Inspection · 2025-07-30
Licensing Inspector
Arlene Agustin
(804) 629-7519
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
22.1 Religious Exempt; Background Checks Code
32.1 Report by person other than physician
63.2 Child abuse and neglect
8VAC20-770 Background Checks
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 monitoring inspection was initiated on July 30, 2025 and completed on September 16, 2025, in response to a self-report received by the licensing office on July 23, 2025 relating to child supervision. The inspector reviewed a child?s record and 4 staff records on-site. 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 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 September 24, 2025. A POC submitted after this date will not appear on the public website.
Standard 22.1-289.031-A-4
Each person in a supervisory position has been certified by a practicing physician or physician assistant to be free from any disability which would prevent him from caring for children under his supervision. There was no information available for Staff #2, that was working during summer camp, to demonstrate they have been certified being free from any disability which would prevent her from caring for children under her supervision.
Plan of Correction: Our staff health forms have been collected for each person in a supervisory position of children and the files are being kept at the school.
Standard 22.1-289.031-B-2
The center shall establish and implement procedures for appropriate supervision of all children in care. On July 22, 2025, Child #1, two-year-old, left the playground area through a gap in their fence allowing access to a grass front area facing a street with the speed limit of 35 MPH. Staff members were not aware that Child #1 left the playground. Another student saw Child #1 outside the fence and pointed at him alerting Staff #1. At that point, Staff #1 intervened and caught up with the child as he was running into oncoming traffic. A driver reported cars slammed on their breaks to avoid an accident.
Plan of Correction: Monthly staff trainings and reviews of the expectations for doing head counts and for monitoring children have been held and that all staff are in complete understanding of the procedures for monitoring the children at all times.
Standard 22.1-289.031-B-4
The center shall establish and implement procedures for ensuring that all children in the center are in compliance with the provisions of ? 32.1-46 regarding the immunization of children against certain diseases. Staff did not ensure that Child #1, two years old, was in compliance with regulations of being immunized against certain diseases while in attendance at the program.
Plan of Correction: The school has been updating files to be in compliance with immunization records and they are being kept at the school.
Standard 22.1-289.031-B-5
The center shall ensure that all areas of the premises accessible to children are free of obvious injury hazards. The center?s outdoor playground area had a gap in the fence allowing access to a grass front area facing a street with the speed limit of 35 MPH. On July 22, 2025, a 2 year old child was able to walk out of the playground area through the gap in the fence.
Plan of Correction: The fence area that was compromised has ben fixed and is completely secure. The procedures for checking the area for hazards and for monitoring the children have been reviewed by staff.
Standard 22.1-289.035-B-1
Any individual required to undergo a background check shall provide a sworn statement or affirmation disclosing whether he has ever been convicted of or is the subject of pending charges for any offense within or outside the Commonwealth and whether he has been the subject of a founded complaint of child abuse or neglect within or outside the Commonwealth. Two of four staff members that worked during the summer camp did not provide a sworn statement prior to employment.
Plan of Correction: All staff have completed the sworn statement disclosure document provided by the state and they are on file at the school.
Standard 22.1-289.035-B-3
REPEAT VIOLATION
The center must request a search of the central registry prior to the employee's first day of employment. Two of the four staff members that worked during the summer camp, did not have central registry checks in their file.
Plan of Correction: Central registry checks have been run for all staff and are on file at the school.