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Shining Stars Montessori

Inspection · 2025-02-25

Date
2025-02-25
Complaint Related
No
Licensing Inspector
Monique Anderson
(540) 309-2397
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 record
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 02/25/2025 and completed on 03/07/2025. The on-site inspection began at 9:00 a.m. and ended at 11:45 a.m. Two inspectors reviewed compliance in the areas listed above. There were 17 children present and 4 staff. The inspectors reviewed 5 children?s records and 7 staff records on-site and addition documents electronically on 03/07/2025. 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.

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 03/13/2025. A POC submitted after this date will not appear on the public website.

Violations

16
Standard 22.1-289.035-B-1
REPEAT VIOLATION, SYSTEMIC VIOLATION
The center is required to obtain a completed sworn statement prior to the employee's first day of employment.

The sworn statement for Staff 2 was dated two weeks after their first day of employment. There was no sworn statement available for Staff 4, employed over three months. The sworn statement for Staff 5, employed over three months, was not signed.
Plan of Correction: Already corrected.
Statement in employee files.
Standard 22.1-289.035-B-2
SYSTEMIC VIOLATION
Providers must obtain a completed national criminal background check prior to the employee's first day of employment.

Staff 6, employed for one month, did not have a completed national criminal background check.
Plan of Correction: Already ordered CSR.
Waiting on CSR return
Contacted CSR 2/26/25
Standard 22.1-289.035-B-3
SYSTEMIC VIOLATION
The center must request a search of the central registry prior to the employee's first day of employment.

The record for Staff 7, employed over three months, had no documentation a search of the central registry was requested.
Plan of Correction: Already ordered CSR.
Waiting on CSR return.
Contacted CSR 2/26/2025.
Standard 22.1-289.035-B-4
REPEAT VIOLATION, SYSTEMIC VIOLATION
The center is required to obtain background checks from any state in which the individual has resided in the preceding five years.

Staff 7, employed over three months, did not have documentation of an out-of-state criminal history record check, a sex offender registry check, or a search of the child abuse and neglect registry.
Plan of Correction: Already ordered CSR.
Waiting on CSR.
Contacted CSR on 02/26/2025.
Standard 8VAC20-780-130-A
SYSTEMIC VIOLATION
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.

There were no immunization records for Child 4 and Child 5, who had been enrolled for three weeks.
Plan of Correction: Instructed parent to provide copy.
Standard 8VAC20-780-160-A
REPEAT VIOLATION, SYSTEMIC VIOLATION
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.

Staff 1, Staff 4, Staff 5, and Staff 6 had no documentation of a negative TB screening.
The TB screening for Staff 2 was obtained one year prior to employment. The TB screening for Staff 3 was obtained one year and five months prior to employment.
Plan of Correction: Staff ordered TB copy with signature.
Standard 8VAC20-780-160-B
SYSTEMIC VIOLATION
Acceptable forms of documentation of tuberculosis screening are a clearance statement signed by a physician, the physician designee or official of the local health department.

The TB screening for Staff 7 was not signed by a physician, physician's designee, or an official of the local health department.
Plan of Correction: Record added to files.
Standard 8VAC20-780-240-A
Staff are to complete the VDOE sponsored online orientation course within 90 days of hire.

Staff 2, Staff 4, Staff 5, Staff 6, and Staff 7 did not have the VDOE sponsored online orientation course. All staff have been employed for over 90 days.
Plan of Correction: Staff completed
Standard 8VAC20-780-240-B
Staff shall complete orientation training prior to the staff member working alone with children and no later than seven days of the date of assuming job responsibilities.

Staff 4, employed over three months, and Staff 7, employed over three months, had no documentation of orientation training.
Plan of Correction: Added records as proof orientation was completed.
Standard 8VAC20-780-260-B
Annual approval from the health department shall be provided.

Approval from the health department was overdue by 2 months.
Plan of Correction: Provided copy to inspector.
Standard 8VAC20-780-280-B
Hazardous substances such as cleaning materials shall be kept in a locked place using a safe locking method that prevents access by children.

A spray bottle labeled ?Bleach/water? was unlocked hanging on a wall vent in Bathroom 1.
Plan of Correction: Locked substances away.
Standard 8VAC20-780-340-D
In each grouping of children at least one staff member who meets the qualifications of a program leader or program director shall be regularly present.

Staff 2, identified as the program leader of a group of children, did not meet program leader qualifications.
Plan of Correction: Not available online. Contact Inspector for more information.
Standard 8VAC20-780-350-C
When children are in ongoing mixed age groups, the staff to child ratio and group size applicable to the youngest child in the group shall apply to the entire group.

On 02/25/2025, Staff 1 was the only staff member supervising the on-going mixed age group of 13 children aged 2 years to 4 years. The required staff to child ratio for this group of children would be 1:8. Two staff were required for this group.
Plan of Correction: Changed staff schedule to ensure ratio
Standard 8VAC20-780-520-C
Diaper ointment shall be inaccessible to children.

In restroom 1, three diaper ointments were stored in open bins beneath the changing table and were accessible to children. Children were observed using this restroom.
Plan of Correction: Placed ointment in first aid container out of reach from children.
Standard 8VAC20-780-60-A
REPEAT VIOLATION,SYSTEMIC VIOLATION
Each center shall maintain and keep at the center a separate record for each child enrolled that contains all of the required information.

The records for Child 1, Child 2, Child 3, Child 4 and Child 5, enrolled from 3 weeks to over five months, were each missing several of the required components.
Plan of Correction: Instructed parent to provide copy
Standard 8VAC20-780-70
REPEAT VIOLATION, SYSTEMIC VIOLATION
Staff records shall be kept for each staff person that contain all of the required information.

The records for all 7 staff were each missing several of the required components.
Plan of Correction: Records updated