Inspection · 2025-09-26
Date
2025-09-26
Complaint Related
No
Licensing Inspector
Pamela Sneed
(804) 629-2691
(804) 629-2691
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
Inspector Notes
An unannounced monitoring inspection was initiated on 9/26/25 and completed on 9/29/25 with a local agency in response to a self-report received by the licensing office on 9/24/25 relating to behavioral guidance, supervision of children and operational responsibilities. The inspection included document review, tour of program area at the facility and interviews. 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 10/24/25. A POC submitted after this date will not appear on the public website.
Violations
4Standard 8VAC20-780-340-A
When staff are supervising children, they shall always ensure their care and protection.
On 9/22/25, staff did not ensure the care and protection of a 5 year-old child, Child #1, when after receiving allegations/report of concerns about Staff #1's recent interactions with Child #1, they immediately placed the child back into the direct-care of Staff #1.
When interviewed, Staff #2 stated that staffing could have been rearranged to prevent Child #1 and Staff #1 from being placed together.
On 9/22/25, staff did not ensure the care and protection of a 5 year-old child, Child #1, when after receiving allegations/report of concerns about Staff #1's recent interactions with Child #1, they immediately placed the child back into the direct-care of Staff #1.
When interviewed, Staff #2 stated that staffing could have been rearranged to prevent Child #1 and Staff #1 from being placed together.
Plan of Correction: SACC staff will ensure care and protection of all children within the program. When an allegation or concerns is shared the staff member will be removed from the site until an investigation is complete and further guidance is received. [sic]
Standard 8VAC20-780-40-E
The operational responsibilities of the licensee shall include ensuring that the center's services are maintained in compliance with these standards and the center's own policies and procedures that are required by these standards.
No staff ensured compliance with licensing standards and SACC mandated reporting policies/procedures when delaying a report of suspected abuse to child protective services (CPS) for over 48-hours after receiving the allegations from a parent.
During the 48-hour time period of when the allegations were reported to SACC staff and when SACC staff reported the allegations to CPS (9/22/25-9/24/25), Staff #2, on 9/22/25, reported to the regional manager, Staff #5, the plans to interview Staff #1, #3 and #4, about the allegations. Staff #5 reportedly attempted to contact another program manger, Staff #6, to discuss the allegations but was unsuccessful in reaching them and told Staff #2 to "use your judgement" in deciding as to whether to report the allegations to CPS. On 9/24/25, at 8:37am, Staff #2 filed an incident report within the SACC reporting system that included the allegations made and interviews conducted. Also on 9/24/25, Staff #1 was transferred to work at a SACC administrative office due to the allegations made. Staff #2 reported that they are told to "get the stories first" before reporting to CPS and questioned SACC training and policy being inconsistent with the mandated reporting requirements.
The SACC mandated reporting written policy states that staff are to report suspected abuse and neglect "as soon as possible but no later than 24 hours after having a suspicion of a reportable offense."
No staff ensured compliance with licensing standards and SACC mandated reporting policies/procedures when delaying a report of suspected abuse to child protective services (CPS) for over 48-hours after receiving the allegations from a parent.
During the 48-hour time period of when the allegations were reported to SACC staff and when SACC staff reported the allegations to CPS (9/22/25-9/24/25), Staff #2, on 9/22/25, reported to the regional manager, Staff #5, the plans to interview Staff #1, #3 and #4, about the allegations. Staff #5 reportedly attempted to contact another program manger, Staff #6, to discuss the allegations but was unsuccessful in reaching them and told Staff #2 to "use your judgement" in deciding as to whether to report the allegations to CPS. On 9/24/25, at 8:37am, Staff #2 filed an incident report within the SACC reporting system that included the allegations made and interviews conducted. Also on 9/24/25, Staff #1 was transferred to work at a SACC administrative office due to the allegations made. Staff #2 reported that they are told to "get the stories first" before reporting to CPS and questioned SACC training and policy being inconsistent with the mandated reporting requirements.
The SACC mandated reporting written policy states that staff are to report suspected abuse and neglect "as soon as possible but no later than 24 hours after having a suspicion of a reportable offense."
Plan of Correction: All staff will adhere to the operational policies of the SACC program and VDOE Licensing Standards. All staff will review mandated reporting procedures to ensure that they are within compliance of VDOE Licensing standards and SACC mandated reporting policies. Mandated reporter refresher training for all LCC staff will be completed by 10/30/25
Standard 8VAC20-780-400-A
In order to promote the child's physical, intellectual, emotional, and social well-being and growth, staff shall interact with the child and one another to provide needed help, comfort, support.
During interviews conducted, it was learned that Staff #1, has a history of inappropriate interactions with other staff, to include verbal disagreements and outbursts that include sarcastic comments made in front of the children. On at least one occasion Staff #1 used profane language in the presence of children, and on 9/19/25 Staff #1 spoke to Child #1 in a strong/stern tone of voice that caused the child to cry.
During interviews conducted, it was learned that Staff #1, has a history of inappropriate interactions with other staff, to include verbal disagreements and outbursts that include sarcastic comments made in front of the children. On at least one occasion Staff #1 used profane language in the presence of children, and on 9/19/25 Staff #1 spoke to Child #1 in a strong/stern tone of voice that caused the child to cry.
Plan of Correction: Staff will ensure all children's physical, intellectual, emotional and social well-being within our care. HDS III will monitor rooms daily to ensure compliance. Any concerns will be addressed immediately. Training to all LCC staff will be provided prior to November 7th 2025
Standard 8VAC20-780-80-B
Any suspected incident of child abuse shall be reported in accordance with the Code of Virginia 63.2-1509-Mandated reporting of suspected child abuse to child protective services (CPS) as soon as possible, but not longer than 24 hours.
No staff reported allegations of suspected abuse to CPS within 24 hours of having knowledge of a parent's reported concerns. On 9/22/25, at approximately 7:05am, Staff #2 received a report of allegations/concerns about an incident between Staff #1 and Child #1 that occurred on 9/19/25. On 9/24/25, at 1:16pm, over 48 hours later, in response to the parents persistence of wanting a response and remedy to the reported concerns, Staff #2 made a report to CPS.
When interviewed, Staff #2 stated that although they believed at the time they were following SACC policy, they now felt like the child's voice had been silenced by staff not reporting the incident promptly to CPS.
No staff reported allegations of suspected abuse to CPS within 24 hours of having knowledge of a parent's reported concerns. On 9/22/25, at approximately 7:05am, Staff #2 received a report of allegations/concerns about an incident between Staff #1 and Child #1 that occurred on 9/19/25. On 9/24/25, at 1:16pm, over 48 hours later, in response to the parents persistence of wanting a response and remedy to the reported concerns, Staff #2 made a report to CPS.
When interviewed, Staff #2 stated that although they believed at the time they were following SACC policy, they now felt like the child's voice had been silenced by staff not reporting the incident promptly to CPS.
Plan of Correction: All staff will review mandated reporting procedures to ensure that they are knowledgeable of and adhere to Code of Virginia 63.2-1509-Mandated Reporting. Mandated reporter refresher training for all LCC staff will be completed by 10/30/25