Inspection · 2025-05-22
Date
2025-05-22
Complaint Related
No
Licensing Inspector
Cathy Aylor
(540) 222-6352
(540) 222-6352
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 renewal inspection was initiated on 5/22/25 and completed on 5/23/25, as a part of the conditional licensure period.The on-site inspection began at 11:45 am and ended at 4:15 pm. The inspector reviewed compliance in the areas listed above. There were 26 children present and 6 staff. The inspector reviewed 7 children?s records and 6 staff records on site on 5/22/25 and electronically on 5/23/25. 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 6/23/25. A POC submitted after this date will not appear on the public website.
Violations
13Standard 22.1-289.035-B-4
Repeat Violation:
Systemic Deficiency:
Out-of-state Central Registry background checks must be requested prior to employment
for each state a staff has resided in the past 5 years.
An out-of-state central registry background check had not been requested for staff A, this request was19 weeks overdue.
Systemic Deficiency:
Out-of-state Central Registry background checks must be requested prior to employment
for each state a staff has resided in the past 5 years.
An out-of-state central registry background check had not been requested for staff A, this request was19 weeks overdue.
Plan of Correction: Background check was completed prior to the inspection and was reprinted and provided to licensor post visit.
Standard 8VAC20-780-130-A
Systemic Deficiency:
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 on file for child B or child C, which was overdue by 4 months for child B ad 3 days for child C.
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 on file for child B or child C, which was overdue by 4 months for child B ad 3 days for child C.
Plan of Correction: Management was retrainned on enrollment process.
Document was obtained
Document was obtained
Standard 8VAC20-780-150-B
Systemic Deficiency:
Each report shall include the dates immunizations were received and shall be signed by a physician, his designee, or an official of a local health department.
The immunizations for child D was not signed by a physician/designee or health department. Child D enrolled the day of the inspection.
Each report shall include the dates immunizations were received and shall be signed by a physician, his designee, or an official of a local health department.
The immunizations for child D was not signed by a physician/designee or health department. Child D enrolled the day of the inspection.
Plan of Correction: Staff were retrained on student files.
Parent provided a signed immunization record.
Parent provided a signed immunization record.
Standard 8VAC20-780-160-A
Systemic Deficiency:
Each staff member shall submit documentation of a negative tuberculosis screening. The documentation shall have been completed within the last 30 calendar days of the date of employment and has be signed by a physician, their designee or health department official.
Staff A's tuberculosis test was dated 11 weeks prior to employment.
Each staff member shall submit documentation of a negative tuberculosis screening. The documentation shall have been completed within the last 30 calendar days of the date of employment and has be signed by a physician, their designee or health department official.
Staff A's tuberculosis test was dated 11 weeks prior to employment.
Plan of Correction: A new TB test was completed.
Standard 8VAC20-780-210-A-4
Repeat Violation:
Systemic Deficiency::
Program leaders(lead teachers) shall be at least 18 years of age and fulfill a high school program or the equivalent, have 3 months of programmatic experience and within one month of being promoted or beginning work have a minimum of 24 hours of lead teacher training to include child development, health and safety , preventing and reporting abuse and neglect and playground safety.
Staff A has functioning as a lead teacher for 5 weeks but there is no documentation of the 24 hours of lead teacher training.
Staff B has been functioning as a lead teacher for 4 months and has 10 of the required 24 hours of lead teacher training.
Staff C has been functioning as a lead teacher for 4 months and has no documentation of the 24 hours of lead teacher training.
Systemic Deficiency::
Program leaders(lead teachers) shall be at least 18 years of age and fulfill a high school program or the equivalent, have 3 months of programmatic experience and within one month of being promoted or beginning work have a minimum of 24 hours of lead teacher training to include child development, health and safety , preventing and reporting abuse and neglect and playground safety.
Staff A has functioning as a lead teacher for 5 weeks but there is no documentation of the 24 hours of lead teacher training.
Staff B has been functioning as a lead teacher for 4 months and has 10 of the required 24 hours of lead teacher training.
Staff C has been functioning as a lead teacher for 4 months and has no documentation of the 24 hours of lead teacher training.
Plan of Correction: This employee was originally hired under the previous management team.
Following a staff file audit, a classification error was
identified, and the employee was subsequently reclassified as an Assistant Teacher working alongside a Lead Teacher.
Following a staff file audit, a classification error was
identified, and the employee was subsequently reclassified as an Assistant Teacher working alongside a Lead Teacher.
Standard 8VAC20-780-340-A
When staff are supervising children, they shall always ensure their care, protection, and guidance.
In the two year old classroom, two children repeatedly jumped on, walked on their cots as well as trying to balance themselves on the edge of the cots, like a balance beam. The children were directed to stop once, the children ignored this directive and repeatedly engaged in the same behavior without further intervention or redirection to ensure their care and protection.
In the two year old classroom, two children repeatedly jumped on, walked on their cots as well as trying to balance themselves on the edge of the cots, like a balance beam. The children were directed to stop once, the children ignored this directive and repeatedly engaged in the same behavior without further intervention or redirection to ensure their care and protection.
Plan of Correction: The observed teacher was retrained but was later dismissed due to continued lack of attention to and disregard for established policies and procedures in the classroom.
Standard 8VAC20-780-40-M
Repeat Violation:
Systemic Deficiency:
The center shall maintain, in a way that is accessible to all staff who work with children, a current written list of all children's allergies, sensitivities, and dietary restrictions documented in the allergy plan required in 8VAC20-780-60 A 8. This list shall be dated and kept confidential in each room or area where children are present.
Child A has a diagnosed allergy to citrus per their physical, dated 2/27/25, this allergy was not on the center's April 2025 allergy list.
Systemic Deficiency:
The center shall maintain, in a way that is accessible to all staff who work with children, a current written list of all children's allergies, sensitivities, and dietary restrictions documented in the allergy plan required in 8VAC20-780-60 A 8. This list shall be dated and kept confidential in each room or area where children are present.
Child A has a diagnosed allergy to citrus per their physical, dated 2/27/25, this allergy was not on the center's April 2025 allergy list.
Plan of Correction: This inspection was completed 3 days after a change of management.
During the new Director's training she was trained on how to pull the report and the frequency of how often the report needs to be completed
During the new Director's training she was trained on how to pull the report and the frequency of how often the report needs to be completed
Standard 8VAC20-780-420-A
Systemic Deficiency:
Before the child's first day of attending, parents shall be provided in writing the center's policies and procedures, operational information etc.
There were no policies or procedures or operational information provided to parents in writing for child B ( overdue 4 months) and child C( overdue 3 days).
Before the child's first day of attending, parents shall be provided in writing the center's policies and procedures, operational information etc.
There were no policies or procedures or operational information provided to parents in writing for child B ( overdue 4 months) and child C( overdue 3 days).
Plan of Correction: Management was retrainined on enrollment process.
At no time should a child be in attenendce unless all enrollemnt forms are
completed and returned.
At no time should a child be in attenendce unless all enrollemnt forms are
completed and returned.
Standard 8VAC20-780-550-P
Repeat Violation:
Systemic Deficiency:
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 date and time when parents were notified.
There were 3 injury/accident reports that did not contain the time parents were notified of injuries.
Systemic Deficiency:
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 date and time when parents were notified.
There were 3 injury/accident reports that did not contain the time parents were notified of injuries.
Plan of Correction: Teachers have been retrained on the proper procedures for completing incident reports.
Standard 8VAC20-780-60-A
Systemic Deficiency:
Each center shall maintain and keep at the center a separate record for each child enrolled which shall contain the following information: parents work and home numbers, physician information, authorized pick up, emergency contact or allergy/intolerances.
There was no parent contact number, work information, physician information, authorization to pick up, emergency contact information or allergy/intolerances on file for child B and child C. This information was over due by 4 months for child B and by 3 days for child C.
Each center shall maintain and keep at the center a separate record for each child enrolled which shall contain the following information: parents work and home numbers, physician information, authorized pick up, emergency contact or allergy/intolerances.
There was no parent contact number, work information, physician information, authorization to pick up, emergency contact information or allergy/intolerances on file for child B and child C. This information was over due by 4 months for child B and by 3 days for child C.
Plan of Correction: Management was retrained on the enrollment process.
Children should not attend the program unless all enrollment forms have been completed and submitted.
Children should not attend the program unless all enrollment forms have been completed and submitted.
Standard 8VAC20-780-60-A-8
Repeat Violation:
Systemic Deficiency:
A written care plan for each child with a diagnosed food allergy, to include instructions from a physician regarding the food to which the child is allergic and the steps to be taken in the event of a suspected or confirmed allergic reaction.
There was no allergy care plan on file for child A's who has a citrus allergy, this plan was overdue by 2 months.
Systemic Deficiency:
A written care plan for each child with a diagnosed food allergy, to include instructions from a physician regarding the food to which the child is allergic and the steps to be taken in the event of a suspected or confirmed allergic reaction.
There was no allergy care plan on file for child A's who has a citrus allergy, this plan was overdue by 2 months.
Plan of Correction: The parent informed previous management of an allergy change, but no updated records were on file.Updated documentation was requested and has since been provided.
Standard 8VAC20-780-80-A
Repeat Violation:
Systemic Deficiency:
For each group of children, the center shall maintain a written record of daily attendance that documents the arrival and departure of each child in care as it occurs.
There were 8 children present in the two year old classroom and the 3/4 year old classroom however 7 children were marked present on the attendance for each room.
There were 6 children present in the Pre-K classroom however 8 children were marked as present.
Systemic Deficiency:
For each group of children, the center shall maintain a written record of daily attendance that documents the arrival and departure of each child in care as it occurs.
There were 8 children present in the two year old classroom and the 3/4 year old classroom however 7 children were marked present on the attendance for each room.
There were 6 children present in the Pre-K classroom however 8 children were marked as present.
Plan of Correction: Retraining was completed regarding how to clock children in and out of the Playground app.
Standard 8VAC20-780-90-A
Systemic Deficiency:
A written agreement between the parent and the center shall be in each child's record by the first day of the child's attendance. The agreement shall be signed by the parent and include authorization to seek emergency medical care, the parent(s) agrees to pick up their child as soon as possible if the child becomes ill and agree to informing the center within 24 hours or the next business day after the child or any household member contracts a reportable communicable disease.
There were no written agreements between the parent and center for child B ( overdue 4 months) and child C ( overdue 3 days).
A written agreement between the parent and the center shall be in each child's record by the first day of the child's attendance. The agreement shall be signed by the parent and include authorization to seek emergency medical care, the parent(s) agrees to pick up their child as soon as possible if the child becomes ill and agree to informing the center within 24 hours or the next business day after the child or any household member contracts a reportable communicable disease.
There were no written agreements between the parent and center for child B ( overdue 4 months) and child C ( overdue 3 days).
Plan of Correction: Management was retrained on the enrollment process.
Children should not attend the program unless all enrollment forms have been completed and submitted.
Children should not attend the program unless all enrollment forms have been completed and submitted.