Inspection · 2025-09-29
Date
2025-09-29
Complaint Related
No
Licensing Inspector
D'Nae Goodwin
(757) 404-3063
(757) 404-3063
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.
8VAC20-770 Background Checks
20 Access to minor?s records
22.1 Early Childhood Care and Education
63.2 Child Abuse and 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 and completed on 9/29/25.The on-site inspection began at 4:00pm and ended at 5:15pm. The inspector reviewed compliance in the areas listed above. There were 52 children present and four staff. The inspector reviewed five children?s records and four staff records electronically on 10/7/25. This inspection included document review, a 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 10/15/25. A POC submitted after this date will not appear on the public website.
Violations
15Standard 22.1-289.035-B-1
Repeat 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 (employed for four months) was dated one day after their first day of employment.
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 (employed for four months) was dated one day after their first day of employment.
Plan of Correction: The sworn statement for Staff #2 has been corrected. Going forward, all new hires will complete the sworn statement prior to the first day of work.
Standard 22.1-289.035-B-2
Repeat Violation
Providers must obtain a completed national criminal background check prior to the employee's first day of employment.
The criminal history background check for Staff #2 (employed for four months) was not obtained prior to the employee's first day of employment.
Providers must obtain a completed national criminal background check prior to the employee's first day of employment.
The criminal history background check for Staff #2 (employed for four months) was not obtained prior to the employee's first day of employment.
Plan of Correction: The required national background check for Staff #2 has now been obtained and filed. Going forward, the criminal history background check will be completed prior to the first day of employment.
Standard 8VAC20-780-240-A
Repeat Violation
The Virginia Department of Education-sponsored orientation course shall be completed within 90 calendar days of employment.
The record for Staff #2 (employed for four months) did not contain documentation of The Virginia Department of Education-sponsored orientation course.
The Virginia Department of Education-sponsored orientation course shall be completed within 90 calendar days of employment.
The record for Staff #2 (employed for four months) did not contain documentation of The Virginia Department of Education-sponsored orientation course.
Plan of Correction: The program director will ensure that all staff complete the orientation course within their first 90 days of employment. Staff #2 is working on this training and has been given a deadline to complete this training.
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.
Orientation documentation for Staff #2 (employed for four months) show that the staff member completed orientation training past seven days of the date of assuming job responsibilities.
Orientation documentation for Staff #2 (employed for four months) show that the staff member completed orientation training past seven days of the date of assuming job responsibilities.
Plan of Correction: Going forward, the required orientation training will be completed within the first 7 days of assuming job responsibilities.
Standard 8VAC20-780-260-A
The center shall provide to the licensing representative an annual fire inspection report from the appropriate fire official having jurisdiction.
The fire inspection documentation for review was expired.
The fire inspection documentation for review was expired.
Plan of Correction: The program director has requested an updated fire inspection report from the school where the program operates.
Standard 8VAC20-780-260-B
The center shall provide annual approval from the health department.
There was no documentation to show that an environmental sanitation report was completed in 2025, which is required annually.
There was no documentation to show that an environmental sanitation report was completed in 2025, which is required annually.
Plan of Correction: The program director has requested an updated environmental sanitation report from the school where the program operates.
Standard 8VAC20-780-340-B
During the center's hours of operation, one adult on the premises shall be in charge of the administration of the center. This person shall be either the administrator or an adult appointed by the licensee or designated by the administrator.
On the day of the inspection, there was not one adult in charge of the administration of the center, which is required.
On the day of the inspection, there was not one adult in charge of the administration of the center, which is required.
Plan of Correction: A written chain of command has been posted at the site. The program director will designate a person in charge in their absence and ensure all staff are aware of whom this person is during orientation.
Standard 8VAC20-780-340-F
Children under 10 years of age always shall be within actual sight and sound supervision of staff.
During the inspection, a child under the age of ten was observed leaving their group outside, and entering the building to go to the water fountain. The child was not within sight and sound supervision of staff.
During the inspection, a child under the age of ten was observed leaving their group outside, and entering the building to go to the water fountain. The child was not within sight and sound supervision of staff.
Plan of Correction: Staff have been retrained on sight and sound supervision requirements. Children are now escorted indoors in pairs with staff when leaving outdoor areas.
Standard 8VAC20-780-350-B-5
The required ratio for children ages school age eligible up to nine years is one staff per 18 children.
Staff #4 was observed supervising over the required ratio, two times during the inspection.
Staff #4 was observed supervising over the required ratio, two times during the inspection.
Plan of Correction: Staff schedules were adjusted to ensure coverage. Staff were reminded that leaving a group unattended violates ratio standards.
Standard 8VAC20-780-350-B-6
The required ratio for children ages nine years through 12 years is one staff per 20 children. Staff #1 and Staff #2 (working together on the day of the inspection), were observed leaving each other to care for the group of children alone, resulting in a staff member having to supervise more children than allowed (one staff per 20 children).
Plan of Correction: Staff schedules were adjusted to ensure overlapping coverage. Staff were reminded that leaving a group unattended violates ratio standards.
Standard 8VAC20-780-550-D
The center shall implement a monthly practice evacuation drill.
A monthly evacuation drill was not completed for the months of April through June of 2025.
A monthly evacuation drill was not completed for the months of April through June of 2025.
Plan of Correction: The program director has scheduled monthly evacuation drills on their calendar. The program director will ensure this gets completed and is documented monthly.
Standard 8VAC20-780-550-E
Shelter in place procedures shall be practiced a minimum of twice per year.
Shelter in place procedures were not practiced, at a minimum of two times during the 2024-2025 school year.
Shelter in place procedures were not practiced, at a minimum of two times during the 2024-2025 school year.
Plan of Correction: The program director has scheduled shelter in place drills on their calendar. The program director will ensure this gets completed and documented.
Standard 8VAC20-780-550-F
Lockdown procedures shall be practiced at least annually.
Lockdown procedures were not practiced during the 2024-2025 school year. One lockdown drill is required.
Lockdown procedures were not practiced during the 2024-2025 school year. One lockdown drill is required.
Plan of Correction: The program director has scheduled lockdown drills on their calendar. The program director will ensure this gets completed and is documented.
Standard 8VAC20-780-550-P
The center shall maintain a written record of children's serious and minor injuries in which entries are made the day of occurrence. The record shall include all the required information.
Two of four injury reports reviewed did not contain one of the following: staff and parent signatures or two staff signatures.
Two of four injury reports reviewed did not contain one of the following: staff and parent signatures or two staff signatures.
Plan of Correction: The program director will ensure that a staff person makes contact with a parent after the incident and that all injury reports will have at least two staff signatures, since parents do not pick up their children from the program.
Standard 8VAC20-780-70
Repeat Violation
Staff records shall be kept for each staff person and contain all the required information.
The record for Staff #1 (employed for less than one month) did not contain documentation to demonstrate that the individual possesses orientation training. The record for Staff #3 (employed for 11 months) only contained one reference, when two are required.
Staff records shall be kept for each staff person and contain all the required information.
The record for Staff #1 (employed for less than one month) did not contain documentation to demonstrate that the individual possesses orientation training. The record for Staff #3 (employed for 11 months) only contained one reference, when two are required.
Plan of Correction: The orientation training for Staff #1 has been completed. The references for Staff #3 has also been completed. Going forward, the program director will ensure these items are completed by the required timeline.