on how to open the medication lock box. "
-I will continue to conduct regular staff meetings to reinforce trainings, address any emerging concerns, and ensure ongoing compliance with all licensing regulations.
I am committed to providing a safe and nurturing environment for all children in our care. Therefore, I am committed to maintain open and transparent communication with the licensing agency regarding our staffing and supervision practice and will promptly address any further concerns.
All managers have been informed on and trained on how to open the medication lock box. "
Standard 8VAC20-780-550-D
(Repeat Violation) The center shall implement a monthly practice evacuation drill.
An evacuation drill was not practiced in November or December 2024.
An evacuation drill was not practiced in November or December 2024.
Plan of Correction: Per the Center: "-I recognize the critical importance of conducting monthly safety drills, including fire drills, and meticulously maintaining all associated documentation. As the acting director, I have diligently reviewed all previous safety records to ensure proper record-keeping moving forward. The following outlines my plan of action for enhancing safety protocols at the center.
? Establish a monthly drill schedule using company tools and resources
? Set calendar reminders each month for drills to ensure completion
? Conduct regular reviews of fire drills documentation to ensure compliance and identify any areas for improvement.
? Familiarizing teachers and staff with evacuation procedures.
Emergency drill logs have been reviewed to current and all drills moving forward have been calendared to ensure timely completion. Drill logs will be reviewed weekly to ensure compliance. "
? Establish a monthly drill schedule using company tools and resources
? Set calendar reminders each month for drills to ensure completion
? Conduct regular reviews of fire drills documentation to ensure compliance and identify any areas for improvement.
? Familiarizing teachers and staff with evacuation procedures.
Emergency drill logs have been reviewed to current and all drills moving forward have been calendared to ensure timely completion. Drill logs will be reviewed weekly to ensure compliance. "
Standard 8VAC20-780-550-E
Shelter in place procedures shall be practiced a minimum of twice per year.
There is no documentation indicating the center practiced the shelter-in-place procedures more than once in 2024. The last documented shelter-in-place drill was on 01/16/24.
There is no documentation indicating the center practiced the shelter-in-place procedures more than once in 2024. The last documented shelter-in-place drill was on 01/16/24.
Plan of Correction: Per the Center: "I recognize the critical importance of conducting? Shelter in Place procedures?. As the acting director, I have diligently reviewed all previous safety records to ensure proper record-keeping moving forward.
Emergency drill logs have been reviewed to current and all drills moving forward have been calendared to ensure timely completion. Drill logs will be reviewed weekly to ensure compliance to include shelter in place drills."
Emergency drill logs have been reviewed to current and all drills moving forward have been calendared to ensure timely completion. Drill logs will be reviewed weekly to ensure compliance to include shelter in place drills."
Standard 8VAC20-780-550-F
Lockdown procedures shall be practiced at least annually.
There is no documentation indicating the center practiced the lockdown procedures in 2024.
There is no documentation indicating the center practiced the lockdown procedures in 2024.
Plan of Correction: Per the Center: "I recognize the critical importance of conducting a lockdown drill, and meticulously maintaining all associated documentation. The following outlines my plan of action for enhancing safety protocols at the center.
? Establish a monthly drill schedule using company tools and resources
? Set calendar reminders each month for drills to ensure completion"
? Establish a monthly drill schedule using company tools and resources
? Set calendar reminders each month for drills to ensure completion"
Standard 8VAC20-780-570-E
Prepared infant formula shall be refrigerated, dated, and labeled with the child?s name.
The bottles in the fridge in the Infant 1 classroom were observed without a date. Some of the bottles were prepared infant formula.
The bottles in the fridge in the Infant 1 classroom were observed without a date. Some of the bottles were prepared infant formula.
Plan of Correction: Per the Center: "Staff were immediately reminded the importance of labeling bottles in the room. All staff will receive a refresher training on infant labeling as well.
All staff have been retrained on proper labeling of infant bottles to include name and date. All parents have also been reminded of the expectation for labeling of infant bottles."
All staff have been retrained on proper labeling of infant bottles to include name and date. All parents have also been reminded of the expectation for labeling of infant bottles."
Standard 8VAC20-780-60-A
Each center shall maintain and keep at the center a separate record for each child enrolled that contains all the required information.
The record of Child #2, enrolled for more than a week, was missing a second emergency contact. The record of Child #3, enrolled for more than two months, was missing two emergency contacts.
The record of Child #2, enrolled for more than a week, was missing a second emergency contact. The record of Child #3, enrolled for more than two months, was missing two emergency contacts.
Plan of Correction: Per the Center: "All current child files have been audited and any missing or expired documents have been requested from the families. Families have been given a deadline to provide documentation or care will be suspended. In the future, new families will be required to meet with the school prior to their first day and bring all required paperwork for review. No child will be allowed to start in care without a complete paperwork packet.
Child #1, Child #2, Child #3
-This matter has been corrected by the director. All requested documents have been obtained and filed into the child?s file."
Child #1, Child #2, Child #3
-This matter has been corrected by the director. All requested documents have been obtained and filed into the child?s file."
Standard 8VAC20-780-70
(Repeat Violation) Documentation of at least two references to character, reputation, and competency are to be checked prior to employment.
The references in the following staff records were obtained after employment: Staff #1 (obtained more than seven months late); Staff #2 (obtained two days late); Staff #4 (obtained nine days late); and Staff #5 (obtained 11 days late).
The references in the following staff records were obtained after employment: Staff #1 (obtained more than seven months late); Staff #2 (obtained two days late); Staff #4 (obtained nine days late); and Staff #5 (obtained 11 days late).
Plan of Correction: Per the Center: "I understand the seriousness of repeated violations and have been working diligently to correct and implement these changes as followed:
- Contacting all references prior to the staff?s first day of attendance.
No staff member will be allowed to begin employment without the proper reference checks. Each new staff will attend a paperwork appointment prior to their first day of employment to ensure their file is complete."
- Contacting all references prior to the staff?s first day of attendance.
No staff member will be allowed to begin employment without the proper reference checks. Each new staff will attend a paperwork appointment prior to their first day of employment to ensure their file is complete."