Inspection · 2025-10-21
Licensing Inspector
Sharon Curlee
(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 21, 2025, and completed on October 21, 2025, as a part of the licensure period. The on-site inspection began at 12:00 pm and ended at 3:30 pm. The inspector reviewed compliance in the areas listed above. There were 39 children present and eight staff. The inspector reviewed five children?s records and six staff records on-site. 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 October 30, 2025. A POC submitted after this date will not appear on the public website.
Standard 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 #4, employed for three months, had documentation of a central registry being requested 18 days after employment.
Plan of Correction: Per administration: All central registry search will be submitted prior to start date.
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. Provisional hires, effect 7/1/2024, require all out of state background checks to be requested prior to employment. The record of staff #6, who lived in a non-NFF state outside of Virginia in the past five years and has been employed for 14 months, did not contain documentation of a request for a child abuse and neglect search and a criminal history search prior to employment.
Plan of Correction: Per administration: The required out of state checks have been submitted. Moving forward these will be required prior to staff start date.
Standard 8VAC20-780-130-E
Repeat
The center shall obtain documentation of additional immunizations once every six months for children under the age of two years. The record of child #2, under the age of two years, did not have an updated immunization record in file. An updated immunization record was due five months ago.
Plan of Correction: Per administration: Parent informed immediately of requirement, provided immunization record.
Standard 8VAC20-780-160-A
Each staff member shall submit documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with children. The documentation shall have been completed within the last 30 calendar days of the date of employment and be signed by a physician, physician designee, or an official of the local health department. 1. The record of staff #2 contained documentation of a TB screening that was completed two days after the date of employment. 2. The record of staff #3 contained documentation of a TB screening that was completed two days after the date of employment. 3. The record of staff #6 contained documentation of a tuberculosis screening completed 11 months prior to employment.
Plan of Correction: Per administrator: Moving forward all TB risk assessments will be submitted prior to start day. TB test of staff#6 has been submitted.
Standard 8VAC20-780-270-A
Repeat
Areas and equipment of the center, inside and outside, shall be maintained in a clean, safe and operable condition. 1. In the school age classroom, there is peeling and chipped paint on the support columns. 2. The timbers around the merry-go-round and the climbing bars have deteriorating wood creating jagged edges. 3. The steps of the climber/slide on the pre-school playground are rusted and the plastic coating is cracked creating sharp edges. 4. The pour-in-place resilient surfacing around the climbing boulder, preschool swings, and climbing bars have multiple sink holes along with rippling of the surface that poses a risk of altering the effectiveness of the resilient surfacing and being a tripping hazard. 5. The merry-go-round on the school age playground is broken at the axle. 6. Approximately 2 inches of a steal rod is protruding from the timbers around the merry-go-round.
Plan of Correction: Per administration: Reported all concerns to maintenance immediately. Timbers and metal rods to be removed. A temporary fence is to be placed around the merry-go-round until removal.
Standard 8VAC20-780-370-5
Infants, who cannot turn themselves over and are awake, shall be placed on their stomachs a total of 30 minutes each day to facilitate upper body strength and to address misshapen head concerns. There was no documentation of tummy time for child #8 and child #9, both identified as not being able to turn themselves over. Staff stated tummy time is conducted, however it is not documented.
Plan of Correction: Per administration: Teachers will document non-mobile infants tummy time on their digital daily sheets.
Standard 8VAC20-780-60-A
Each center shall maintain and keep at the center a separate record for each child enrolled which shall contain all required information. 1. The record of child #1, enrolled for one month, did not contain the name, address, and phone number of one emergency contact. 2. The record of child #3, enrolled one month, did not contain the work phone number for either parent. 3. The record of child #4, enrolled for six months, did not contain the place of employment and work phone number for each parent who has custody. 4. The record of child #5, enrolled for 14 months, did not contain the addresses for the two emergency contacts listed. The record also did not contain annual confirmation of up-to-date information.
Plan of Correction: Per administration: Child records will be required prior to start date. 1. The form was complete immediately. 2. Parent completed forms that afternoon. 3. Parent provided info that afternoon. 4. Records were on digital kangaroo time file. Parent completed form at pick up.
Standard 8VAC20-780-70
Staff records shall be kept for each staff person and include the documentation to demonstrate that the individual possesses the education, certification, and experience required by the job position. The record of staff #2, identified as a program leader, did not contain documentation that the individual possesses the education required by the job position.
Plan of Correction: Per administration: The staff member has requested the transcript. Diploma/transcript will be required prior to staff start date moving forward.