Inspection · 2025-05-29
Date
2025-05-29
Complaint Related
No
Licensing Inspector
Christine Mahan
(757) 404-0568
(757) 404-0568
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.
8VAC20-820 Hearing Procedures.
8VAC20-770 Background Checks
20 Access to minors 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 renewal inspection was initiated on 5-29-2025 and completed on 6-5-2025. The onsite inspection began at 11:40am and ended at 3:10pm. The inspector reviewed compliance in the areas listed above. There were 67 children present and 7 staff. The inspector
reviewed 7 children?s records and 8 staff records electronically (5-30-2025 to 6-4-2025). This inspection included document review, tour of the facility, interviews, observations, and measurements. 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 6/12/2025.
A POC submitted after this date will not appear on the public website.
Violations
13Standard 22.1-289.035-B-1
The center is required to obtain a completed sworn statement prior to the employee's first day of employment. Staff #7, who was observed working, did not have a sworn statement and had been working for more than 8 weeks.
Plan of Correction: The employee is no longer employed with us. We will ensure all requirements are met moving forward by following the added staff checklist that includes all due dates.
Standard 22.1-289.035-B-3
The center must request a search of the central registry (CPS) prior to the employee's first day of employment. If the results are not returned within 45 days of submitting the request, the program should follow up with the appropriate state agency and document the results. Staff #7 was observed working alone during the inspection and has been working for more than 8 weeks. There was no documentation of follow up on the request for CPS results.
Plan of Correction: The employee is no longer employed with us. We will ensure all requirements are met moving forward by following the added staff checklist that includes all due dates.
Standard 22.1-289.035-B-4
The center is required to obtain background checks from any state in which the individual has resided in the preceding five years. Staff #4, employed for more than 6 months, did not have documentation of requesting a central registry check from one state outside of Virginia. Staff #4 was observed working during the inspection.
Plan of Correction: We have completed all background checks again and have filed all documentation in her file. We have added a 30 reminder to the regional director?s calendar to ensure this is completed before 45 days.
Standard 8VAC20-780-240-E
Within 30 days of the first day of employment, staff must complete orientation training in first aid and cardiopulmonary resuscitation (CPR), as appropriate to the age of the children in care. Staff #3 has been employed for more than 4 months and does not have documentation of orientation training in first aid and CPR.
Plan of Correction: Staff #3 has completed her CPR & First Aid Training
Standard 8VAC20-780-270-A
The areas and equipment of the center, inside and outside, are maintained in a clean, safe and operable condition. Unsafe conditions shall include, but not be limited to, splintered, cracked or otherwise deteriorating wood; chipped or peeling paint; visible cracks, bending or warping, rusting or breakage of any equipment; head entrapment hazards; and protruding nails, bolts or other components that could entangle clothing or snag skin.
1.The following were determined to be hazards on the Pre-K playground:
a. One wooden balancing disc was broken, splintered and exposing sharp edges and a protruding screw.
b. One of the wooden support posts for the metal parallel bars was splintered and rotting at the bottom.
c. The metal climber had flaking rust and peeling paint on the bottom bars and two of the metal bars at the base are missing exposing sharp edges.
4. One metal playground bolt was protruding from the playground boarder around the sand box.
2.The following were determined to be hazards on the Toddler playground:
a. There were two plastic broken picnic tables with exposed sharp plastic edges.
b. There was a metal red car with chipped and peeling paint and splintering wood.
1.The following were determined to be hazards on the Pre-K playground:
a. One wooden balancing disc was broken, splintered and exposing sharp edges and a protruding screw.
b. One of the wooden support posts for the metal parallel bars was splintered and rotting at the bottom.
c. The metal climber had flaking rust and peeling paint on the bottom bars and two of the metal bars at the base are missing exposing sharp edges.
4. One metal playground bolt was protruding from the playground boarder around the sand box.
2.The following were determined to be hazards on the Toddler playground:
a. There were two plastic broken picnic tables with exposed sharp plastic edges.
b. There was a metal red car with chipped and peeling paint and splintering wood.
Plan of Correction: 1. A. We have removed the protruding screw and sanded the wooden balance until we are able to replace it with a vendor this month.
B. We have an appointment scheduled for 6/23/25 to repair the issue. Until the appointment date, the support post has been roped off with caution tape to ensure children are not around it.
C. We have an appointment scheduled for 6/23/25 to repair the issue. Until the appointment date, the support post has been roped off with caution tape to ensure children are not around it. We have hammered in the sharp edge to eliminiate that particular hazard
4.We have hit the bolt into the ground to remove the hazard
2. We have removed the picnic table from the playground
D. b. We have an appointment scheduled for 6/23/25 to repair the issue. Until the appointment date, the support post has been roped off with caution tape to ensure children are not around it.
B. We have an appointment scheduled for 6/23/25 to repair the issue. Until the appointment date, the support post has been roped off with caution tape to ensure children are not around it.
C. We have an appointment scheduled for 6/23/25 to repair the issue. Until the appointment date, the support post has been roped off with caution tape to ensure children are not around it. We have hammered in the sharp edge to eliminiate that particular hazard
4.We have hit the bolt into the ground to remove the hazard
2. We have removed the picnic table from the playground
D. b. We have an appointment scheduled for 6/23/25 to repair the issue. Until the appointment date, the support post has been roped off with caution tape to ensure children are not around it.
Standard 8VAC20-780-340-D
Repeat Violation
In each grouping of children at least one staff member who meets the qualifications of a program leader or program director. Staff #9 was the only staff designated to work in Room A and was observed alone supervising 10 children Staff #9 was an assistant teacher and does not have documentation to meet the program lead qualifications.
In each grouping of children at least one staff member who meets the qualifications of a program leader or program director. Staff #9 was the only staff designated to work in Room A and was observed alone supervising 10 children Staff #9 was an assistant teacher and does not have documentation to meet the program lead qualifications.
Plan of Correction: The employee is no longer employed with us. We will ensure all requirements are met moving forward by following the added staff checklist that includes all due dates.
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. This list shall be dated and kept confidential in each room or area where children are present. Child #4 was in classroom E and has a dietary restriction (no pork) and it was not on the allergy/sensitivity/ dietary restriction list.
Plan of Correction: We have updated the allergy list that includes allergies, dietary preferences, and sensitivities and provided every classroom with a copy. During our 6/4/25 staff meeting, we reviewed how to access this information in our Procare Engage App that all staff have access to.
Standard 8VAC20-780-440-E
There shall be at least 12 inches of space between occupied cots, beds, and rest mats. Some children in Room C and Room E were observed during sleeping with only between 4 to 5 1/2 inches between their cots.
Plan of Correction: We completed a staff meeting on 6/4/25 and reviewed the requirements for cot placements. We have created new cot maps to ensure this.
Standard 8VAC20-780-500-A
Children's hands shall be washed with soap and running water or disposable wipes before and after eating meals or snacks. Children in Room F were observed eating and their hands were not washed before or after eating.
Plan of Correction: We completed a staff meeting on 6/4/25 and reviewed handwashing rules as well as best practice transition strategies to prevent recontamination.
Standard 8VAC20-780-530-A
At least one staff in each classroom or area where children are present shall have current certification in both CPR and first aid. Staff #9 was alone during naptime with a group of ten, three-year-old children and was not certified in CPR or first aid.
Plan of Correction: Staff #9 is no longer employed
Standard 8VAC20-780-540-E
The center did not have all required nonmedical emergency supplies. The center was missing one working, battery-operated radio.
Plan of Correction: We have ordered and placed the weather radio in the office.
Standard 8VAC20-780-60-A
Each center shall maintain and keep at the center a separate record for each child enrolled that contains all of the required information.
1.Child #1?s record did not include the annual update, the second emergency contact name, address and phone number, the employment location and or phone number for both parents listed and the home address and phone number for one parent listed. Child #1 did not have a copy of a physical conducted by a physician. The physical is required within 30 days after the first day of attendance. Child #1 has been attending for more than 1 year.
2.Child #2?s record did not include the annual update, employment location and phone number for both parents listed .
3. Child #4?s record did not include the annual update, written agreements between the parent and the center, an immunization record required prior to attending or a copy of a physical conducted by a physician. The physical is required within 30 days after the first day of attendance. Child #4 has been attending for more than 2 1/2 years.
4.Child #5 and Child #7's record did not include the employment phone number for one parent listed.
1.Child #1?s record did not include the annual update, the second emergency contact name, address and phone number, the employment location and or phone number for both parents listed and the home address and phone number for one parent listed. Child #1 did not have a copy of a physical conducted by a physician. The physical is required within 30 days after the first day of attendance. Child #1 has been attending for more than 1 year.
2.Child #2?s record did not include the annual update, employment location and phone number for both parents listed .
3. Child #4?s record did not include the annual update, written agreements between the parent and the center, an immunization record required prior to attending or a copy of a physical conducted by a physician. The physical is required within 30 days after the first day of attendance. Child #4 has been attending for more than 2 1/2 years.
4.Child #5 and Child #7's record did not include the employment phone number for one parent listed.
Plan of Correction: We have completed this and added to their file. We will ensure all requirements are met moving forward by following the added staff checklist that includes all due dates. Staff #9 is no longer employeed.
Standard 8VAC20-780-70
All required documentation shall be maintained for staff records.
1.Staff #1, Staff #2, Staff #4 and Staff #7 did not have documentation required to be kept at the center regarding any health problems that may interfere with fulfilling the job responsibilities and emergency contacts.
2. Staff #2 and Staff #7 have been employed do not have documentation that two or more references as to character and reputation as well as competency were checked before employment.
3.The record for Staff #9 was not available for review to include background checks. Staff #9 was observed working alone with children.
1.Staff #1, Staff #2, Staff #4 and Staff #7 did not have documentation required to be kept at the center regarding any health problems that may interfere with fulfilling the job responsibilities and emergency contacts.
2. Staff #2 and Staff #7 have been employed do not have documentation that two or more references as to character and reputation as well as competency were checked before employment.
3.The record for Staff #9 was not available for review to include background checks. Staff #9 was observed working alone with children.
Plan of Correction: We have completed this and added to their file. We will ensure all requirements are met moving forward by following the added staff checklist that includes all due dates. Staff #9 is no longer employeed.