Inspection · 2025-10-17
Date
2025-10-17
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.
Inspector Notes
An unannounced, on-site focused inspection was initiated on 10-17-2025 and completed on 10-21-2025, as a part of an Intensive Plan of Correction (IPOC). The on-site inspection began at 10:20am and ended at 11:35am. The inspector reviewed compliance in the areas listed above. There was 1 child present and 2 staff. The inspector reviewed 1 child's records and 2 staff records on-site and electronically on 10-20-2025 and 10-21-2025.
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 10-29-2025. A POC submitted after this date will not appear on the public website.
Violations
5Standard 8VAC20-780-160-B
The results of a negative tuberculin skin test shall include the date the test was given and results of the test and be signed by a physician, physician's designee or an official of the local health department. The TB results for Staff #1 did not include signature by a physician, physician's designee or an official of the local health department.
Plan of Correction: To comply with the current regulation that TST results "be signed by a physician, physician's designee or an official of the local health department," Staff #1 will immediately obtain an official, correctly signed copy of their negative TST results from the administering healthcare provider or local health department. This official document will be placed in the staff member's personnel file within 7 business days. Furthermore, the Program Director will conduct an audit of all current staff personnel files to ensure every required medical document, including TST
results, meets all signature and date requirements for future compliance.
results, meets all signature and date requirements for future compliance.
Standard 8VAC20-780-270-A
Repeat Violation
Areas and equipment of the center, inside and outside, shall be maintained in a clean, safe and operable condition.
1.The playground had a wooden post and fence with areas of chipped and peeling paint.
2. The snack area had one wall with an area of chipped and peeling paint
Areas and equipment of the center, inside and outside, shall be maintained in a clean, safe and operable condition.
1.The playground had a wooden post and fence with areas of chipped and peeling paint.
2. The snack area had one wall with an area of chipped and peeling paint
Plan of Correction: Due to recent rain, the exterior damage may have been exacerbated. To immediately rectify this, all affected areas, both indoor and outdoor, will be scraped, sanded, and repainted with non-toxic, lead-free paint within seven days.
While waiting for repairs, the damaged playground section will be temporarily blocked off using blue tape to prevent all child access. We will implement and maintain a system of daily safety checks between 9:30 AM and 10:00 AM,
focusing on surfaces, equipment, and walls, and will maintain a written log to document inspection findings and track all necessary repairs to ensure ongoing compliance
While waiting for repairs, the damaged playground section will be temporarily blocked off using blue tape to prevent all child access. We will implement and maintain a system of daily safety checks between 9:30 AM and 10:00 AM,
focusing on surfaces, equipment, and walls, and will maintain a written log to document inspection findings and track all necessary repairs to ensure ongoing compliance
Standard 8VAC20-780-340-C
During the stated hours of operation, there always shall be on the premises when one or more children are present, one staff member who meets the qualifications of a program leader or program director and an immediately available staff member.
1.Staff #1 was the only staff was on site with one child for approximately 30 minutes.
2.During the inspection there was not a staff on site that meets the qualifications for program leader or program director.
1.Staff #1 was the only staff was on site with one child for approximately 30 minutes.
2.During the inspection there was not a staff on site that meets the qualifications for program leader or program director.
Plan of Correction: To correct this, we will immediately re-review and enforce the opening procedure to ensure that at least two qualified staff members are always on the premises before any child is admitted, regardless of early arrivals. Furthermore, we will verify the current program leader/director qualifications of all existing staff and ensure a staff member with the correct credentials is always present during operational
hours. All staff will sign an acknowledgment of this policy change and receive retraining on staffing requirements by the end of the week.
hours. All staff will sign an acknowledgment of this policy change and receive retraining on staffing requirements by the end of the week.
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 shall be regularly present. Staff #1 and Staff #2 do not have documentation of program lead or program director qualifications and were the only staff supervising the child in care.
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 #1 and Staff #2 do not have documentation of program lead or program director qualifications and were the only staff supervising the child in care.
Plan of Correction: We will consult the standards and will verify the current program leader/director
qualifications of all existing staff and ensure a staff member with the correct credentials is always present during operational hours. All staff will sign an acknowledgment of this policy change and receive retraining on staffing requirements by the end of the week.
qualifications of all existing staff and ensure a staff member with the correct credentials is always present during operational hours. All staff will sign an acknowledgment of this policy change and receive retraining on staffing requirements by the end of the week.
Standard 8VAC20-780-70
Repeat Violation
The provider shall keep for each staff person all the required information. Staff #1 and Staff #2 were missing documentation to demonstrate they possessed the education, certification, and experience required by the job position. Staff #1 and Staff #2 are designated as program leaders and they do not have documentation to support the qualifications.
The provider shall keep for each staff person all the required information. Staff #1 and Staff #2 were missing documentation to demonstrate they possessed the education, certification, and experience required by the job position. Staff #1 and Staff #2 are designated as program leaders and they do not have documentation to support the qualifications.
Plan of Correction: We will consult the standards and will verify the current program leader/director qualifications of all existing staff and ensure a staff member with the correct credentials is always present during operational hours. All staff will sign an
acknowledgment of this policy change and receive retraining on staffing requirements by the end of the week.
acknowledgment of this policy change and receive retraining on staffing requirements by the end of the week.