Inspection · 2025-05-29
Date
2025-05-29
Complaint Related
No
Licensing Inspector
Morgan Bryson
(540) 270-0057
(540) 270-0057
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
22.1 Religious Exempt; Background Checks Code, Carbon Monoxide
8VAC20-770 Background Checks
32.1 Report by person other than physician
54.1 Must be MAT certified
63.2 Child Abuse and Neglect
During the inspection, the inspector reviewed the areas listed above. 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 code compliance inspection was initiated and completed on 5/29/2025. The on-site inspection began at 9:40am and ended at 10:50am. The inspector reviewed compliance in the areas listed above. There were 9 children present with 2 staff. The inspector reviewed 9 children?s records and 3 staff records on-site and electronically. This inspection included document review, tour of the facility, interviews, and observations. Information gathered during the inspection determined non-compliances with applicable code sections, 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 6/6/2025. A POC submitted after this date will not appear on the public website.
Violations
13Standard 22.1-289.031-A
The Religious Exempt Child Day Center is required to post the fact that it is exempt from licensure in a visible location on the premises, the qualifications of the personnel employed therein, and the tax exempt status as a nonprofit religious institution.
The center did not have documentation posted that they are exempt from licensure, the qualifications of employed personnel, or their tax exempt status.
The center did not have documentation posted that they are exempt from licensure, the qualifications of employed personnel, or their tax exempt status.
Plan of Correction: A memo will be issued and staff wide retraining sessions shall be held to ensure full and complete awareness and adherence to policy and procedures.
Standard 22.1-289.031-A-3-a
The Religious Exempt Child Day Center is required to maintain a ratio of one staff member to four children for children ages zero to 16 months.
From 10:04am to 10:10am there were 9 children with 1 staff and from 10:10am to 10:50am there were 9 children with 2 staff. The youngest child in the group was 12 months old making the ratio one staff to four children.
From 10:04am to 10:10am there were 9 children with 1 staff and from 10:10am to 10:50am there were 9 children with 2 staff. The youngest child in the group was 12 months old making the ratio one staff to four children.
Plan of Correction: A memo will be issued and staff wide retraining sessions will be held to ensure full and complete awareness and adherence to policy and procedures.
Standard 22.1-289.031-A-3-b
The Religious Exempt Child Day Center is required to maintain a ratio of one staff member to five children for children ages 16 months to 24 months.
At 9:40am there were six children with one volunteer and the youngest child was 23 months old. A second staff member arrived at 10:10am.
At 9:40am there were six children with one volunteer and the youngest child was 23 months old. A second staff member arrived at 10:10am.
Plan of Correction: A memo will be issued and staff wide retraining sessions shall be held to ensure full and complete awareness and adherence to policy and procedures.
Standard 22.1-289.031-A-6
The Religious Exempt Child Day Center is required to provide a written statement to parents or guardians of the children in the center and made available to the general public including their physical facilities, enrollment, food services, health requirements for the staff, and public liability insurance.
There was no documentation that the required written statement was provided to parents or made available to the general public.
There was no documentation that the required written statement was provided to parents or made available to the general public.
Plan of Correction: A memo will be issued and staff wide retraining sessions shall be held to ensure full and complete awareness and adherence to policy and procedures.
Standard 22.1-289.031-A-8
A person trained and certified in first aid and cardiopulmonary resuscitation (CPR) will be present at the center whenever children are present.
Volunteer #1 was the only adult present at the beginning of the inspection at 9:40am. Volunteer #1 does not have CPR/First Aid certification and was alone with 9 children ages 12 months to five years old until 10:10am.
Volunteer #1 was the only adult present at the beginning of the inspection at 9:40am. Volunteer #1 does not have CPR/First Aid certification and was alone with 9 children ages 12 months to five years old until 10:10am.
Plan of Correction: A memo will be issued and staff wide retraining sessions shall be held to ensure full and complete awareness and adherence to policy and procedures.
Standard 22.1-289.031-B-3
A daily simple health screening and exclusion of sick children shall be conducted by a person trained to perform such screenings.
There were no staff present who have received training to conduct a daily simple health screening.
There were no staff present who have received training to conduct a daily simple health screening.
Plan of Correction: A memo will be issued and staff wide retraining sessions shall be held to ensure full and complete awareness and adherence to policy and procedures.
Standard 22.1-289.031-B-4
The Religious Exempt Child Day Center shall ensure that all children in the center are in compliance with the provisions of ? 32.1-46 regarding the immunization of children against certain diseases.
Child #1, Child #2, Child #4, Child #5, Child #7, Child #8, and Child #9 did not have immunizations on file.
Child #1, Child #2, Child #4, Child #5, Child #7, Child #8, and Child #9 did not have immunizations on file.
Plan of Correction: Updated student health forms to be sent to all students to ensure uniform compliance.
Standard 22.1-289.035-B-1
The Religious Exempt Child Day Center shall obtain a sworn disclosure statement for all volunteers prior to volunteering.
Volunteer #1 has volunteered at the program for approximately one year and did not have a sworn disclosure statement on file.
Volunteer #1 has volunteered at the program for approximately one year and did not have a sworn disclosure statement on file.
Plan of Correction: Sworn disclosure statements will be completed by all outstanding team members to ensure full and complete compliance.
Standard 22.1-289.035-B-2
The Religious Exempt Child Day Center shall obtain the results of a fingerprint-based criminal history background check for all staff and volunteers prior to employment or volunteering.
Staff #1 and Staff #2, employed for approximately one year, did not have fingerprinting results on file. Volunteer #1, who has volunteered for approximately on year, did not have fingerprinting results on file. Volunteer #1 was left alone with the children from the beginning of the inspection at 9:40am until 10:10am.
Staff #1 and Staff #2, employed for approximately one year, did not have fingerprinting results on file. Volunteer #1, who has volunteered for approximately on year, did not have fingerprinting results on file. Volunteer #1 was left alone with the children from the beginning of the inspection at 9:40am until 10:10am.
Plan of Correction: Finger-print based criminal history checks will be completed by all outstanding team members will be conducted through Prince William county police to ensure full and complete compliance.
Standard 22.1-289.035-B-3
The Religious Exempt Child Day Center shall request the results of a central registry search for all staff and volunteers prior to employment or volunteering.
Staff #1 and Staff #2, employed for approximately one year, and Volunteer #1, who has volunteered for approximately one year, did not have central registry search requests or results on file.
Staff #1 and Staff #2, employed for approximately one year, and Volunteer #1, who has volunteered for approximately one year, did not have central registry search requests or results on file.
Plan of Correction: A central registry background screening will be conducted through Prince William county policy to ensure full and complete compliance.
Standard 22.1-289.049-A
The Religious Exempt Child Day Center shall obtain proof of the child's identity and age upon enrollment.
Child #1, Child #2, Child #3, Child #4, Child #5, Child #6, Child #7, Child #8, and Child #9 did not have documentation their proof of identity and age was verified upon enrollment.
Child #1, Child #2, Child #3, Child #4, Child #5, Child #6, Child #7, Child #8, and Child #9 did not have documentation their proof of identity and age was verified upon enrollment.
Plan of Correction: Updated student enrollment forms to be sent to all students to ensure uniform compliance.
Standard 22.1-289.057-A
The Religious Exempt Child Day Center is required to submit to VDH and implement a plan to test potable water for lead.
The center serves preschool age children and did not have evidence of a testing plan submitted to VDH.
The center serves preschool age children and did not have evidence of a testing plan submitted to VDH.
Plan of Correction: Instead of developing and implementing a plan for testing or remediation, our program has chosen to use bottled water, water coolers, or other similar water sources for human consumption that meets the U.S. Food and Drug Administration (FDA) standards for bottled water. Pursuant to 32.1-167 of the Code of Virginia, human consumption.
Standard 22.1-289.057-B
The Religious Exempt Child Day Center is required to submit results of potable water testing to VDH.
The Religious Exempt Child Day Center did not have evidence of submitting test results to VDH.
The Religious Exempt Child Day Center did not have evidence of submitting test results to VDH.
Plan of Correction: Instead of developing and implementing a plan for testing or remediation, our program has chosen to use bottled water, water coolers, or other similar water sources for human consumption that meets the U.S. Food and Drug Administration (FDA) standards to bottle water. Pursuant to 32.167 of the Code of Virginia, human consumption.