Inspection · 2025-09-12
Licensing Inspector
Heather Harrell
(757) 334-4329
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.
8VAC20-770 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 and completed on 9/12/25. The on-site inspection began at 10:15am and ended at 1:45pm. The inspector reviewed compliance in the areas listed above. There were 50 children present and 13 staff. The inspector reviewed 5 children's records and 5 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 9/22/25. A POC submitted after this date will not appear on the public website.
Standard 22.1-289.035-B-2
The center must obtain a completed national criminal background check prior to the employee's first day of employment. Staff 1 began employment at the center prior to the results of the national criminal background check being received.
Plan of Correction: The center responded with the following: Background check was received on 7/7/25. Issue with national recruiter and confusion on returned background check for DL. Staff 1 was in a different center doing virtual training and was not with children.
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 2, employed for over a year and a half, did not have documentation of requesting a sex offender registry check or a central registry check from one state and no documentation of requesting a central registry check or criminal history check from a different state.
Plan of Correction: The center responded with the following: All 3 missing checks were initiated on 9/16/25 by center management, DL verified. Center management will notify licensing once they have been returned.
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 was no physical examination in the record of child 1, who had been enrolled for over two years.
Plan of Correction: The center responded with the following: CD has requested physical for child 1 to be returned by 9/19/25 for child to continue attendance in the program. Center management will ensure all new children's files are completed for physicals within the first 30 days of enrollment moving forward.
Standard 8VAC20-780-160-C
A tuberculosis (TB) screening is required every two years from the last screening. The updated TB screenings for staff 3 and staff 4 were both overdue by three months. The updated screenings have not yet been completed.
Plan of Correction: The center responded with the following: Change in center management after expiration so screenings were missed. Staff are scheduled for 9/19/25 for TB screenings. Retraining for new CD/AD on state compliance and regulations for staff. Full staff file audit will be done by 9/26/25 with DL verification.
Standard 8VAC20-780-510-G
Medication shall be labeled with the child's name. Medication for child 2 was onsite, but was not labeled with the child's name.
Plan of Correction: The center responded with the following: Parent has provided original packaging with child's name. Parent has made appointment to get new medication plan and new medication authorization forms for medication.
Standard 8VAC20-780-510-P
When an authorization for medication expires, the facility shall notify parents that the medication must be picked up within 14 days of the authorization expiring or that a new authorization should be completed. Medication for child 2 was onsite, but the medication authorization had expired over a month ago. The authorization had not been renewed and the medication was not returned or disposed of as required.
Plan of Correction: The center responded with the following: Medication was returned to the parent on 9/12/25. Center management will audit medication weekly to ensure all medications have proper authorization on file. Retraining for new CD/AD on medication policies.
Standard 8VAC20-780-550-H
The center shall maintain a record fo the dates of the practice drills for one year. There was no documentation of practice drills being completed for the months of May, June or August 2025.
Plan of Correction: The center responded with the following: Change in center management and drills were not completed. Fire drill has been scheduled. Center management will calendar all drills proactively moving forward so they are not missed.
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.The record for child 1, enrolled for over two years, does not contain the place of employment and work phone number for one parent.
Plan of Correction: The center responded with the following: Parent's info has been updated in child's file. Moving forward, CD/AD will verify file compliance and all agreements prior to the child's start date to ensure we have all necessary components. Full child file audit will be completed by 9/26/25 with DL verification.
Standard 8VAC20-780-70
Staff records shall contain documentation to demonstrate that the individual possesses the education required by the job position. Staff 1 has a documented job title of program director. There was no written documentation to verify that staff 1 meets the educational components required for a program director.
Plan of Correction: The center responded with the following: Staff 1 has enrolled in the CDA program to start on 10/6/25 to meet that requirement. Two additional staff members hold credentials to be PD qualified. Those have been sent to licensing for review. Center is willing to assign an acting qualified program director in order to maintain compliance until CDA is final for staff 1.