Inspection · 2025-10-21
Date
2025-10-21
Complaint Related
No
Licensing Inspector
Florence Martus
(804) 389-0157
(804) 389-0157
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 on 10/21/2025 and completed on 10/28/2025, as a part of the conditional licensure period. The on-site inspection began at 2:20pm and ended at 4:50pm. The inspector reviewed compliance in the areas listed above. There were 20 children present and 2 staff directly supervising. The inspector reviewed 5 children's records on-site and 2 staff records electronically between 10/22/2025 and 10/28/2025. 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 11/14/2025. A POC submitted after this date will not appear on the public website.
Violations
10Standard 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.
Staff #2, who had been employed for over two months, had a central registry search requested 10 days after the staff started employment.
Staff #2, who had been employed for over two months, had a central registry search requested 10 days after the staff started employment.
Plan of Correction: Per the Center: "We have worked with our Senior Leadership Team putting processes in place to ensure moving forward no staff are hired without proof of
submission of a central registry search."
submission of a central registry search."
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 prior to employment.
The out-of-state sex offender registry search and the out-of-state child abuse and neglect registry search for Staff #1 were requested over two months after the staff started employment. Staff #1 was observed working with children.
The out-of-state sex offender registry search and the out-of-state child abuse and neglect registry search for Staff #1 were requested over two months after the staff started employment. Staff #1 was observed working with children.
Plan of Correction: Per the Center: "We have worked with our Senior Leadership and HR/Onboarding
Team putting processes in place to ensure moving forward no staff are hired without proof of submission of out of state background checks to include out of state criminal history check, out of state sex offender registry search, out of state child abuse and neglect registry search"
Team putting processes in place to ensure moving forward no staff are hired without proof of submission of out of state background checks to include out of state criminal history check, out of state sex offender registry search, out of state child abuse and neglect registry search"
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 records of Child #1, Child #2, Child #3, and Child #5, did not contain documentation of immunizations. The children had been in attendance for over two months.
The records of Child #1, Child #2, Child #3, and Child #5, did not contain documentation of immunizations. The children had been in attendance for over two months.
Plan of Correction: Per the Center: "We are currently working on a process to ensure we obtain immunizations prior to a child's first day. This may include a signed release of information from the parents to obtain them directly from the school which would be provided along with a welcome letter prior to enrollment."
Standard 8VAC20-780-140-A
(Systemic Deficiency) 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.
The records of Child #1, Child #2, Child #3, and Child #5 did not contain a physical examination. The children had been in attendance for over two months.
The records of Child #1, Child #2, Child #3, and Child #5 did not contain a physical examination. The children had been in attendance for over two months.
Plan of Correction: Per the Center: "Families were contacted and given a deadline of 11.14.25 to produce missing documentation or they will be dis-enrolled. Going forward staff will work with families to obtain physical exams within 30 days of attendance.
Children that do not have physical examinations within 30 days of attendance will be disenrolled."
Children that do not have physical examinations within 30 days of attendance will be disenrolled."
Standard 8VAC20-780-160-A
(Systemic Deficiency) Each staff member shall submit documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with children.
Staff #1, employed for over two months, does not have a negative tuberculosis screening on file. Staff #1 was observed working with children.
Staff #1, employed for over two months, does not have a negative tuberculosis screening on file. Staff #1 was observed working with children.
Plan of Correction: Per the Center: "Staff #1 received a TB screening on 11.6.25. We have worked with Senior Leadership and our HR / Onboarding Team to ensure staff submit a negative TB screening prior to coming in contact with children."
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 and Staff #2, who were the two staff present during the inspection, have not obtained training in performing daily health observation of children within the last three years.
Staff #1 and Staff #2, who were the two staff present during the inspection, have not obtained training in performing daily health observation of children within the last three years.
Plan of Correction: Per the Center: "Staff #1 completed the daily health observation training on 11.3.25.
Staff #2 completed the training on 11.6. Going forward at least one staff member present will have documentation of completing the daily health observation training
within the last three years."
Staff #2 completed the training on 11.6. Going forward at least one staff member present will have documentation of completing the daily health observation training
within the last three years."
Standard 8VAC20-780-280-B
Hazardous substances such as cleaning materials, insecticides, and pesticides shall be kept in a locked place using a safe locking method that prevents access by children.
Disinfectant wipes and spray were observed in a caddy basket that was accessible to the children in care.
Disinfectant wipes and spray were observed in a caddy basket that was accessible to the children in care.
Plan of Correction: Per the Center: "Location was provided with a half cabinet on 11.11.25 to keep
hazardous materials locked to prevent access by children."
hazardous materials locked to prevent access by children."
Standard 8VAC20-780-550-D
The center shall implement a monthly practice evacuation drill.
An evacuation drill was not completed for August 2025 or September 2025.
An evacuation drill was not completed for August 2025 or September 2025.
Plan of Correction: Per the Center: "Area Manager will create a group text to include all locations to send 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."
text back a picture of the completed drill logged in the licensing binder."
Standard 8VAC20-780-60-A
(Systemic Deficiency) Each center shall maintain and keep at the center a separate record for each child enrolled that contains all the required information.
The record of Child #1, enrolled for over two months, was missing the child and parent?s home address, and phone number; the name and phone number of child?s physician; the name, address, and phone number of two emergency contacts; names of persons authorized to pick up the child; allergy and health information; and written agreements between the parent and the center.
The record of Child #2, enrolled for over two months, was missing a second emergency contact.
The record of Child #3, enrolled for over two months, was missing the child and parent?s home address, and phone number; the name and phone number of child?s physician; the name, address, and phone number of two emergency contacts; names of persons authorized to pick up the child; allergy and health information; and written agreements between the parent and the center.
The record of Child #5, enrolled for over two months, was missing the child and parent?s home address, and phone number; the name and phone number of child?s physician; the name, address, and phone number of two emergency contacts; names of persons authorized to pick up the child; allergy and health information; and written agreements between the parent and the center.
The record of Child #1, enrolled for over two months, was missing the child and parent?s home address, and phone number; the name and phone number of child?s physician; the name, address, and phone number of two emergency contacts; names of persons authorized to pick up the child; allergy and health information; and written agreements between the parent and the center.
The record of Child #2, enrolled for over two months, was missing a second emergency contact.
The record of Child #3, enrolled for over two months, was missing the child and parent?s home address, and phone number; the name and phone number of child?s physician; the name, address, and phone number of two emergency contacts; names of persons authorized to pick up the child; allergy and health information; and written agreements between the parent and the center.
The record of Child #5, enrolled for over two months, was missing the child and parent?s home address, and phone number; the name and phone number of child?s physician; the name, address, and phone number of two emergency contacts; names of persons authorized to pick up the child; allergy and health information; and written agreements between the parent and the center.
Plan of Correction: Per the Center: "Families were contacted and notified of missing information. They were also given a deadline of 11.14.25 to produce the documentation or their
child will be dis-enrolled. Going forward the Area Manager and Program Manager will work with families to obtain all required information."
child will be dis-enrolled. Going forward the Area Manager and Program Manager will work with families to obtain all required information."
Standard 8VAC20-780-70
(Systemic Deficiency) A record shall be kept for each staff person that contains the required information.
Staff #1 and Staff #2, who have been employed for over two months, and were present during the inspection, did not have a name, address, and telephone number of a person to be notified in an emergency and information about any health problems that may interfere with fulfilling the job responsibilities at the center. This information shall be kept at the center.
Staff #2 did not have documentation that two or more references as to character and reputation as well as competency were checked before employment.
Staff #1 and Staff #2, who have been employed for over two months, and were present during the inspection, did not have a name, address, and telephone number of a person to be notified in an emergency and information about any health problems that may interfere with fulfilling the job responsibilities at the center. This information shall be kept at the center.
Staff #2 did not have documentation that two or more references as to character and reputation as well as competency were checked before employment.
Plan of Correction: Per the Center: "Staff #1 and Staff #2 both have the required information on file at the center. Staff #2 continues to work on getting references. If references cannot be
obtained within the next 30 days she will be removed from the schedule. Going forward we have worked with Senior Leadership and HR/Onboarding Team to change hiring practices to include having two references prior to hire."
obtained within the next 30 days she will be removed from the schedule. Going forward we have worked with Senior Leadership and HR/Onboarding Team to change hiring practices to include having two references prior to hire."