Inspection · 2025-10-15
Date
2025-10-15
Complaint Related
No
Licensing Inspector
Sharon Curlee
(804) 840-8312
(804) 840-8312
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
63.2 Child Abuse & Neglect
22.1 Early Childhood Care and Education
20 Access to minor?s records
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 on October 15, 2025, and completed on October 20, 2025, as a part of the conditional licensure period. The on-site inspection began at 3:16 pm and ended at 4:30 pm. The inspector reviewed compliance in the areas listed above. There were 21 children present and two staff. The inspector reviewed five children?s records and three staff records electronically on October 20, 2025. 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 business days from today, which will be the close of business on November 17, 2025. A POC submitted after this date will not appear on the public website.
Violations
11Standard 22.1-289.035-B-3
The center must request a search of the central registry prior to the employee's first day of employment. 1. Staff #1, employed for two months, did not have documentation the central registry was requested prior to employment. The results of the central registry had not been received. 2. The record of staff #2, employed for two months, had documentation of a completed central registry dated 15 days after employment. There was no documentation that the central registry check was requested prior to employment. 3. The record of staff #3, employed for one month, did not have documentation the central registry was requested prior to employment. The results of the central registry had not been received.
Plan of Correction: Per administration: We have worked with our Senior Leadership and HR / On-boarding Team to ensure no staff are hired prior to having proof of submission for background checks to include central registry checks and all out of state background checks. Staff #1's central registry check was received on 10.29.25. Staff #3's results were received on 11.10.25.
Standard 22.1-289.035-B-4
The center is required to obtain background checks from any state in which the individual has resided in the preceding five years.
Staff #3, employed for one month, did not have documentation of requesting a central registry check and a criminal history check from one state.
Staff #3, employed for one month, did not have documentation of requesting a central registry check and a criminal history check from one state.
Plan of Correction: Per administration: Staff #3 received their central registry results on 11.10, and out of state criminal history on 11.12.
We have worked with our Senior Leadership and HR / On-boarding Team to ensure no staff are hired prior to having proof of submission for our of state background checks.
We have worked with our Senior Leadership and HR / On-boarding Team to ensure no staff are hired prior to having proof of submission for our of state background checks.
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. The record of child #4, enrolled for one month and 28 days, did not contain documentation of immunizations. 2. The record of child #5, enrolled for one month and 28 days, did not contain documentation of immunizations.
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. The record of child #4, enrolled for one month and 28 days, did not contain documentation of immunizations. 2. The record of child #5, enrolled for one month and 28 days, did not contain documentation of immunizations.
Plan of Correction: Per administration: We are currently working with the families and school district on a process to obtain immunizations prior to the child starting. Families were given to 11.14.25 to produce immunizations or they would be dis-enrolled from program.
Standard 8VAC20-780-140-A
Systemic Deficiency
Each child shall have a physical examination by or under the direction of a physician before the child's attendance or within 30 days after the first day of attendance. The record of child #4, enrolled for one month and 28 days, did not contain documentation of a physical. 2. The record of child #5, enrolled for one month and 28 days, did not contain documentation of a physical.
Each child shall have a physical examination by or under the direction of a physician before the child's attendance or within 30 days after the first day of attendance. The record of child #4, enrolled for one month and 28 days, did not contain documentation of a physical. 2. The record of child #5, enrolled for one month and 28 days, did not contain documentation of a physical.
Plan of Correction: Per administration: We are currently working with families and the district on a process to obtain a physical exam within 30 days of attendance. Child #5 had until
11.14.25 to produce a physical or the child would be dis- enrolled.
11.14.25 to produce a physical or the child would be dis- enrolled.
Standard 8VAC20-780-160-A
Systemic Deficiency
Each staff member and individual from an independent contractor shall submit documentation of a negative tuberculosis screening. Documentation of the screening shall be submitted at the time of employment and prior to coming into contact with children and shall have been completed within the last 30 calendar days prior to the date of employment and be signed by a physician. The record of staff #1 (employed for two months) and staff #3 (employed for one month) did not contain documentation of a tuberculosis screening.
Each staff member and individual from an independent contractor shall submit documentation of a negative tuberculosis screening. Documentation of the screening shall be submitted at the time of employment and prior to coming into contact with children and shall have been completed within the last 30 calendar days prior to the date of employment and be signed by a physician. The record of staff #1 (employed for two months) and staff #3 (employed for one month) did not contain documentation of a tuberculosis screening.
Plan of Correction: Per administration: We have worked with our Senior Leadership and HR / On-boarding Team to develop a process to ensure TB screenings occur prior to hire.
Standard 8VAC20-780-190-A
Systemic Deficiency
Program directors shall be at least 21 years of age and shall meet one of the required qualifications. The record of staff #1, identified as the program director, contained documentation of education with a completed 120 hours however, it did not include at least 12 semester hours in child-related subjects and one year of programmatic experience.
Program directors shall be at least 21 years of age and shall meet one of the required qualifications. The record of staff #1, identified as the program director, contained documentation of education with a completed 120 hours however, it did not include at least 12 semester hours in child-related subjects and one year of programmatic experience.
Plan of Correction: Per administration: We are currently actively recruiting internal and external candidates that meet the requirements.
Standard 8VAC20-780-245-L
Systemic Deficiency
There shall always be at least one staff member on duty who has obtained within the last three years instruction in performing the daily health observation of children. The center did not have a staff member present on October 15, 2025, that was trained in daily health observation training.
There shall always be at least one staff member on duty who has obtained within the last three years instruction in performing the daily health observation of children. The center did not have a staff member present on October 15, 2025, that was trained in daily health observation training.
Plan of Correction: Per administration: Staff #1 completed the daily health observation training on 10.30.25. Other staff are encouraged to take the training as well to ensure at least one staff member at all times has the daily health observation training.
Standard 8VAC20-780-550-D
Systemic Deficiency
The center shall implement a monthly practice evacuation drill. The center did not conduct a practice evacuation drill during the month of August and September 2025.
The center shall implement a monthly practice evacuation drill. The center did not conduct a practice evacuation drill during the month of August and September 2025.
Plan of Correction: Per administration: Area Manager will create a group text including all locations with an action item to complete the monthly drill. All locations will be required to text back a picture of the completed drill logged in the licensing binder.
Standard 8VAC20-780-550-P
Systemic Deficiency
The center shall maintain a written record of children's serious and minor injuries in which entries are made on the day of occurrence. The record shall include all required documentation. 1. Injury report #1, dated 08/27/2025, did not contain the date and time when parents were notified of the injury, any future action to prevent recurrence of the injury and documentation on how the parent was notified. 2. Injury report #2, dated 09/10/025, did not contain the date and time when parents were notified, any future action to prevent recurrence of the injury, documentation on how the parent was notified and a second staff signature or the parent?s signature. 3. Injury report #3, dated 09/25/2025, did not contain documentation of the staff present, the date and time when parents were notified, any future action to prevent recurrence of the injury, documentation on how the parent was notified, and staff and parent signatures or two staff signatures. 4. Injury report #5, dated 10/07/2025, did not contain the time when parents were notified of the injury.
The center shall maintain a written record of children's serious and minor injuries in which entries are made on the day of occurrence. The record shall include all required documentation. 1. Injury report #1, dated 08/27/2025, did not contain the date and time when parents were notified of the injury, any future action to prevent recurrence of the injury and documentation on how the parent was notified. 2. Injury report #2, dated 09/10/025, did not contain the date and time when parents were notified, any future action to prevent recurrence of the injury, documentation on how the parent was notified and a second staff signature or the parent?s signature. 3. Injury report #3, dated 09/25/2025, did not contain documentation of the staff present, the date and time when parents were notified, any future action to prevent recurrence of the injury, documentation on how the parent was notified, and staff and parent signatures or two staff signatures. 4. Injury report #5, dated 10/07/2025, did not contain the time when parents were notified of the injury.
Plan of Correction: Per administration: The location was using RAS computer software to record injuries. At the time of the visit completed information was unavailable in the software system. Moving forward the location will be using the VA DOE injury report form to ensure all necessary information is captured.
Standard 8VAC20-780-60-A
Systemic Deficiency
The center shall maintain and keep at the center a separate record for each child enrolled which shall contain all required documentation. 1. The record of child #2, enrolled for one month and 28 days, did not contain the work phone number of each parent who has custody. 2. Child #3, enrolled for one month and 28 days, did not have a record. 3. Child #4, enrolled for one month and 28 days, did not have a record. 4. The record of child #5, enrolled for one month and 28 days, did not contain the work phone number and place of employment of each parent who has custody.
The center shall maintain and keep at the center a separate record for each child enrolled which shall contain all required documentation. 1. The record of child #2, enrolled for one month and 28 days, did not contain the work phone number of each parent who has custody. 2. Child #3, enrolled for one month and 28 days, did not have a record. 3. Child #4, enrolled for one month and 28 days, did not have a record. 4. The record of child #5, enrolled for one month and 28 days, did not contain the work phone number and place of employment of each parent who has custody.
Plan of Correction: Per administration:Area manager and Program Manager worked with families to obtain documentation no later than 11.14.25 or the children will be dis-enrolled. Moving forward we will be working with families to obtain all necessary information prior to enrollment
Standard 8VAC20-780-70
Systemic Deficiency
A record shall be kept for each staff person that contains the required information. The record of staff #1 (employed for two months), staff #2 (employed for two months), and staff #3 (employed for one month), did not contain the name, address, and telephone number of a person to be notified in an emergency which shall be kept at the center and documentation that two or more references as to character and reputation as well as competency were checked before employment or volunteering.
A record shall be kept for each staff person that contains the required information. The record of staff #1 (employed for two months), staff #2 (employed for two months), and staff #3 (employed for one month), did not contain the name, address, and telephone number of a person to be notified in an emergency which shall be kept at the center and documentation that two or more references as to character and reputation as well as competency were checked before employment or volunteering.
Plan of Correction: Per administration: Staff have until 12.17.25 to produce references or risk being taken off the schedule. Going forward we have worked with Senior Leadership and HR / On- boarding Team to ensure no staff are hired prior to references being received..