Inspection · 2025-10-01
Date
2025-10-01
Complaint Related
Yes
Licensing Inspector
Pamela Sneed
(804) 629-2691
(804) 629-2691
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 Staffing and Supervision
8VAC20-780 Programs
8VAC20-780 Special Care Provisions and Emergencies
Inspector Notes
An unannounced inspection was conducted on 10/1/25 in response to a complaint received by the licensing office on 9/29/25 relating to allegations of inaccurate injury reporting and the cause of an injury to a child. The inspector reviewed related records while on-site and additional records electronically on 10/3/25, 10/10/25 and 10/22/25. This inspection included interviews, document review and observations. The preponderance of evidence gathered during the investigation supports the allegations; therefore, the complaint is determined to be valid. Information gathered during the inspection determined non-compliance with applicable standards or law and the 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 10/30/25. A POC submitted after this date will not appear on the public website
Violations
4Standard 8VAC20-780-340-A
When staff are supervising children, they shall always ensure their care and protection.
On 9/26/25, staff reported that a group of 23 3-year-old children were combined with groups of older children, to include school-age children, on the outdoor blacktop. Areas and activities were not defined for each age-group to ensure active safe play, which did not ensure the care and protection of younger children.
On 9/26/25, staff reported that a group of 23 3-year-old children were combined with groups of older children, to include school-age children, on the outdoor blacktop. Areas and activities were not defined for each age-group to ensure active safe play, which did not ensure the care and protection of younger children.
Plan of Correction: Cones and other barrier will be used to define space for each age group.
Standard 8VAC20-780-360-A
The variety of daily activities for all age groups shall be age and stage appropriate.
On 9/26/25, a group of 3-year-old children, were playing basketball with a regulation size basketball and hoop, which are not age and stage appropriate. There were minimal age appropriate supplies/equipment observed on the blacktop area at the time. A few children were observed with a bucket and digging in the dirt surrounding the blacktop, some were running/jumping on the blacktop, others were gathered and sitting along the edge of the blacktop.
On 9/26/25, a group of 3-year-old children, were playing basketball with a regulation size basketball and hoop, which are not age and stage appropriate. There were minimal age appropriate supplies/equipment observed on the blacktop area at the time. A few children were observed with a bucket and digging in the dirt surrounding the blacktop, some were running/jumping on the blacktop, others were gathered and sitting along the edge of the blacktop.
Plan of Correction: Admin will purchase more age-appropriate outdoor supplies/equipment.
Standard 8VAC20-780-40-E
The operational responsibilities of the licensee shall include ensuring that the center's activities and services are maintained in compliance with these standards, and the center's own policies and procedures that are required by these standards.
The center's written minor injury policy states that first aid shall include the washing, applying of antibiotic ointment and covering with a bandage for scratches, cuts and abrasions. The written injury report documented the washing of the child's knee abrasions, but no additional first aid was provided to the knee abrasions.
The center's written minor injury policy states that ice will be applied to bumps/bruises. The first injury report, written 9/26/25, documented that ice was offered but the child refused the ice. The second report, written 10/1/25, documented that while the child declined ice, it was later applied when staff noticed a bump forming on the child's forehead.
The center's written serious injury policy has provisions for concussions, which is not known to have occurred however, there is no documentation of staff having been trained to assess a child for concussions. The child did receive what is considered to be a potential serious injury, a head injury, when they were pushed to the ground causing their head to hit the blacktop and a bump to form on the forehead area.
The center's written serious injury policy includes notification of the parent as to the extent of the injury and informing the parent it is their decision whether to pick up the child, or have the center call 911. On 9/26/25, the parents of Child #1 were not notified of the potential serious injury until they arrived to pick up the child approximately 32 minutes later. At that time, the verbal and written accounts of the injury were not accurately communicated to the parent. The parent later learned the cause of the accident from the child.
The center's written minor injury policy states that first aid shall include the washing, applying of antibiotic ointment and covering with a bandage for scratches, cuts and abrasions. The written injury report documented the washing of the child's knee abrasions, but no additional first aid was provided to the knee abrasions.
The center's written minor injury policy states that ice will be applied to bumps/bruises. The first injury report, written 9/26/25, documented that ice was offered but the child refused the ice. The second report, written 10/1/25, documented that while the child declined ice, it was later applied when staff noticed a bump forming on the child's forehead.
The center's written serious injury policy has provisions for concussions, which is not known to have occurred however, there is no documentation of staff having been trained to assess a child for concussions. The child did receive what is considered to be a potential serious injury, a head injury, when they were pushed to the ground causing their head to hit the blacktop and a bump to form on the forehead area.
The center's written serious injury policy includes notification of the parent as to the extent of the injury and informing the parent it is their decision whether to pick up the child, or have the center call 911. On 9/26/25, the parents of Child #1 were not notified of the potential serious injury until they arrived to pick up the child approximately 32 minutes later. At that time, the verbal and written accounts of the injury were not accurately communicated to the parent. The parent later learned the cause of the accident from the child.
Plan of Correction: Teachers will be retrained on first aid for minor injuries. Teachers will be required to complete on-line concussion training, which will be documented in their staff files. Teachers will be reminded to alert admin to call parents for any head injury. Staff will be re-trained on how to accurately communicate with parents.
Standard 8VAC20-780-550-P
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 the following, but not limited to: type and circumstance of the injury, staff present, treatment, and future action to prevent recurrence of the injury.
On 9/26/25, a 3-year-old child, Child #1, was playing basketball when knocked down onto the blacktop by Staff #2, who was moving and focused on catching a basketball. The fall caused Child #1 to scrape both knees, hit their head on the blacktop and cry. The circumstance of injury was written on the injury report as the children bumping into one another while playing basketball causing Child #1 to fall onto the blacktop resulting in scraped knees and a bump on the forehead.
There were 5 staff present at the time of injury. The written injury report stated there were 4 staff present. Staff #2 was not identified as being present.
The first aid/treatment included cleaning the scrapes and offering ice that was initially refused by the child however, ice was later given when a bump on the child's head was noticed by staff. The written report stated the treatment included cleaning scrapes and ice being offered and refused by the child.
The future action to prevent recurrence of the injury was written on the injury report as making sure children were aware of their surroundings and being careful. The report did not include a staff person causing the injury and how that could be prevented.
Staff #1, who wrote the injury report, said the report was intentionally written in a way that would not reflect the fact that the injury was caused by Staff #2.
On 9/26/25, a 3-year-old child, Child #1, was playing basketball when knocked down onto the blacktop by Staff #2, who was moving and focused on catching a basketball. The fall caused Child #1 to scrape both knees, hit their head on the blacktop and cry. The circumstance of injury was written on the injury report as the children bumping into one another while playing basketball causing Child #1 to fall onto the blacktop resulting in scraped knees and a bump on the forehead.
There were 5 staff present at the time of injury. The written injury report stated there were 4 staff present. Staff #2 was not identified as being present.
The first aid/treatment included cleaning the scrapes and offering ice that was initially refused by the child however, ice was later given when a bump on the child's head was noticed by staff. The written report stated the treatment included cleaning scrapes and ice being offered and refused by the child.
The future action to prevent recurrence of the injury was written on the injury report as making sure children were aware of their surroundings and being careful. The report did not include a staff person causing the injury and how that could be prevented.
Staff #1, who wrote the injury report, said the report was intentionally written in a way that would not reflect the fact that the injury was caused by Staff #2.
Plan of Correction: Teachers will be trained again in the proper way to accurately document any injuries (minor or major) on injury report forms.