Inspection · 2025-10-15
Date
2025-10-15
Complaint Related
No
Licensing Inspector
Cindy Horne
(804) 297-4469
(804) 297-4469
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
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 monitoring inspection was initiated and completed on 10/15/2025 as a part of the conditional licensure period. The on-site inspection began at 2:40 p.m. and ended at 4:50 p.m. The inspector reviewed compliance in the areas listed above. There were 26 children present and one staff at 2:40.p.m. A second staff member arrived at 3:37 p.m. The inspector reviewed five children?s records on site. Two staff records were reviewed electronically on 10/27/2025. This inspection included document review (i.e. daily schedule, license, attendance records, fire drills, and incident reports), 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 11/06/2025. A POC submitted after this date will not appear on the public website.
Violations
12Standard 22.1-289.035-B-2
Providers must obtain a completed national criminal background check prior to the employee's first day of employment. Staff #2, who has been actively working at the center for the past two months, did not have a completed national criminal background check.
Plan of Correction: Staff #2 has not worked as of 10.17 and was terminated on 11.3. We have worked with our HR/onboarding team and Senior Leadership to ensure moving forward no staff are hired without a completed national criminal background check.
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 #1, employed for the past two months, did not have documentation of requesting a central registry check from one state. Staff #2, employed for the past two months, did not have documentation of requesting central registry checks from two states.
Plan of Correction: We have worked with our HR/onboarding team and Senior Leadership to develop processes to ensure staff are not hired without having proof of out of state background check submissions. Staff #1 had an out of state background check submitted on 10.16.25
Standard 8VAC20-780-130-A
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. Child #1, Child #2, Child #3, Child #4, and Child #5, who had all been enrolled for two months, did not have documentation of immunization records on file.
Plan of Correction: Area Manager and Program Manager are communicating to and working with families to obtain the information no later than 11.13 or they will be disenrolled. Moving forward the Program Manager will work with families to notify them of the upcoming 30 day deadline to produce a physical examination. Children will be disenrolled after 30 days if they don't have a physical.
Standard 8VAC20-780-140-A
Physical examinations completed by a physician shall be obtained prior to the first day of attendance or within 30 days after the first day of attendance. There were no physical examinations in the records of Child #1, Child #2, Child #3, Child #4, or Child #5, who had all been enrolled for two months.
Plan of Correction: Area Manager and Program Manager are communicating to and working with
families to obtain the information no later than 11.13 or they will be disenrolled.
Moving forward the Program Manager will work with families to notify them of
upcoming deadlines to produce a physical examination. Children will be disenrolled after 30 days if they do not submit a physical examination.
families to obtain the information no later than 11.13 or they will be disenrolled.
Moving forward the Program Manager will work with families to notify them of
upcoming deadlines to produce a physical examination. Children will be disenrolled after 30 days if they do not submit a physical examination.
Standard 8VAC20-780-160-A
Documentation of a negative tuberculosis (TB) screening must be submitted at the time of employment, before coming into contact with children, and shall have been completed within the last 30 days of the date of employment. Staff #2, who has been actively working at the center for the past two months, had no documentation of a negative tuberculosis (TB) screening.
Plan of Correction: Staff #2 has been terminated on 11.3. Moving forward we are changing our hiring practice to require TB screening prior to employment.
Standard 8VAC20-780-245-L
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. Staff #1 who was observed supervising 26 children alone from approximately 2:40 p.m. -3:37 p.m. had not received instruction in performing the daily health observation of children.
Plan of Correction: Staff #1 has completed the training on 10.29. In addition all other currently hired staff were instructed to complete the training to ensure we have staff present to complete the daily health observation of children.
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, volunteer or other employee who is at least 16 years of age, with direct means for communication between the two of them. At 2:40 p.m. on 10/15/25, Staff #1 was observed alone with 26 children. A second staff member arrived at 3:37 p.m. Staff #1 reported that she had been alone since 2:00 p.m. and that it has happened many times before.
Plan of Correction: Staff #2 arrived late at work on this day and has since been terminated. We have replaced this staff member and are in the process of hiring five new Educators to ensure we have enough coverage to ensure at least two staff members are present with children.
Standard 8VAC20-780-350-B-5
The required ratio for children school age eligible up to 9 years is one staff per 18 children. On 10/15/25, Staff #1 was observed supervising 26 children (youngest child 5 years old) from approximately 2:40 p.m -3:37 p.m. When asked about the ratio Staff #1 reported that she had been alone at the center since 2:00 p.m.
Plan of Correction: Staff #2 arrived late at work on this day and has been terminated on 11.3. We have replaced this staff and are in the process of hiring five new Educators to ensure we have enough coverage to ensure at least two staff members are present with children.
Standard 8VAC20-780-420-A
Before the child's first day of attending, parents shall be provided in writing the center's philosophy and any religious affiliation, operating information, transportation policy, policies for arrival and departure, policy regarding medication, policy regarding sunscreen, diaper ointment, and insect repellent, lines of authority, policy for reporting suspected child abuse, parent's right to be admitted to the center, communicating emergency situations, general daily schedule, food and discipline policies, and termination policies. The records of Child #1, #2, #3, #4, and #5 did not contain documentation that the parents were provided with this information in writing before the children?s first day of attending.
Plan of Correction: Families are provided our online family handbook that covers all of these policies when they enroll their children through our online enrollment system. There is an online acknowledgment that parent's sign. We are working on a process to retrieve the acknowledgement from the computer system to place in the child's file.
Standard 8VAC20-780-560-J
Tables shall be sanitized before and after each use for feeding. The children had snacks at approximately 3:00 p.m. Staff #1 did not sanitize the tables before or after serving snacks.
Plan of Correction: Area Manager has discussed sanitizing expectations with the Program Manager and how they can be challenging without another team member present. We are in the process of hiring five additional staff members to ensure two staff are present and able to adhere to cleaning and sanitizing requirements.
Standard 8VAC20-780-60-A
Each center shall maintain and keep at the center a separate record for each child enrolled that contains all of the required information. Nine children, Child #6 through Child #14 had no records. The records of Child #1, Child #3, and Child #5 did not contain work phone numbers for the parents. The records of Child #1, Child #3, Child #4, and Child #5 did not contain phone numbers of the children's physicians. The records of Child #1, Child #2, Child #3, Child #4, and Child #5 did not contain documentation of viewing proof of the children's identities and ages.
Plan of Correction: Area Manager is conducting child file audits. Families will be notified of missing information that will be required to be returned no later than 11.13 or they will be disenrolled. Children #3, #4, #10 and #14 are no longer enrolled.
Standard 8VAC20-780-70
Documentation of at least 2 references to character, reputation, and competency are to be checked prior to employment. Staff #2, who has been actively working at the center for the past two months, had no completed reference verifications on file.
Plan of Correction: Staff #2 has been terminated on 11.3. We have changed our hiring practices to include having references prior to the hire date.