Inspection · 2026-03-06
Licensing Inspector
Mark Davis
(804) 629-7103
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
22.1 Early Childhood Care and Education
63.2 Child Abuse & Neglect
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 monitoring inspection was initiated on 3/6/2026 and completed on 3/13/2026, with local agencies, in response to a self-report received by the licensing office on 2/26/2026 relating to supervision. The Department issued a Special Order on October 27 2025, to place the licensee on probation and require the licensee to contact parents, guardians, or other responsible persons regarding health and safety as a result of high-risk violations. The inspector reviewed nine staff records onsite. 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. Though not a part of the original self report, violations that were not reported were found related to physical plant and are documented on the
violation notice issued to the program.
Standard 22.1-289.036-B-1
New individuals to the business entity must have three letters of reference within thirty days. The center did not have three reference letters for the seven new Board Officers listed on the Business Entity. Board Officer #1 had joined the Business Entity over eighteen months ago. Board Officers #2, #4, #5, #6 and #7 had joined the Business Entity over six months ago. Board Officer #3 had joined the Business Entity over fifteen months ago.
Plan of Correction: All board officers were contacted to obtain the required three references. A board onboarding checklist and deadline tracking system were implemented to ensure future compliance within 30 days.
Standard 63.2-1509-A
Staff employed by a child day program who have reason to suspect that a child is abused or neglected shall report the matter immediately to the local department's toll-free child abuse and neglect hotline.
Staff #1 became aware of an allegation, and did not report it to their supervisor until two days after, despite being a mandated reporter. Staff #2 became aware of an allegation, and did not report it to the local social services department for an additional four days.
Plan of Correction: All staff received a refresher on mandated reporter obligations, including the requirement that each individual must immediately report any suspected abuse or neglect. Signed acknowledgments will be maintained in personnel files. The center will complete a full staff training on mandated reporting requirements within the next 30 days and will require annual refresher training on an ongoing basis.
Standard 8VAC20-780-350-B-4
The required ratio for children ages three years through school age is one staff per ten children. Two staff were supervising twenty-six preschool-aged children, from approximately 5:08pm- 5:22pm on the playground.
Plan of Correction: Staff were retrained on ratio requirements and end-of-day supervision procedures. The center implemented required ratio counts before and during playground transitions and a closing staffing plan to maintain compliance at all times.
Standard 8VAC20-780-40-E
The operational responsibilities of the licensee shall include ensuring that the center's activities, services, and facilities are maintained in compliance with these standards, the center's own policies and procedures that are required by these standards, and the terms of the current license issued by the department. The center's employee handbook states "Any employee who has reason to suspect that a child has been abused or neglected must
report the suspicion immediately, but no later than twenty-four hours after forming the suspicion. Reports must be made to Child Protective Services (CPS) in the appropriate jurisdiction."
The center did not follow their policy to report the suspicion of a child being abused within twenty-four hours. CPS was not informed for six days after the center was initially made aware of the allegation.
Plan of Correction: All staff received an immediate refresher on proper CPS reporting procedures, including the requirement that suspected abuse or neglect be reported without delay. In addition, a full center-wide staff training on mandated reporting requirements and internal reporting procedures will be completed within the next 30 days. The center has implemented a written CPS reporting procedure and incident escalation checklist. Administration will document the receipt of future allegations, reporting timelines, and ongoing compliance monitoring on a monthly basis.