Inspection · 2024-11-12
Licensing Inspector
Florence Martus
(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.
8VAC20-820 THE LICENSE.
8VAC20-820 THE LICENSING PROCESS.
8VAC20-820 HEARINGS PROCEDURES.
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 11/12/2024 and completed on 11/21/2024, as a part of the licensure period. The on-site inspection began at 12:20pm and ended at 3:50pm. The inspector reviewed compliance in the areas listed above. There were 39 children present and eight staff. The inspector reviewed five children?s records and nine staff records on-site. Additional documentation was reviewed electronically on 11/21/2024. 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 (5) business days from today, which will be the close of business on 12/11/2024. A POC submitted after this date will not appear on the public website.
Standard 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 08/12/2024, were not posted in a conspicuous place on the premises.
Plan of Correction: Per the Center: "**The License and inspection reports are posted out front underneath each other so that it can be seen but cannot fall or be removed easily."
Standard 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.
The sworn statement of Staff #1, who is currently working, was dated one day after their first day of employment.
Plan of Correction: Per the Center: "**We have created an on-boarding package and check list for new hires so that they complete all necessary documents on time."
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 #1, employed for more than 6 months, did not have documentation of requesting a central registry check from two states.
Staff #2, employed for more than 10 months, did not have documentation of requesting a central registry check from one state.
Plan of Correction: Per the Center: "**We are creating a step-by-step manual on how to do out-of-state background checks with the assistance of my inspector. This will be something that will make it easier and keep us compliant in this area."
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 three months after the child?s first day of attendance.
Plan of Correction: Per the Center: "**We collect all documents from parents at the time of enrollment. If there is an appointment set for the child, we will enroll and let them start if it is within two weeks."
Standard 8VAC20-780-140-A
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 obtained three months after the child?s first day of attendance.
Plan of Correction: Per the Center: "** We collect all documents from parents at the time of enrollment. If there is an appointment set for the child, we will enroll and let them start if it is within two weeks."
Standard 8VAC20-780-160-A
Documentation of a negative tuberculosis (TB) screening must be submitted at the time of employment, before coming into contact with children, and shall have been completed within the last 30 days of the date of employment.
The TB in the record of Staff #2 was dated more than one month prior to the date of employment.
Plan of Correction: Per the Center: "** We have created on-boarding packages for new hires so that they complete all necessary documents at one time, on time."
Standard 8VAC20-780-240-A
Staff are to complete the VDOE-sponsored orientation course within 90 calendar days of employment.
Staff #4 completed the course 18 days late.
Plan of Correction: Per the Center: "** We have created on-boarding packages for new hires so that they complete all necessary documents at one time, on time."
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.
The record of Child #1, enrolled for over nine months, was missing previous child day care and schools attended by the child.
The record of Child #2, enrolled for a month, was missing the following required components: name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached; and previous child day care and schools attended by the child.
The record of Child #3, enrolled for three months, was missing previous child day care and schools attended by the child.
The record of Child #5, enrolled for over six months, was missing previous child day care and schools attended by the child.
Plan of Correction: Per the Center: "**We have created new 2025-2026 applications that include VDSS application information and all the information from our previous application. This ensures that all information required is a part of the application."
Standard 8VAC20-780-60-A-7
Each center shall maintain and keep at the center a separate record for each child enrolled that contains information on allergies and intolerance to medication or any other substances, and actions to take in an emergency situation.
The records of Child #1, Child #2, Child #3, and Child #5 did not contain information on allergies and intolerance to medication or any other substances, and actions to take in an emergency situation. The children had been enrolled between one to nine months.
Plan of Correction: Per the Center: "**We have created new 2025-2026 applications that include VDSS application information and all the information from our previous application. This ensures that all information required is a part of the application."
Standard 8VAC20-780-70
Documentation of at least 2 references to character, reputation, and competency are to be checked prior to employment.
The references in the record of Staff #1 were checked five and nine days after the staff started employment.
Plan of Correction: Per the Center: "** We have created on-boarding packages for new hires so that they complete all necessary documents at one time, on time; this includes references to be checked prior to the first day of employment."