Bright Beginnings, Inc. - Forest Lakes

8VAC20-780-370-1

“Based on observation and interview, the center failed to ensure when an infant is placed in his crib, he shall be placed on his back (supine). Evidence: Infant #1 (age 6 weeks) was observed to be placed in the crib on the infant's left side to sleep. Administration acknowledged the infant was placed on his side, and not on his back (supine).”

8VAC20-780-370-1

“Based on observation and interview, the center failed to ensure when an infant is placed in his crib, he shall be placed on his back (supine). Evidence: Infant #1 (age 6 weeks) was observed to be placed in the crib on the infant's left side to sleep. Administration acknowledged the infant was placed on his side, and not on his back (supine).”

8VAC20-780-340-A

“Based on observation and interview, the center failed to ensure when staff are supervising children, they shall always ensure their care, protection, and guidance. Evidence: 1. In the lion's infant room, two children were observed sleeping in bouncy chairs. Child #6 was observed asleep with a blanket covering him up to his chin and a stuffed animal resting against his face. Another child was observed sleeping with a bib attached around his neck. 2. According to The American Academy of Pediatrics website "infants need to sleep on their backs on a firm, flat non-inclined surface without soft bedding. Keep soft objects, such as pillow-like toys, quilts, comforters, and loose bedding, such as blankets away from the infant's sleep area to reduce the risk of SIDS and suffocation." 3. Administration confirmed the babies should not have had a blanket, stuffed animal, or bib on while sleeping.”

8VAC20-780-350-Q

“Based on documentation and interview, the center failed to ensure that written assessments were completed by the program director and program leader before choosing to assign a child to a different age group. Evidence: 1. Documentation from the records of children #1, 2, 3, 4, and 5, all age two and assigned to the 3 year old group, contained written assessments that had designated spaces for two teacher signatures and two parent signatures. These assessments were not signed by the program director at the time of inspection. 2. Interview with the program director confirmed that she did not conduct the assessments of the children with the program leader.”

8VAC20-780-500-A

“Based on observation, the center failed to ensure children's hands are washed with soap and running water after toileting. Evidence: In the Cheetah classroom, child #12 was observed exiting the restroom without washing his hands. Staff #4 confirmed the child used the restroom and staff were unaware the child's hands were not washed.”

8VAC20-780-70

“Repeat VIolation Based on record review, the center failed to ensure that a staff record contained documentation to demonstrate that the individual possesses the education, certification, and experience required by the job position, and orientation and training as required in 8VAC20-780-240 and 8VAC20-780-245. Evidence: 1. The record for staff #3, Program Leader, did not contain documentation that the staff fulfilled a high school program completion or the equivalent.”

8VAC20-780-160-C

“Based on record review, the center failed to ensure that at least every two years from the date of the initial screening or testing, staff members obtained and submitted the results of a follow-up tuberculosis screening. Evidence: 1.The record for staff #3 contained TB results dated 05/10/2021. The follow-up screening was not obtained until 09/04/2023.”

8VAC20-780-40-E

“Based on observation and document review, the licensee failed to ensure that the center’s activities and services were maintained in compliance with the center’s own policies and procedures that are required by these standards. Evidence: 1.Per the center’s Playground Safety Procedures: ?Supervision on the playground is active. Staff must stand, interact, and circulate to ensure all children are playing safely. A combination of supervision ?zones? with some staff also circulating the playground is to be used. - A staff member must always monitor and assist children while on playground equipment. -Staff must spread out into zones to maintain full visualization of the entire playground, and to be sure children are not exiting the playground or reentering the building on their own. -If a single staff member is supervising the playground, that staff member must limit children from playing in areas that are not in line of sight of that staff member. -Teachers must not congregate.? 2. Upon driving into the parking lot while arriving at the center, the Licensing Inspector (LI) and Licensing Administrator (LA)observed a group of children and two staff on the playground. The two staff were standing face-to-face at the top of the hillside, engaged in conversation amongst themselves. After circling the parking lot, the LI and LA observed that the two staff remained standing face-to-face engaged in conversation while children were observed at the bottom of the hillside. One child was punched approximately three times by another child and a different child was pushed to the ground. The LA intervened by calling attention to the activities of the children to the staff, who had been engaged in conversation amongst themselves for approximately two minutes.”

8VAC20-780-160-A

“Based on record review, the center failed to ensure that a staff member submitted documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with children. Evidence: 1. The record for staff #2, hired on 05/15/2023, did not contain documentation of a negative tuberculosis screening.”

8VAC20-780-280-B

“Repeat Violation Based on observation, the center failed to ensure that 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. Evidence: 1. The door to the cabinet above the sink in the Tiger room was open and unlocked. The cabinet contained a bottle of Comet Classic Foam Cleaner with Bleach, a spray bottle labeled ?Bleach Water? dated 11/27, and a spray bottle labeled ?Table Bleach? dated 11/17. Staff working in the Tiger room verified that both spray bottles contained a bleach mixture. 2. There is not a lock on the door to the kitchen, located in the main hallway. A cabinet under a sink, which did not have a locking method, contained a spray bottle of Simple Green and a bottle of Proface ready to Use Heavy Duty Degreaser, both labels indicated ?Keep Out of Reach of Children?. The kitchen also contained unlocked bottle of Dawn Ultra, label indicating ?Keep Out of Reach of Children? and a spray bottle labeled Antibacterial Cleaner.”

8VAC20-780-550-F

“Based on a review of the log for procedures for emergencies, the center failed to ensure lockdown procedures are practiced at least annually. Evidence: There was no documentation of a lockdown drill being practiced in 2021 and 2022.”

8VAC20-780-280-B

“Based on observation and interview, the center failed to ensure that hazardous substances were kept in a locked place using a safe locking method that prevents access by children. Evidence: 1. The Giraffe classroom, ages 18 months-24 months, had an unlocked upper cabinet that contained disinfectant, Windex, and Febreze with labels that stated "keep out of reach of children" and "caution." 2. Staff # 5 confirmed the cabinet was not locked.”

8VAC20-780-280-D

“Based on observation and interview, the center failed to ensure the cleaning and sanitizing materials shall not be located above food and shall be stored in areas physically separate from food. Evidence: 1. In the Giraffe classroom, hand sanitizer was located laying on it's side, on a wire shelf directly above food from a child's lunch in ziplock bags. 2. Staff #5 confirmed the hand sanitizer was located above food.”

8VAC20-780-550-E

“Based on a review of records, the center failed to ensure to implement a minimum of two shelter-in-place drills per year for the most likely to occur scenarios. Evidence: There was no documentation of shelter-in-place drills being practiced in 2021 and 2022.”

8VAC20-780-440-B

“Based on observation and interview, the center failed to ensure that cribs shall be identified for use by a specific child. Evidence: In the Lion room, two cribs were occupied by infants and the cribs were not labeled to identify use by a specific child. Staff #1 confirmed the cribs were not labeled.”

22.1-289.035-B-4

“Repeat Violation Based on a review of staff records and interview, the center failed to ensure to obtain the results of a check of an out-of-state child abuse and neglect registry or equivalent by the end of the 30th day of employment for each employee who has resided in any other state in the preceding five years. Evidence: 1. The record of staff #6, hired 04/03/2023, did not contain documentation of an out-of-state child abuse and neglect result. Staff #6 indicated living in a previous state on the staff's sworn disclosure statement. 2. Staff #7 confirmed the result was not obtained.”

8VAC20-780-60-A

“Repeat Violation Systemic Deficiency Based on a review of children's records and interview, the center failed to ensure that each child's record contained the required information. Evidence: 1. The record of child #4, enrolled 06/12/2022, contained documentation of immunizations that were dated 06/19/2023, which was not prior to enrollment. 2. The record of child #4, enrolled 06/12/2022, contained documentation of a physical that was dated 06/12/2023, which was not before the child's attendance or within 30 days after the first day of attendance. 3. Staff #1 confirmed that child #4 did not have immunizations and a physical in the required timeframe.”

8VAC20-780-270-A

“Based on observation and interview, the center failed to ensure areas and equipment of the center, inside and outside, shall be maintained in a clean, safe, and operable condition. Evidence: 1. On the playground, approximately six steps and the handrails, going up the play structure contained chipped paint and rust and rusted bolts. 2. The bike carousel contained five bikes with rusted handlebars and the center disc was also rusted. 3. Staff #1 and staff #5 confirmed the equipment contained rust.”

8VAC20-780-570-C

“Based on observation and interview, the center failed to ensure to maintain a record of each child on formula to include the brand of formula. Evidence: 1. The Lion room did not contain documentation of the brand of formula for seven children on formula. 2.The Monkey room did not contain documentation of the brand of formula for two children on formula. 3. Staff #5 confirmed they did not have the brand of formula.”

8VAC20-780-560-G

“Based on observation and interview on September 6, 2023, the center failed to ensure food from home shall be sealed and clearly dated and labeled in a way that identifies the owner. Evidence: 1. In the Lion room, there were six infant bottles not dated. There were two bottles dated 8/21. 2. In the Monkey room, there was one bottle dated 8/6. 3. In the Giraffe room, there were four thermos containers not dated. 4. In the Zebra room, there was crackers and yogurt in a cubby which were not labeled or dated. 5. In the Cheetah room, there were 13 lunchboxes that were not dated.”

8VAC20-780-70

“Based on a review of staff records, the center failed to ensure that two or more references were checked before employment. Evidence: The records of staff #2, hired 08/04/2023, and staff #4, hired 09/01/2023, did not contain documentation of two references.”

8VAC20-780-550-F

“Based on a review of the log for procedures for emergencies, the center failed to ensure lockdown procedures are practiced at least annually. Evidence: There was no documentation of a lockdown drill being practiced in 2021 and 2022.”

8VAC20-780-280-B

“Based on observation and interview, the center failed to ensure that hazardous substances were kept in a locked place using a safe locking method that prevents access by children. Evidence: 1. The Giraffe classroom, ages 18 months-24 months, had an unlocked upper cabinet that contained disinfectant, Windex, and Febreze with labels that stated "keep out of reach of children" and "caution." 2. Staff # 5 confirmed the cabinet was not locked.”

8VAC20-780-280-D

“Based on observation and interview, the center failed to ensure the cleaning and sanitizing materials shall not be located above food and shall be stored in areas physically separate from food. Evidence: 1. In the Giraffe classroom, hand sanitizer was located laying on it's side, on a wire shelf directly above food from a child's lunch in ziplock bags. 2. Staff #5 confirmed the hand sanitizer was located above food.”

8VAC20-780-550-E

“Based on a review of records, the center failed to ensure to implement a minimum of two shelter-in-place drills per year for the most likely to occur scenarios. Evidence: There was no documentation of shelter-in-place drills being practiced in 2021 and 2022.”

8VAC20-780-440-B

“Based on observation and interview, the center failed to ensure that cribs shall be identified for use by a specific child. Evidence: In the Lion room, two cribs were occupied by infants and the cribs were not labeled to identify use by a specific child. Staff #1 confirmed the cribs were not labeled.”

22.1-289.035-B-4

“Repeat Violation Based on a review of staff records and interview, the center failed to ensure to obtain the results of a check of an out-of-state child abuse and neglect registry or equivalent by the end of the 30th day of employment for each employee who has resided in any other state in the preceding five years. Evidence: 1. The record of staff #6, hired 04/03/2023, did not contain documentation of an out-of-state child abuse and neglect result. Staff #6 indicated living in a previous state on the staff's sworn disclosure statement. 2. Staff #7 confirmed the result was not obtained.”

8VAC20-780-60-A

“Repeat Violation Systemic Deficiency Based on a review of children's records and interview, the center failed to ensure that each child's record contained the required information. Evidence: 1. The record of child #4, enrolled 06/12/2022, contained documentation of immunizations that were dated 06/19/2023, which was not prior to enrollment. 2. The record of child #4, enrolled 06/12/2022, contained documentation of a physical that was dated 06/12/2023, which was not before the child's attendance or within 30 days after the first day of attendance. 3. Staff #1 confirmed that child #4 did not have immunizations and a physical in the required timeframe.”

8VAC20-780-270-A

“Based on observation and interview, the center failed to ensure areas and equipment of the center, inside and outside, shall be maintained in a clean, safe, and operable condition. Evidence: 1. On the playground, approximately six steps and the handrails, going up the play structure contained chipped paint and rust and rusted bolts. 2. The bike carousel contained five bikes with rusted handlebars and the center disc was also rusted. 3. Staff #1 and staff #5 confirmed the equipment contained rust.”

8VAC20-780-570-C

“Based on observation and interview, the center failed to ensure to maintain a record of each child on formula to include the brand of formula. Evidence: 1. The Lion room did not contain documentation of the brand of formula for seven children on formula. 2.The Monkey room did not contain documentation of the brand of formula for two children on formula. 3. Staff #5 confirmed they did not have the brand of formula.”

8VAC20-780-560-G

“Based on observation and interview on September 6, 2023, the center failed to ensure food from home shall be sealed and clearly dated and labeled in a way that identifies the owner. Evidence: 1. In the Lion room, there were six infant bottles not dated. There were two bottles dated 8/21. 2. In the Monkey room, there was one bottle dated 8/6. 3. In the Giraffe room, there were four thermos containers not dated. 4. In the Zebra room, there was crackers and yogurt in a cubby which were not labeled or dated. 5. In the Cheetah room, there were 13 lunchboxes that were not dated.”

8VAC20-780-70

“Based on a review of staff records, the center failed to ensure that two or more references were checked before employment. Evidence: The records of staff #2, hired 08/04/2023, and staff #4, hired 09/01/2023, did not contain documentation of two references.”

8VAC20-780-60-A

“SYSTEMIC DEFICIENCY Based on the review of nine child records, the program failed to ensure that each enrolled child has a record including all required information for five children. Evidence: 1. The record for Child #1 was missing the following: parent's work phone number, doctor's name and phone number, two emergency contacts, and signed written agreement. 2. The record for Child #2 was missing the following: proof of identity, first day immunizations, and physical. 3. The record for Child #7 was missing the following: sex, address, parent(s) name, address, and phone number, parent(s) work and phone number, doctor's name and phone number, two emergency contacts, authorization to pick up information, signed written agreement, proof of identity, immunizations, and physical. 4. The record for Child #8 was missing the following: sex, address, parent(s) name, address, and phone number, parent(s) work and phone number, doctor's name and phone number, two emergency contacts, authorization to pick up information, signed written agreement, proof of identity, and physical. 5. The record for Child #9 was missing the following: immunizations by the first day of attendance. 6. The administrator confirmed that the items were missing from the files and that they were currently working on cleaning up files and contacting parents regarding missing information.”

8VAC20-780-60-A

“SYSTEMIC DEFICIENCY Based on the review of nine child records, the program failed to ensure that each enrolled child has a record including all required information for five children. Evidence: 1. The record for Child #1 was missing the following: parent's work phone number, doctor's name and phone number, two emergency contacts, and signed written agreement. 2. The record for Child #2 was missing the following: proof of identity, first day immunizations, and physical. 3. The record for Child #7 was missing the following: sex, address, parent(s) name, address, and phone number, parent(s) work and phone number, doctor's name and phone number, two emergency contacts, authorization to pick up information, signed written agreement, proof of identity, immunizations, and physical. 4. The record for Child #8 was missing the following: sex, address, parent(s) name, address, and phone number, parent(s) work and phone number, doctor's name and phone number, two emergency contacts, authorization to pick up information, signed written agreement, proof of identity, and physical. 5. The record for Child #9 was missing the following: immunizations by the first day of attendance. 6. The administrator confirmed that the items were missing from the files and that they were currently working on cleaning up files and contacting parents regarding missing information.”

8VAC20-780-60-A

“SYSTEMIC DEFICIENCY Based on the review of nine child records, the program failed to ensure that each enrolled child has a record including all required information for five children. Evidence: 1. The record for Child #1 was missing the following: parent's work phone number, doctor's name and phone number, two emergency contacts, and signed written agreement. 2. The record for Child #2 was missing the following: proof of identity, first day immunizations, and physical. 3. The record for Child #7 was missing the following: sex, address, parent(s) name, address, and phone number, parent(s) work and phone number, doctor's name and phone number, two emergency contacts, authorization to pick up information, signed written agreement, proof of identity, immunizations, and physical. 4. The record for Child #8 was missing the following: sex, address, parent(s) name, address, and phone number, parent(s) work and phone number, doctor's name and phone number, two emergency contacts, authorization to pick up information, signed written agreement, proof of identity, and physical. 5. The record for Child #9 was missing the following: immunizations by the first day of attendance. 6. The administrator confirmed that the items were missing from the files and that they were currently working on cleaning up files and contacting parents regarding missing information.”

8VAC20-780-60-A

“SYSTEMIC DEFICIENCY Based on the review of nine child records, the program failed to ensure that each enrolled child has a record including all required information for five children. Evidence: 1. The record for Child #1 was missing the following: parent's work phone number, doctor's name and phone number, two emergency contacts, and signed written agreement. 2. The record for Child #2 was missing the following: proof of identity, first day immunizations, and physical. 3. The record for Child #7 was missing the following: sex, address, parent(s) name, address, and phone number, parent(s) work and phone number, doctor's name and phone number, two emergency contacts, authorization to pick up information, signed written agreement, proof of identity, immunizations, and physical. 4. The record for Child #8 was missing the following: sex, address, parent(s) name, address, and phone number, parent(s) work and phone number, doctor's name and phone number, two emergency contacts, authorization to pick up information, signed written agreement, proof of identity, and physical. 5. The record for Child #9 was missing the following: immunizations by the first day of attendance. 6. The administrator confirmed that the items were missing from the files and that they were currently working on cleaning up files and contacting parents regarding missing information.”

8VAC20-770-60-B

“REPEAT VIOLATION Based on a review of ten staff records, the program did not ensure that a sworn statement was completed prior to the first day of employment for one staff. Evidence: 1. The start date for Staff # 2 was 10/10/2022. The completed sworn statement was dated 10/17/2022. 2. Administrators confirmed date of 10/17/2022 on the form signed through DocuSign.”

22.1-289.035-B-4

“REPEAT VIOLATION Based on review of ten staff records, the program did not ensure that the results from a criminal history record check, a sex offender registry check, and a search of the child abuse and neglect registry were obtained from any state in which the individual has resided in the preceding five years for one staff. Evidence: 1. The date of employment for Staff #7 was 10/20/2022. There were no results from a search of the child abuse and neglect registry in the file for the two previous states of residence. The request for one of the states was mailed 11/30/2022, more than thirty days after employment began.”

8VAC20-780-240-B Complaint related: No

“Based on review of four staff files, program did not ensure that orientation was completed within seven days of assuming job responsibilities for one staff. Evidence: The start date for Staff #1 was 10/10/2022. Orientation paperwork was not in the file.”

8VAC20-770-60-B Complaint related: No

“Based on a review of four staff records, the program did not ensure that a sworn statement was completed prior to the first day of employment for one staff. Evidence: The start date for Staff # 1 was 10/10/2022. There was no valid sworn statement in the file.”

22.1-289.035-B-2 Complaint related: No

“Based on a review of four staff records, the program did not ensure that a national criminal history record check was completed prior to the first day of employment for one staff. Evidence: The start date for Staff #1 was 10/10/2022. There were no valid results in the file.”

22.1-289.023-B Complaint related: No

“Based on observation, program failed to post the Special Order (SO) issued by the Superintendent. Evidence: When the Licensing inspector and Licensing Administrator arrived on 10/18/2022, the SO was not posted at the entrance.”

22.1-289.023-A Complaint related: No

“Based on observation, program failed to post the notice of the Superintendent's intent (NOI) at a prominent place at each public entrance. Evidence: When the Licensing inspector and Licensing Administrator arrived on 10/18/2022, the NOI was not posted at the entrance. The NOI was issued 7/21/2022.”

8VAC20-770-60-C-2 Complaint related: No

“Based on a review of four staff records, the program did not deny continued employment for five staff when the results from the central registry check were not received within 30 days of employment. Evidence: The start date for Staff #1 was 10/10/2022. There were no results in the file.”

8VAC20-780-160-A Complaint related: No

“Based on the review of four staff records, the program did not ensure that the documentation of a negative tuberculosis (TB) screening was completed within the last thirty calendar days of the date of employment for one staff. Evidence: The dated of employment for Staff #1 was 10/10/2022. The TB screening in the file was dated 8/10/2022.”

22.1-289.035-B-2

“Based on a review of ten staff records, the program did not ensure that a national criminal history record check was completed prior to the first day of employment for two staff. Evidence: 1. The start date for Staff #2 was 4/7/2022. The results in the file were dated 4/11/2022. 2. The start date for Staff #5 was 2/2/2022. The results in the file were dated 2/14/2022.”

22.1-289.035-B-4

“Based on review of ten staff records, program did not ensure that the results from a criminal history record check, a sex offender registry check, and a search of the child abuse and neglect registry wer obtained from any state in which the individual has resided in the preceding five years for two staff. Evidence: 1. The start date for Staff #2 was 4/7/2022. There were no results from a search of the child abuse and neglect registry in the file for the previous state of residence. 2. The start date for Staff # 5 was 2/2/2022. There were no results from a criminal history record check, a sex offender registry check, nor a search of the child abuse and neglect registry for either of the two previous states of residence.”

8VAC20-770-60-B

“Based on a review of ten staff records, the program did not ensure that a sworn statement was completed prior to the first day of employment for one staff. Evidence: The start date for Staff # 4 was 4/11/2022. The sworn statement was completed on 8/27/2022.”

8VAC20-770-60-C-2

“Based on a review of ten staff records, the program did not deny continued employment for five staff when the results from the central registry check were not received within 30 days of employment. Evidence: 1. The start date for Staff #1 was 8/1/2022. Request was mailed 8/17/2022. There are no results in the file. 2. The start date for Staff #3 was 5/30/2022. Third request was mailed 8/17/2022. There are no results in the file. 3. The start date for Staff #4 was 4/11/2022. Request was mailed 9/9/2022. There are no results in the file. 4. The start date for Staff #5 was 2/2/2022. The results in the file were dated 9/11/2022. 5. The start date for Staff #9 was 7/28/2022. The results in the file were dated 9/11.2022.”

8VAC20-780-160-A

“Based on the review of ten staff records, the program did not ensure that the documentation of a negative tuberculosis (TB) screening was completed within the last thirty calendar days of the date of employment for seven staff. Evidence: 1. The date of employment for Staff #1 was 8/1/2022. The TB screening in the file was dated 9/9/2022. 2. The date of employment for Staff #2 was 4/7/2022. The TB screening in the file was dated 4/12/2022. 3. The date of employment for Staff #4 was 4/11/2022. The TB screening in the file was dated 9/6/2019. 4. The date of employment for Staff #5 was 2/2/2022. The TB screening in the file was dated 2/11/2022. 5. The date of employment for Staff #7 was 1/3/2022. The TB screening in the file was dated 5/11/2022. 6. The date of employment for Staff #8 was 3/14/2022. The TB screening in the file was dated 3/17/2022. 7. The date of employment for Staff #9 was 7/28/2022. The TB screening in the file was dated 12/14/2021.”

8VAC20-780-440-B

“Based on observation, the program did not ensure that cribs are identified for use by a specific child. Evidence: There were four cribs in the Lions room, but none of them were identified for use by a specific child.”

8VAC20-780-440-G

“Based on observation and interview, the program did not ensure that cribs are used for children under 12 months of age. Evidence: 1. There were seven children, aged 8 weeks to 8 months old, in the Lions room. Only four cribs were available. 2. When Staff #1 was asked where the other three children slept, she pointed to the center of the room where children were sleeping in their bouncy chair.”

8VAC20-780-570-E

“Based on observation, the program did not ensure that prepared infant formula was dated and labeled with the child's name. Evidence: There were two bottles in the refrigerator of the Lions room that had no name or date.”

8VAC20-820-120-E-1

“Based on observation and interview, the program did not ensure that the most recently issued license was posted. Evidence: 1. The license that was posted expired 9/19/2019. 2. Administrator looked and confirmed that the license was expired.”

8VAC20-820-120-E-5

“Based on observation and interview, the program did not ensure that a copy of the notice of intent from the Superintendent was posted in a prominent place at each public entrance to the facility to advise consumers of serious or persistent violations. Evidence: 1. The notice of intent (NOI), issued to facility yn 7/21/2022, was not posted at the entrance. 2. When Staff #6 (first day of employment was 8/15/2022) was asked where the NOI was posted, she was not aware of its existence.”

8VAC20-780-500-A

“Based on observation, the program did not ensure that children's hands were washed with soap and running water or disposable wipes before and after eating snacks or meals. Evidence: Two children in the Monkeys room were eating upon inspector's arrival. Once the children finished eating, they were removed from the table and placed on the rug to play, without washing hands.”

22.1-289.035-B-2

“Based on a review of ten staff records, the program did not ensure that a national criminal history record check was completed prior to the first day of employment for two staff. Evidence: 1. The start date for Staff #2 was 4/7/2022. The results in the file were dated 4/11/2022. 2. The start date for Staff #5 was 2/2/2022. The results in the file were dated 2/14/2022.”

22.1-289.035-B-4

“Based on review of ten staff records, program did not ensure that the results from a criminal history record check, a sex offender registry check, and a search of the child abuse and neglect registry wer obtained from any state in which the individual has resided in the preceding five years for two staff. Evidence: 1. The start date for Staff #2 was 4/7/2022. There were no results from a search of the child abuse and neglect registry in the file for the previous state of residence. 2. The start date for Staff # 5 was 2/2/2022. There were no results from a criminal history record check, a sex offender registry check, nor a search of the child abuse and neglect registry for either of the two previous states of residence.”

8VAC20-770-60-B

“Based on a review of ten staff records, the program did not ensure that a sworn statement was completed prior to the first day of employment for one staff. Evidence: The start date for Staff # 4 was 4/11/2022. The sworn statement was completed on 8/27/2022.”

8VAC20-770-60-C-2

“Based on a review of ten staff records, the program did not deny continued employment for five staff when the results from the central registry check were not received within 30 days of employment. Evidence: 1. The start date for Staff #1 was 8/1/2022. Request was mailed 8/17/2022. There are no results in the file. 2. The start date for Staff #3 was 5/30/2022. Third request was mailed 8/17/2022. There are no results in the file. 3. The start date for Staff #4 was 4/11/2022. Request was mailed 9/9/2022. There are no results in the file. 4. The start date for Staff #5 was 2/2/2022. The results in the file were dated 9/11/2022. 5. The start date for Staff #9 was 7/28/2022. The results in the file were dated 9/11.2022.”

8VAC20-780-160-A

“Based on the review of ten staff records, the program did not ensure that the documentation of a negative tuberculosis (TB) screening was completed within the last thirty calendar days of the date of employment for seven staff. Evidence: 1. The date of employment for Staff #1 was 8/1/2022. The TB screening in the file was dated 9/9/2022. 2. The date of employment for Staff #2 was 4/7/2022. The TB screening in the file was dated 4/12/2022. 3. The date of employment for Staff #4 was 4/11/2022. The TB screening in the file was dated 9/6/2019. 4. The date of employment for Staff #5 was 2/2/2022. The TB screening in the file was dated 2/11/2022. 5. The date of employment for Staff #7 was 1/3/2022. The TB screening in the file was dated 5/11/2022. 6. The date of employment for Staff #8 was 3/14/2022. The TB screening in the file was dated 3/17/2022. 7. The date of employment for Staff #9 was 7/28/2022. The TB screening in the file was dated 12/14/2021.”

8VAC20-780-440-B

“Based on observation, the program did not ensure that cribs are identified for use by a specific child. Evidence: There were four cribs in the Lions room, but none of them were identified for use by a specific child.”

8VAC20-780-440-G

“Based on observation and interview, the program did not ensure that cribs are used for children under 12 months of age. Evidence: 1. There were seven children, aged 8 weeks to 8 months old, in the Lions room. Only four cribs were available. 2. When Staff #1 was asked where the other three children slept, she pointed to the center of the room where children were sleeping in their bouncy chair.”

8VAC20-780-570-E

“Based on observation, the program did not ensure that prepared infant formula was dated and labeled with the child's name. Evidence: There were two bottles in the refrigerator of the Lions room that had no name or date.”

8VAC20-820-120-E-1

“Based on observation and interview, the program did not ensure that the most recently issued license was posted. Evidence: 1. The license that was posted expired 9/19/2019. 2. Administrator looked and confirmed that the license was expired.”

8VAC20-820-120-E-5

“Based on observation and interview, the program did not ensure that a copy of the notice of intent from the Superintendent was posted in a prominent place at each public entrance to the facility to advise consumers of serious or persistent violations. Evidence: 1. The notice of intent (NOI), issued to facility yn 7/21/2022, was not posted at the entrance. 2. When Staff #6 (first day of employment was 8/15/2022) was asked where the NOI was posted, she was not aware of its existence.”

8VAC20-780-500-A

“Based on observation, the program did not ensure that children's hands were washed with soap and running water or disposable wipes before and after eating snacks or meals. Evidence: Two children in the Monkeys room were eating upon inspector's arrival. Once the children finished eating, they were removed from the table and placed on the rug to play, without washing hands.”

22.1-289.035-B-2

“Based on a review of ten staff records, the program did not ensure that a national criminal history record check was completed prior to the first day of employment for two staff. Evidence: 1. The start date for Staff #2 was 4/7/2022. The results in the file were dated 4/11/2022. 2. The start date for Staff #5 was 2/2/2022. The results in the file were dated 2/14/2022.”

22.1-289.035-B-4

“Based on review of ten staff records, program did not ensure that the results from a criminal history record check, a sex offender registry check, and a search of the child abuse and neglect registry wer obtained from any state in which the individual has resided in the preceding five years for two staff. Evidence: 1. The start date for Staff #2 was 4/7/2022. There were no results from a search of the child abuse and neglect registry in the file for the previous state of residence. 2. The start date for Staff # 5 was 2/2/2022. There were no results from a criminal history record check, a sex offender registry check, nor a search of the child abuse and neglect registry for either of the two previous states of residence.”

8VAC20-770-60-B

“Based on a review of ten staff records, the program did not ensure that a sworn statement was completed prior to the first day of employment for one staff. Evidence: The start date for Staff # 4 was 4/11/2022. The sworn statement was completed on 8/27/2022.”

8VAC20-770-60-C-2

“Based on a review of ten staff records, the program did not deny continued employment for five staff when the results from the central registry check were not received within 30 days of employment. Evidence: 1. The start date for Staff #1 was 8/1/2022. Request was mailed 8/17/2022. There are no results in the file. 2. The start date for Staff #3 was 5/30/2022. Third request was mailed 8/17/2022. There are no results in the file. 3. The start date for Staff #4 was 4/11/2022. Request was mailed 9/9/2022. There are no results in the file. 4. The start date for Staff #5 was 2/2/2022. The results in the file were dated 9/11/2022. 5. The start date for Staff #9 was 7/28/2022. The results in the file were dated 9/11.2022.”

8VAC20-780-160-A

“Based on the review of ten staff records, the program did not ensure that the documentation of a negative tuberculosis (TB) screening was completed within the last thirty calendar days of the date of employment for seven staff. Evidence: 1. The date of employment for Staff #1 was 8/1/2022. The TB screening in the file was dated 9/9/2022. 2. The date of employment for Staff #2 was 4/7/2022. The TB screening in the file was dated 4/12/2022. 3. The date of employment for Staff #4 was 4/11/2022. The TB screening in the file was dated 9/6/2019. 4. The date of employment for Staff #5 was 2/2/2022. The TB screening in the file was dated 2/11/2022. 5. The date of employment for Staff #7 was 1/3/2022. The TB screening in the file was dated 5/11/2022. 6. The date of employment for Staff #8 was 3/14/2022. The TB screening in the file was dated 3/17/2022. 7. The date of employment for Staff #9 was 7/28/2022. The TB screening in the file was dated 12/14/2021.”

8VAC20-780-440-B

“Based on observation, the program did not ensure that cribs are identified for use by a specific child. Evidence: There were four cribs in the Lions room, but none of them were identified for use by a specific child.”

8VAC20-780-440-G

“Based on observation and interview, the program did not ensure that cribs are used for children under 12 months of age. Evidence: 1. There were seven children, aged 8 weeks to 8 months old, in the Lions room. Only four cribs were available. 2. When Staff #1 was asked where the other three children slept, she pointed to the center of the room where children were sleeping in their bouncy chair.”

8VAC20-780-570-E

“Based on observation, the program did not ensure that prepared infant formula was dated and labeled with the child's name. Evidence: There were two bottles in the refrigerator of the Lions room that had no name or date.”

8VAC20-820-120-E-1

“Based on observation and interview, the program did not ensure that the most recently issued license was posted. Evidence: 1. The license that was posted expired 9/19/2019. 2. Administrator looked and confirmed that the license was expired.”

8VAC20-820-120-E-5

“Based on observation and interview, the program did not ensure that a copy of the notice of intent from the Superintendent was posted in a prominent place at each public entrance to the facility to advise consumers of serious or persistent violations. Evidence: 1. The notice of intent (NOI), issued to facility yn 7/21/2022, was not posted at the entrance. 2. When Staff #6 (first day of employment was 8/15/2022) was asked where the NOI was posted, she was not aware of its existence.”

8VAC20-780-500-A

“Based on observation, the program did not ensure that children's hands were washed with soap and running water or disposable wipes before and after eating snacks or meals. Evidence: Two children in the Monkeys room were eating upon inspector's arrival. Once the children finished eating, they were removed from the table and placed on the rug to play, without washing hands.”

8VAC20-780-350-B-4 Complaint related: Yes

“Based on observation and interviews, the program did not ensure that the required staff-to-children ratios were followed when children were in care. Evidence: 1. While touring the facility on March 8, 2022 beginning at 12:04 pm, the LI observed eighteen children in the care of one staff member in the Tigers room (Children aged three and four). 2. Staff #3 admitted that there were some staff that were out with illness, but stated she is typically out of ratio.”

8VAC20-780-350-B-3 Complaint related: Yes

“Based on observation, the program did not ensure that the required staff-to-children ratios were followed when children were in care. Evidence: 1. While touring the facility on March 8, 2022 beginning at 12:04 pm, the LI observed twenty children in the care of two staff members in the Elephant room (Two year old children).”

8VAC20-780-350-B-1 Complaint related: Yes

“Based on observation and interviews, the program did not ensure that the required staff-to-children ratios were followed when children were in care. Evidence: 1. While touring the facility on March 8, 2022 beginning at 12:04 pm, the LI observed five children in the care of one staff member in the Lions room (Infants aged 3 months-9 months). 2. While touring the facility on March 8, 2022 beginning at 12:04 pm, the LI observed five children in the care of one staff member in the Monkeys room (Infants aged 9 months-14 months). 3. When Staff #1 was asked what the staff-to-child ratio was, she stated that it was 1:5. The LI informed her that it was 1:4, to which she responded in the two months of her employment, she usually had five children in her care. 4. When the LI pointed out to Staff #2 that she would have been within ratio had she not taken Child #1 into care when she arrived at 12:04 pm. Staff #2 stated that she did not feel that she could turn away children that were enrolled in the program and that was the responsibility of the director.”

8VAC20-780-340-A Complaint related: Yes

“Based on interviews, the program did not ensure the care and protection of children. Evidence: 1. The Program Director stated that they were made aware of a social media post on 1/13/22 claiming that a child in their care was given the wrong bottle. 2. Two former staff admitted the error to the Program Director when they were questioned. 3, Staff were retrained on proper infant feeding procedures.”

8VAC20-780-550-P Complaint related: No

“Based on review of ten incident reports, the program did not ensure that all required information was completed. Evidence: 1. On the report dated 11/3/21, the time of the incident was not listed on the report. 2. On the report dated 11/8/21, there was only one signature on the report. 3. On the report dated 10/19/21, there was only one signature on the report.”

8VAC20-780-350-B-4 Complaint related: Yes

“Based on observation and interviews, the program did not ensure that the required staff-to-children ratios were followed when children were in care. Evidence: 1. While touring the facility on March 8, 2022 beginning at 12:04 pm, the LI observed eighteen children in the care of one staff member in the Tigers room (Children aged three and four). 2. Staff #3 admitted that there were some staff that were out with illness, but stated she is typically out of ratio.”

8VAC20-780-350-B-3 Complaint related: Yes

“Based on observation, the program did not ensure that the required staff-to-children ratios were followed when children were in care. Evidence: 1. While touring the facility on March 8, 2022 beginning at 12:04 pm, the LI observed twenty children in the care of two staff members in the Elephant room (Two year old children).”

8VAC20-780-350-B-1 Complaint related: Yes

“Based on observation and interviews, the program did not ensure that the required staff-to-children ratios were followed when children were in care. Evidence: 1. While touring the facility on March 8, 2022 beginning at 12:04 pm, the LI observed five children in the care of one staff member in the Lions room (Infants aged 3 months-9 months). 2. While touring the facility on March 8, 2022 beginning at 12:04 pm, the LI observed five children in the care of one staff member in the Monkeys room (Infants aged 9 months-14 months). 3. When Staff #1 was asked what the staff-to-child ratio was, she stated that it was 1:5. The LI informed her that it was 1:4, to which she responded in the two months of her employment, she usually had five children in her care. 4. When the LI pointed out to Staff #2 that she would have been within ratio had she not taken Child #1 into care when she arrived at 12:04 pm. Staff #2 stated that she did not feel that she could turn away children that were enrolled in the program and that was the responsibility of the director.”

8VAC20-780-340-A Complaint related: Yes

“Based on interviews, the program did not ensure the care and protection of children. Evidence: 1. The Program Director stated that they were made aware of a social media post on 1/13/22 claiming that a child in their care was given the wrong bottle. 2. Two former staff admitted the error to the Program Director when they were questioned. 3, Staff were retrained on proper infant feeding procedures.”

8VAC20-780-550-P Complaint related: No

“Based on review of ten incident reports, the program did not ensure that all required information was completed. Evidence: 1. On the report dated 11/3/21, the time of the incident was not listed on the report. 2. On the report dated 11/8/21, there was only one signature on the report. 3. On the report dated 10/19/21, there was only one signature on the report.”

8VAC20-780-350-B-4 Complaint related: Yes

“Based on observation and interviews, the program did not ensure that the required staff-to-children ratios were followed when children were in care. Evidence: 1. While touring the facility on March 8, 2022 beginning at 12:04 pm, the LI observed eighteen children in the care of one staff member in the Tigers room (Children aged three and four). 2. Staff #3 admitted that there were some staff that were out with illness, but stated she is typically out of ratio.”

8VAC20-780-350-B-3 Complaint related: Yes

“Based on observation, the program did not ensure that the required staff-to-children ratios were followed when children were in care. Evidence: 1. While touring the facility on March 8, 2022 beginning at 12:04 pm, the LI observed twenty children in the care of two staff members in the Elephant room (Two year old children).”

8VAC20-780-350-B-1 Complaint related: Yes

“Based on observation and interviews, the program did not ensure that the required staff-to-children ratios were followed when children were in care. Evidence: 1. While touring the facility on March 8, 2022 beginning at 12:04 pm, the LI observed five children in the care of one staff member in the Lions room (Infants aged 3 months-9 months). 2. While touring the facility on March 8, 2022 beginning at 12:04 pm, the LI observed five children in the care of one staff member in the Monkeys room (Infants aged 9 months-14 months). 3. When Staff #1 was asked what the staff-to-child ratio was, she stated that it was 1:5. The LI informed her that it was 1:4, to which she responded in the two months of her employment, she usually had five children in her care. 4. When the LI pointed out to Staff #2 that she would have been within ratio had she not taken Child #1 into care when she arrived at 12:04 pm. Staff #2 stated that she did not feel that she could turn away children that were enrolled in the program and that was the responsibility of the director.”

8VAC20-780-340-A Complaint related: Yes

“Based on interviews, the program did not ensure the care and protection of children. Evidence: 1. The Program Director stated that they were made aware of a social media post on 1/13/22 claiming that a child in their care was given the wrong bottle. 2. Two former staff admitted the error to the Program Director when they were questioned. 3, Staff were retrained on proper infant feeding procedures.”

8VAC20-780-550-P Complaint related: No

“Based on review of ten incident reports, the program did not ensure that all required information was completed. Evidence: 1. On the report dated 11/3/21, the time of the incident was not listed on the report. 2. On the report dated 11/8/21, there was only one signature on the report. 3. On the report dated 10/19/21, there was only one signature on the report.”