Inspection · 2025-09-22
Date
2025-09-22
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 monitoring inspection was initiated and completed on 9/22/25 as part of the department issuing a notice of Intent to deny renewal of the license on 9/22/25 as a result of high-risk violations.
The on-site inspection began at 2:02 pm and ended at 4 pm. The inspector reviewed compliance in the areas listed above. There were 30 children present and 5 staff. The inspector reviewed 4 children?s records and 3 staff records on-site.
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 10/6/25. A POC submitted after this date will not appear on the public website.
Violations
14Standard 22.1-289.035-B-1
Repeat Violation
Systemic Deficiency
A sworn statement or affirmation disclosing whether there has been a conviction of or is the subject of pending charges for any offense within or outside the Commonwealth and whether he has been the subject of a founded complaint of child abuse or neglect within or outside the Commonwealth is required prior to employment.
There was no sworn disclosure statement on file for staff B prior to employment. This background check is overdue by 14 weeks.
Systemic Deficiency
A sworn statement or affirmation disclosing whether there has been a conviction of or is the subject of pending charges for any offense within or outside the Commonwealth and whether he has been the subject of a founded complaint of child abuse or neglect within or outside the Commonwealth is required prior to employment.
There was no sworn disclosure statement on file for staff B prior to employment. This background check is overdue by 14 weeks.
Plan of Correction: Sworn statement is now in the file. Director will ensure that all documents are in the staff files before they can start. The staff fille check list will be used tor every staff file. Staff checks of files will be done monthly to insure all contents are in the file.File checks will be logged.
Standard 22.1-289.035-B-3
Repeat Violation
Systemic Violation
The child day center must obtain a copy of the results of a search of the central registry maintained pursuant to ? 63.2-1515 for any founded complaint of child abuse or neglect. This background check must be requested prior to employment.
1. There was no central registry background check on file for staff C nor was their any documentation or information provided that said background check had been requested. This background check was overdue by 8 months.
2. There was no central registry background check on file for staff B nor was their any documentation or information provided that said background check had been requested. This background check was overdue by 14 weeks.
Systemic Violation
The child day center must obtain a copy of the results of a search of the central registry maintained pursuant to ? 63.2-1515 for any founded complaint of child abuse or neglect. This background check must be requested prior to employment.
1. There was no central registry background check on file for staff C nor was their any documentation or information provided that said background check had been requested. This background check was overdue by 8 months.
2. There was no central registry background check on file for staff B nor was their any documentation or information provided that said background check had been requested. This background check was overdue by 14 weeks.
Plan of Correction: Central registry checks will be completed and results received before a staff member can start. The staff checklist will be used to make sure that all documents are the file. Staff checks of files will be done monthly to insure all content are in the file.File checks will be logged.
Standard 22.1-289.035-B-4
Repeat Violation
Systemic Deficiency
Out of state sex offender registry searches must be completed for each state an employee has resided in the past 5 years prior to employment.
Staff A does not have an out of state sex offender registry search, this background check is overdue by 5 months.
Systemic Deficiency
Out of state sex offender registry searches must be completed for each state an employee has resided in the past 5 years prior to employment.
Staff A does not have an out of state sex offender registry search, this background check is overdue by 5 months.
Plan of Correction: Out of State checks will be completed and results received before a staff member can start. The staff checklist will be used to make sure that all documents are in the file. Staff checks of files will be done monthly to insure all contents are in the file.File checks will be logged.
Standard 8VAC20-780-150-B
Repeat Violation
Systemic Deficiency
Immunizations records for enrolled children shall be signed by a physician/their designee or the local health department.
The immunization records for child A, B and C were not signed by a physician/their designee or health department. This information was overdue by 1 day for child A, by 4 months for children B and C.
Systemic Deficiency
Immunizations records for enrolled children shall be signed by a physician/their designee or the local health department.
The immunization records for child A, B and C were not signed by a physician/their designee or health department. This information was overdue by 1 day for child A, by 4 months for children B and C.
Plan of Correction: All files will be checked for immunization compliance. Files that need signatures will be sent home with parents to be signed by their child peditrician.
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Standard 8VAC20-780-160-A
Repeat Violation
Systemic Deficiency
Each staff member shall submit documentation of a negative tuberculosis test/screening at the time of employment and prior to coming in contact with children.
There was no tuberculosis test/screening on file for staff B, which was 14 weeks overdue.
Systemic Deficiency
Each staff member shall submit documentation of a negative tuberculosis test/screening at the time of employment and prior to coming in contact with children.
There was no tuberculosis test/screening on file for staff B, which was 14 weeks overdue.
Plan of Correction: TB test is now on file. All TB test must be completed before staff can begin working. Staff checklist should be used to determine what documents are in the file.
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 B has not completed orientation training, this training is overdue by 13 weeks.
Staff B has not completed orientation training, this training is overdue by 13 weeks.
Plan of Correction: Orientation training is on file. Staff will be trained the first two days of work before entering in a classroom.
Standard 8VAC20-780-240-D
Prior to working alone with children and within seven days of the first day of employment, staff shall be provided in writing the center's information listed in 8VAC20-780-420 A and information on procedures for supervision, identifying where children are at all times, confirming absences, action for lost, missing or ill children, medication administration, emergency evacuation procedures and transportation precautions.
Staff B was provided none of the written policies and procedures in writing, which were overdue by 14 weeks.
Staff B was provided none of the written policies and procedures in writing, which were overdue by 14 weeks.
Plan of Correction: Staff member was given another orientation. All staff will have access to both our family and staff handbook which are on playground and ADP.
Standard 8VAC20-780-330-B
Repeat Violation
Systemic Deficiency
Where playground equipment is provided, resilient surfacing shall comply with minimum safety standards when tested in accordance with the procedures described in the American Society for Testing and Materials standard F 1292-99 as shown in Figure 2 ( Compressed Loose Fill Synthetic Materials Depth Chart) and 3 ( Use Zones for Equipment) on pages 6-7 of the National Program for Playground Safety's Selecting Playground Surfaces Materials.
On the younger playground the following was determined:
1. There was grass under and surrounding the portable red slide. Grass is not a resilient surfacing.
2. There was a portable blue and yellow swing that was within 6 inches of the wooden border. This swing required 6 feet of clearance from any object. The mulch surrounding the swing was compacted and not resilient.
On the older playground the following was determined:
1. Six to ten inches in front of the double slides and the partially enclosed slide was soil and no resilient surfacing. The mulch that was once there had degraded and turned to soil.
2. The mulch on the sides of these slides measured 1 to 3 inches as the remainder of the mulch was compacted and not resilient. These slides requires at least six inches of resilient surfacing in the fall zones.
3. There was a portable red slide located on the grass and not under resilient surfacing.
4. Staff reported that the playground is being used and was used earlier in the day.
Systemic Deficiency
Where playground equipment is provided, resilient surfacing shall comply with minimum safety standards when tested in accordance with the procedures described in the American Society for Testing and Materials standard F 1292-99 as shown in Figure 2 ( Compressed Loose Fill Synthetic Materials Depth Chart) and 3 ( Use Zones for Equipment) on pages 6-7 of the National Program for Playground Safety's Selecting Playground Surfaces Materials.
On the younger playground the following was determined:
1. There was grass under and surrounding the portable red slide. Grass is not a resilient surfacing.
2. There was a portable blue and yellow swing that was within 6 inches of the wooden border. This swing required 6 feet of clearance from any object. The mulch surrounding the swing was compacted and not resilient.
On the older playground the following was determined:
1. Six to ten inches in front of the double slides and the partially enclosed slide was soil and no resilient surfacing. The mulch that was once there had degraded and turned to soil.
2. The mulch on the sides of these slides measured 1 to 3 inches as the remainder of the mulch was compacted and not resilient. These slides requires at least six inches of resilient surfacing in the fall zones.
3. There was a portable red slide located on the grass and not under resilient surfacing.
4. Staff reported that the playground is being used and was used earlier in the day.
Plan of Correction: Playground checks will be completed on a weekly basis to ensure that the playground is in compliance with standards. Additional mulch quotes have been acquired.
Standard 8VAC20-780-340-A
Repeat Violation
Systemic Deficiency
When staff are supervising children, they shall always ensure their care, protection, and guidance.
1.When asked, staff B informed the Licensing Inspector (LI) that there were 10 PreK children in the classroom. After counting, the Licensing Inspector informed the staff that in fact there were 11 children. On at least 2 additional occasions the staff repeatedly stated that there were 10 children present despite the LI informing the staff otherwise.
2. The two ways the center were capturing the attendance for that room were both inaccurate with the clipboard showing 6 children as present and the tablet showing 16 children as present.
Systemic Deficiency
When staff are supervising children, they shall always ensure their care, protection, and guidance.
1.When asked, staff B informed the Licensing Inspector (LI) that there were 10 PreK children in the classroom. After counting, the Licensing Inspector informed the staff that in fact there were 11 children. On at least 2 additional occasions the staff repeatedly stated that there were 10 children present despite the LI informing the staff otherwise.
2. The two ways the center were capturing the attendance for that room were both inaccurate with the clipboard showing 6 children as present and the tablet showing 16 children as present.
Plan of Correction: Staff will be retrained on the process of using the tablet to track attendance and expectations when using the attendance sheet.
Standard 8VAC20-780-500-A
Children's hands shall be washed with soap and water after toileting.
A preschooler's pull up was changed by staff , afterward the child did not wash their hands and they returned to playing. The staff never directed the child to wash their hands.
A preschooler's pull up was changed by staff , afterward the child did not wash their hands and they returned to playing. The staff never directed the child to wash their hands.
Plan of Correction: Staff will be retrained on diaper changing policies and also handwashing proceudures.
Standard 8VAC20-780-500-B
When children's clothing or diaper becomes wet or soiled, the child shall be cleaned and changed immediately.
Child A, 3 years of age had wet their pants, the child went unnoticed and unchanged for over 30 minutes until the Licensing Inspector requested that the child be changed.
Child A, 3 years of age had wet their pants, the child went unnoticed and unchanged for over 30 minutes until the Licensing Inspector requested that the child be changed.
Plan of Correction: All staff will be required to participate in a diaper changing training. All diaper checks/change must be logged into playground app.
Standard 8VAC20-780-60-A
Repeat Violation
Systemic Deficiency
Each center shall maintain and keep at the center a separate record for each child enrolled which shall contain parent place of employment and work phone numbers.
There was no parental work information on file for child C, which was 4 months overdue.
Systemic Deficiency
Each center shall maintain and keep at the center a separate record for each child enrolled which shall contain parent place of employment and work phone numbers.
There was no parental work information on file for child C, which was 4 months overdue.
Plan of Correction: Director will review all files to be sure that work information is on all applications. Families that do not have work information will be reuqired to place N/A in the section that do not apply to them.
Standard 8VAC20-780-70
Repeat Violation
Systemic Deficiency
Certain information must be kept on each staff person to include two references prior to employment.
There were no references on file for staff B, which were overdue by 14 weeks.
Systemic Deficiency
Certain information must be kept on each staff person to include two references prior to employment.
There were no references on file for staff B, which were overdue by 14 weeks.
Plan of Correction: References have been completed. No staff member will start without references being completed.
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.
In the Pre-K classroom there were 11 children present however the clipboard listed 6 children as being present and the tablet listed 16 children as being present.
The clipboard and tablet are the means by which they keep attendance in this room.
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.
In the Pre-K classroom there were 11 children present however the clipboard listed 6 children as being present and the tablet listed 16 children as being present.
The clipboard and tablet are the means by which they keep attendance in this room.
Plan of Correction: Staff are required to use attendance sheet when logging children in and and out. Staff will also use the tablet Admin will go and check tablet's to ensure accuracy through out the day and log checks on attendance sheet.