Inspection · 2025-10-09
Date
2025-10-09
Complaint Related
No
Licensing Inspector
Shahana Green
(571) 423-6735
(571) 423-6735
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
20 Access to minor?s records
22.1 Early Childhood Care and Education
63.2 Child Abuse & Neglect
8VAC20-790 Introduction
8VAC20-790 Administration
8VAC20-790 Staff Qualifications & Training
8VAC20-790 Physical Plant
8VAC20-790 Program
VAC20-790 Staffing & Supervision
8VAC20-790 Special Care Provisions & Emergencies
8VAC20-790 Special Services
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 renewal inspection was initiated and completed on 10/9/2025. The on-site inspection began at 10:30am and ended at 2:50pm. The inspector reviewed compliance in the areas listed above. There were 101 children present and 23 staff. The inspector reviewed
10 children?s records, 4 board member records and 3 staff records on-site on 10/9/2025. 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.
Violations
9Standard 22.1-289.035-B-2
Staff are required to submit to fingerprinting prior to employment.
Staff #2 did not submit to fingerprinting prior to employment as required.
Staff #2 did not submit to fingerprinting prior to employment as required.
Plan of Correction: The staff member's fingerprints have been submitted and we are currently awaiting the background check results. Additionally, please note that the teacher's last day of employment is Wednesday, October 29, 2025.
Standard 8VAC20-780-160-A
Each staff member is required to submit documentation of a negative tuberculosis screening.
Staff #2 did not have documentation of a negative tuberculosis screening on file at the
time of the inspection.
Staff #2 did not have documentation of a negative tuberculosis screening on file at the
time of the inspection.
Plan of Correction: The staff member is scheduled to obtain a new TB screening on Monday, October 27, 2025. Please note that the staff member's last day of employment is Wednesday, October 29, 2025. The school will ensure that documentation of the completed TB screening is obtained and filed upon receipt. Moving forward, the administrative team will verify that all new hires submit documentation of a negative TB screening prior to the start of employment to ensure continued compliance with licensing regulations.
Standard 8VAC20-780-245-J-3
Any child for whom emergency medications have been prescribed shall always be in the care of a staff member or independent contractor who meets the requirements in subdivision 1 of this section.
Child #1 had an emergency medication prescribed, however, there were no staff on-site with the required training to be able to administer the emergency medication should the need arise.
Child #1 had an emergency medication prescribed, however, there were no staff on-site with the required training to be able to administer the emergency medication should the need arise.
Plan of Correction: To correct this, leadership and designated team members will complete the necessary Medication Administration Training (MAT) and related emergency medication modules to ensure full compliance. Specifically, the Chief Executive Officer, Operations Support Manager, and two Team Leads will complete the training to guarantee that a qualified, trained staff member is always present on-site when a child requiring emergency medication is in care. Upon completion, training certificates will be filed in each staff member's personnel record, and the school will maintain a coverage schedule to ensure that trained staff are always available during operating hours.
Standard 8VAC20-780-40-M
The center shall maintain, in a way that is accessible to all staff who work with children, a current written list of all children's allergies, sensitivities, and dietary restrictions documented in the allergy plan required in 8VAC20-780-60 A 8. This list is required to be dated and kept confidential in each room or area where children are present.
Child #3 had an intolerance/sensitivity listed in their child file that was not listed on the current list of allergies, sensitivities, and dietary restrictions that was given to staff to keep in their classrooms.
Child #3 had an intolerance/sensitivity listed in their child file that was not listed on the current list of allergies, sensitivities, and dietary restrictions that was given to staff to keep in their classrooms.
Plan of Correction: The allergy list has been reviewed and updated in every classroom to ensure all current allergies, sensitivities, and dietary restrictions are accurately reflected and dated. The administrative team has verified that each classroom now has the most up-to-date list posted confidentially in accordance with 8VAC20-780-60 A 8. Moving forward, all allergy plans and lists will be reviewed monthly and updated immediately upon receipt of new or revised information from families to ensure full compliance and staff awareness.
Standard 8VAC20-780-500-B
Disposable diapers are required to be disposed in a leakproof or plastic-lined storage
system that is either foot-operated or used in such a way that neither the staff
member's hand nor the soiled diaper touches an exterior surface of the storage
system during disposal.
There was not a foot-operated storage system or hands-free storage system available for disposing diapers in one of the infant classrooms.
system that is either foot-operated or used in such a way that neither the staff
member's hand nor the soiled diaper touches an exterior surface of the storage
system during disposal.
There was not a foot-operated storage system or hands-free storage system available for disposing diapers in one of the infant classrooms.
Plan of Correction: A Diaper Genie order was placed for all infant classrooms, with two additional units ordered as backups to ensure continued compliance and sanitation in the event that one becomes damaged or unusable.
Standard 8VAC20-780-510-P
Medications that are not picked up by the parent within 14 days are required to be disposed of by the center by either dissolving the medication down the sink or flushing it down the toilet.
There were 15 medications on-site with expired authorizations (all at least by one month or more) that had not been returned to parents or disposed of within the required timeframe.
There were 15 medications on-site with expired authorizations (all at least by one month or more) that had not been returned to parents or disposed of within the required timeframe.
Plan of Correction: All medications that were expired, missing proper documentation, or not in their original packaging have been discarded. Prior to disposal, a notification was sent to families informing them of the action and providing an opportunity to retrieve or replace the medication as needed.
Standard 8VAC20-780-570-E
Prepared infant formula shall be refrigerated, dated and labeled with the child's name.
There were 10 bottles in the refrigerator with no date on them and one of the bottles had no name on it.
There were 10 bottles in the refrigerator with no date on them and one of the bottles had no name on it.
Plan of Correction: To correct this, all bottles have been reviewed, labeled, and dated appropriately. Going forward, teachers will verify that each bottle is labeled and dated upon arrival each morning. If a bottle is not properly labeled, parents will be asked to label it at drop-off before it is stored. In the event a parent forgets, teachers will immediately label the bottle with the correct name and date to ensure compliance and safety. The Classroom Leads and Assistant Director will conduct daily checks of refrigerator contents to confirm continued compliance with labeling and storage requirements.
Standard 8VAC20-780-60-A
Each center shall maintain and keep at the center a separate record for each child enrolled which should contain the required information.
Child #5 and Child #6 are missing annual updates of emergency information. Child #3 is missing the home phone number, parent work number, and did not note if there are any chronic problems or special needs. Child #7 did note if there are any chronic problems or special needs and previous care information was left blank.
Child #5 and Child #6 are missing annual updates of emergency information. Child #3 is missing the home phone number, parent work number, and did not note if there are any chronic problems or special needs. Child #7 did note if there are any chronic problems or special needs and previous care information was left blank.
Plan of Correction: The Owner and CEO completed a comprehensive staff file audit and identified the need for updated documentation from families. Communication has been sent out to families requesting the necessary updates to ensure all records remain current and in full compliance with licensing requirements.
Standard 8VAC20-780-60-A-8
A written care plan is required 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.
Child #4 and Child #5 both have a diagnosed food allergy on file at the facility, however, there was no written care plan on file for either child.
Child #4 and Child #5 both have a diagnosed food allergy on file at the facility, however, there was no written care plan on file for either child.
Plan of Correction: Our Assistant Director contacted both families and provided the correct documentation for completion and signature by each scholar's pediatrician. The updated medication authorization form will be returned to the school by Monday, October 27, 2025.