Childtime Learning Centers - Old Hickory

8VAC20-790-600-F

“Staff shall complete the departments health and safety update course annually. Staff #1 completed the departments health and safety course 48 days late.”

8VAC20-780-270-A

“The center shall ensure that areas and equipment of the center, inside and outside, are maintained in a clean, safe and operable condition. 1.On the toddler playground, a picnic table had broken plastic seats which poses a risk for pinched skin. 2. On the school age playground, the basketball stand had two uncovered anchor bolts. 3. In pre-k bathroom the toilet seat was cracked and in the room a cover for an outlet was coming away from the wall. 4. In the two’s room, the toilet seat was lose and able to move side to side. 5. In the infant room, the soap dispenser was lose and able to move side to side.”

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 the children. The record for staff #1 had documentation of screening completed two days after the date of employment.”

22.1-289.035-A

“The center is required to have employees complete a background check every five years. The updated central registry check results in staff #7?s record was obtained three days late.”

8VAC20-780-500-B

“Disposable diapers shall be disposed in a leakproof or plastic-lined storage system that is either foot-operated or used in such a way that neither the staff member's hand nor the soiled diaper touches an exterior surface of the storage system during disposal. In the two’s bathroom, a foot operated storage system used for disposing diapers was inoperable.”

8VAC20-790-600-F

“Staff shall complete the departments health and safety update course annually. Staff #1 completed the departments health and safety course 48 days late.”

8VAC20-780-270-A

“The center shall ensure that areas and equipment of the center, inside and outside, are maintained in a clean, safe and operable condition. 1.On the toddler playground, a picnic table had broken plastic seats which poses a risk for pinched skin. 2. On the school age playground, the basketball stand had two uncovered anchor bolts. 3. In pre-k bathroom the toilet seat was cracked and in the room a cover for an outlet was coming away from the wall. 4. In the two’s room, the toilet seat was lose and able to move side to side. 5. In the infant room, the soap dispenser was lose and able to move side to side.”

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 the children. The record for staff #1 had documentation of screening completed two days after the date of employment.”

22.1-289.035-A

“The center is required to have employees complete a background check every five years. The updated central registry check results in staff #7?s record was obtained three days late.”

8VAC20-780-500-B

“Disposable diapers shall be disposed in a leakproof or plastic-lined storage system that is either foot-operated or used in such a way that neither the staff member's hand nor the soiled diaper touches an exterior surface of the storage system during disposal. In the two’s bathroom, a foot operated storage system used for disposing diapers was inoperable.”

8VAC20-780-350-I Complaint related: No

“REPEAT VIOLATION Based on observation and interviews; the center did not maintain required staff-to-children ratio. Evidence: 1. On September 16, 2024, in room #1 at approximately 1:09 PM staff #5 went on break leaving staff #2 alone with 14 toddlers (16 months to 2 years old). Staff #3 entered the room after a few minutes. 2. Administrator #2 stated that staff #5 went on break at 1:09 PM.”

8VAC20-780-350-I Complaint related: No

“REPEAT VIOLATION Based on observation and interviews; the center did not maintain required staff-to-children ratio. Evidence: 1. On September 16, 2024, in room #1 at approximately 1:09 PM staff #5 went on break leaving staff #2 alone with 14 toddlers (16 months to 2 years old). Staff #3 entered the room after a few minutes. 2. Administrator #2 stated that staff #5 went on break at 1:09 PM.”

8VAC20-780-350-B-5

“REPEAT VIOLATION Based on documentation and interviews, the center did not maintain required staff-to-children ratio. Evidence: On June 27, 2024, in room #1, at approximately 1:30 PM staff #2 stated she was the only staff member with a group of school age children (ages: 7 years old to 10 years old) for approximately 10 minutes. The face to name transition sheet had documentation of 23 school age children in room #1 at 1:30 PM, requiring a ratio of one staff to 18 children. One additional staff was required.”

8VAC20-780-550-P

“Based on a review of documentation, the center did not ensure to maintain a written record of children's minor injuries that included the required information. Evidence: An incident report from June 27, 2024 did not include documentation of staff present, any future action to prevent recurrence of the injury, and one additional signature from a staff member or parent.”

8VAC20-780-40-E

“Based on review of documentation and interview,the licensee did not ensure operational responsibilities that the center's activities and services were maintained in compliance with the center's own policies and procedures that are required by the standards. Evidence: 1. The standards require the centers have a procedure for identifying where attending children are at all times. The center's Child Supervision Procedure states: ?Children must be supervised, in the direct line of sight and within ear shot of a staff member, at all times.? 2. Staff were unaware that Child #1 (age: 7 years) exited the classroom. Child #1 was unsupervised when child #1 fell approximately 12 feet from the top of the staircase leading from child #1's classroom to the gym.”

8VAC20-780-340-A

“Based on a review of documentation and interviews, the center did not ensure that when staff are supervising children, they shall always ensure their care, protection, and guidance. Evidence: On June 27, 2024, at approximately 1:25 PM child #1 (age: 7 years) fell approximately 12 feet from the arm rail at the top of the staircase that leads from the classroom to the gym. Staff #1 and staff #2 were unaware that child #1 had left the classroom until staff #1 heard someone screaming his name. Child #1 was seen by a doctor who determined child #1 had a broken jaw and wrist.”

8VAC20-780-340-F

“Based on observation and interview, the center did not ensure that children under 10 years of age were always within actual sight and sound supervision of staff. Evidence: In room #1, staff #1 and staff #2 observed child #1 (age: 7 years) standing at the classroom door during quiet time. At approximately 1:25 PM, staff #1 heard someone screaming his name. Staff #1 left the classroom and went down the staircase and saw child #1 on the gym floor. Staff #1 and staff #2 stated that they did not know child #1 had left room #1.”

8VAC20-780-350-B-4 Complaint related: No

“Based on observation and interview, the center failed to follow the required ratio for children from 3 years old to school age eligible: one staff member for every 10 children. 1. Staff A was alone with 20 pre-k children in room #1. 2. Administrator #2 observed video footage and reported that staff A was over the ratio (1:20) from approximately 3:38 PM to 3:41 PM in room #1.”

8VAC20-780-510-P

“Based on a review of medications and authorization forms, the licensee did not ensure that when an authorization for medication expires, the parent shall be notified that the medication needs to be picked up within 14 days or the parent must renew the authorization and that medications that are not picked up by the parent within 14 days are safely disposed of by the center. Evidence: The authorization forms for M# 8 and M# 9 had not been renewed and the medication was not returned or disposed of. The medication was on site.”

8VAC20-780-280-B

“Based on observation, the center did not ensure all hazardous substances such as cleaning materials insecticides and pesticides, were kept in a locked place using a safe locking method that prevents access by children. Evidence: 1. In room #3, two containers of bleach and water and one container of Betco were unlocked in a cabinet on the wall. Children in the classroom are two years of age. 2. Staff in room #3, confirmed that the cabinet was not locked. Administrator #1 stated that she would look for a child proof lock for the cabinet.”

8VAC20-780-510-P

“Based on a review of medications and authorization forms, the licensee did not ensure that when an authorization for medication expires, the parent shall be notified that the medication needs to be picked up within 14 days or the parent must renew the authorization and that medications that are not picked up by the parent within 14 days are safely disposed of by the center. Evidence: The authorization forms for M# 8 and M# 9 had not been renewed and the medication was not returned or disposed of. The medication was on site.”

8VAC20-780-280-B

“Based on observation, the center did not ensure all hazardous substances such as cleaning materials insecticides and pesticides, were kept in a locked place using a safe locking method that prevents access by children. Evidence: 1. In room #3, two containers of bleach and water and one container of Betco were unlocked in a cabinet on the wall. Children in the classroom are two years of age. 2. Staff in room #3, confirmed that the cabinet was not locked. Administrator #1 stated that she would look for a child proof lock for the cabinet.”

8VAC20-780-270-A

“Repeat Violation Based on observation, the center did not ensure areas and equipment of the center, inside and outside, shall be maintained in a clean, safe and operable condition. Evidence: A pipe was sticking out of a fenced in area for the pool equipment, creating a tripping hazard on the playground.”

8VAC20-780-540-C

“Based on observation, the first aid kit did contain the minimum required supplies. Evidence: 1. On bus #1, bus #2, and bus #3, the first aid kit did not include a thermometer, tweezers, or a first aid manual. 2. On bus #4, the first aid kit did not include scissors, tweezers, gauze pads, adhesive tape, band-aids, antiseptic cleansing solution, thermometer, single use gloves, or first aid manual.”

8VAC20-780-510-F

“Based on review of two medications and interviews, the center did not ensure that long term medication authorizations had written authorization from the child’s physician. Evidence: A non-prescription and prescription long-term allergy medication was observed for child #11. There was not written authorization from the child’s physician.”

8VAC20-780-320-B

“Based on observation, the facility did not ensure that restrooms were equipped with soap and paper towels or an air dryer. Evidence: 1. In room #2, one of the two bathrooms did not have soap. Children were observed using both bathrooms. 2. In room #3, the bathroom room did not have soap or paper towels/air dryer. The classroom sink did not have soap or paper towels/air dryer.”

8VAC20-780-280-B

“Based on observation, the center did not ensure all hazardous substances such as cleaning materials insecticides and pesticides, were kept in a locked place using a safe locking method that prevents access by children. Evidence: 1. In the pool pump area, next to the playground, there was Oxidizer labeled ?Danger? and ?Keep Out of Reach of Children?, Algaecide labeled ?Caution? and ?Keep Out of Reach of Children?, amd Algae Complete labeled ?Hazards to Humans and Domestic Animals?, ?Danger?, and ?Keep Out of Reach of Children?. The pool pump was not locked to prevent access by children. 2. In room #2, one container of bleach sanitizing solution labeled ?Keep Out of Reach of Children? and ?Danger? and one container of Sanibet disinfectant labeled ?Danger? and ?Keep Out of Reach of Children? was unlocked in the children’s bathroom. 3. In room #3, one container of bleach sanitizing solution labeled ?Keep Out of Reach of Children? and ?Danger? was sitting on top of the children’s cubbies. 4. In room #5, one container of bleach sanitizing solution labeled ?Keep Out of Reach of Children? and ?danger? was on the diaper changing table. The diaper changing table was not in use.”

8VAC20-780-270-A

“REPEAT VIOLATION Based on observation, the center did not ensure areas and equipment of the center, inside and outside, shall be maintained in a clean, safe and operable condition. Evidence: In room #1, an area on the wall had drywall showing and 17 out of 32 rest mats were torn in various places. In room #2, one of the two bathrooms had a broken soap dispenser and 11 out of 19 rest mats were torn in various places. In room #3, an outlet was being used without a cover plate exposing the electrical receptacle and 7 out of 22 rest mats were torn in various places.”

8VAC20-780-60-C

“Based on a review of children's records, the center did not ensure that each record contains all required information. Evidence: The records for child #5 (enrolled 03/15/22) did not contain documentation of viewing proof of the child's identity and age.”

8VAC20-780-40-M

“Based on observation and interview, the center did not ensure to maintain a current written list of all children's allergies, sensitivities, and dietary restrictions which is dated and kept confidential in each room or area where children are present. Evidence: In room #1, the allergy list was not dated and included child a (last day of attendance 06/30/23), child b (last day of attendance 08/19/23), child c (last day of attendance 06/07/23), and child d (last day of attendance 08/19/23).”

8VAC20-780-130-E

“Based on a review of children's records, the center did not ensure each record contained additional immunizations once every six months for children under the age of two years. Evidence: The record for child #9 (birth date 5/17/21) had one immunization record dated 02/25/22 at the time of enrollment on 03/01/22.”

8VAC20-770-60-C-2

“REPEAT VIOLATION Based on record review and interview, the center did not have documentation of central registry findings for two staff members. Evidence: 1. The record for staff #6 (employed 07/10/23) and staff #9 (employed 07/13/23) did not contain documentation of Central Registry findings. 2. During interview, a member of management acknowledged that the Central Registry findings had not been received and management had not followed up after 30 days.”

22.1-289.035-A

“Based on a review staff records and interview, the center did not ensure staff completed required background check every five years. Evidence: 1. The record of Staff #1 (employed 08/05/91) contained documentation of a fingerprint-based national criminal background check dated 06/06/23. The repeat background check should have been obtained prior to 02/21/18. The record for Staff #1 did not contain an updated Central Registry finding. 2. The record for staff #11 (employed 08/02/99) did not contain documentation of an updated fingerprint-based national criminal background check or an updated Central Registry finding. 3. During interview, a member of management acknowledged the fingerprints and central registry were not completed every five years as required.”

8VAC20-780-330-B

“Based on observation and measurements, the center did not ensure that resilient surfacing shall comply with minimum safety standards when tested. Evidence: Six out of six mulch depth samples taken around the fall zones of the playground all measured less than the required six inches.”

8VAC20-780-540-C

“Based on observation, the first aid kit did contain the minimum required supplies. Evidence: 1. On bus #1, bus #2, and bus #3, the first aid kit did not include a thermometer, tweezers, or a first aid manual. 2. On bus #4, the first aid kit did not include scissors, tweezers, gauze pads, adhesive tape, band-aids, antiseptic cleansing solution, thermometer, single use gloves, or first aid manual.”

8VAC20-780-510-F

“Based on review of two medications and interviews, the center did not ensure that long term medication authorizations had written authorization from the child’s physician. Evidence: A non-prescription and prescription long-term allergy medication was observed for child #11. There was not written authorization from the child’s physician.”

8VAC20-780-320-B

“Based on observation, the facility did not ensure that restrooms were equipped with soap and paper towels or an air dryer. Evidence: 1. In room #2, one of the two bathrooms did not have soap. Children were observed using both bathrooms. 2. In room #3, the bathroom room did not have soap or paper towels/air dryer. The classroom sink did not have soap or paper towels/air dryer.”

8VAC20-780-280-B

“Based on observation, the center did not ensure all hazardous substances such as cleaning materials insecticides and pesticides, were kept in a locked place using a safe locking method that prevents access by children. Evidence: 1. In the pool pump area, next to the playground, there was Oxidizer labeled ?Danger? and ?Keep Out of Reach of Children?, Algaecide labeled ?Caution? and ?Keep Out of Reach of Children?, amd Algae Complete labeled ?Hazards to Humans and Domestic Animals?, ?Danger?, and ?Keep Out of Reach of Children?. The pool pump was not locked to prevent access by children. 2. In room #2, one container of bleach sanitizing solution labeled ?Keep Out of Reach of Children? and ?Danger? and one container of Sanibet disinfectant labeled ?Danger? and ?Keep Out of Reach of Children? was unlocked in the children’s bathroom. 3. In room #3, one container of bleach sanitizing solution labeled ?Keep Out of Reach of Children? and ?Danger? was sitting on top of the children’s cubbies. 4. In room #5, one container of bleach sanitizing solution labeled ?Keep Out of Reach of Children? and ?danger? was on the diaper changing table. The diaper changing table was not in use.”

8VAC20-780-270-A

“REPEAT VIOLATION Based on observation, the center did not ensure areas and equipment of the center, inside and outside, shall be maintained in a clean, safe and operable condition. Evidence: In room #1, an area on the wall had drywall showing and 17 out of 32 rest mats were torn in various places. In room #2, one of the two bathrooms had a broken soap dispenser and 11 out of 19 rest mats were torn in various places. In room #3, an outlet was being used without a cover plate exposing the electrical receptacle and 7 out of 22 rest mats were torn in various places.”

8VAC20-780-60-C

“Based on a review of children's records, the center did not ensure that each record contains all required information. Evidence: The records for child #5 (enrolled 03/15/22) did not contain documentation of viewing proof of the child's identity and age.”

8VAC20-780-40-M

“Based on observation and interview, the center did not ensure to maintain a current written list of all children's allergies, sensitivities, and dietary restrictions which is dated and kept confidential in each room or area where children are present. Evidence: In room #1, the allergy list was not dated and included child a (last day of attendance 06/30/23), child b (last day of attendance 08/19/23), child c (last day of attendance 06/07/23), and child d (last day of attendance 08/19/23).”

8VAC20-780-130-E

“Based on a review of children's records, the center did not ensure each record contained additional immunizations once every six months for children under the age of two years. Evidence: The record for child #9 (birth date 5/17/21) had one immunization record dated 02/25/22 at the time of enrollment on 03/01/22.”

8VAC20-770-60-C-2

“REPEAT VIOLATION Based on record review and interview, the center did not have documentation of central registry findings for two staff members. Evidence: 1. The record for staff #6 (employed 07/10/23) and staff #9 (employed 07/13/23) did not contain documentation of Central Registry findings. 2. During interview, a member of management acknowledged that the Central Registry findings had not been received and management had not followed up after 30 days.”

22.1-289.035-A

“Based on a review staff records and interview, the center did not ensure staff completed required background check every five years. Evidence: 1. The record of Staff #1 (employed 08/05/91) contained documentation of a fingerprint-based national criminal background check dated 06/06/23. The repeat background check should have been obtained prior to 02/21/18. The record for Staff #1 did not contain an updated Central Registry finding. 2. The record for staff #11 (employed 08/02/99) did not contain documentation of an updated fingerprint-based national criminal background check or an updated Central Registry finding. 3. During interview, a member of management acknowledged the fingerprints and central registry were not completed every five years as required.”

8VAC20-780-330-B

“Based on observation and measurements, the center did not ensure that resilient surfacing shall comply with minimum safety standards when tested. Evidence: Six out of six mulch depth samples taken around the fall zones of the playground all measured less than the required six inches.”

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

“Based on a review of the facility's injury reports, all required information was not documented. Evidence: A sample of a child injury reports did not include; date and time parents were notified, and staff and parent signatures or two staff signatures and documentation of how parent was notified.”

8VAC20-780-160-A

“Based on a review of staff records, the center did not ensure that each staff member shall submit documentation of a negative tuberculosis screening (TB) at the time of employment and prior to coming in contact with children. Evidence: 1. The record for staff # 7 (employed 8/29/22) had documentation of a TB screening/test on 9/05/22. Documentation of screening shall e submitted at the time of employment and prior to coming into contact with children. 2. The record for staff #8 (employed 5/09/22) did not have a dated documentation of a TB screening or test.”

8VAC20-780-560-J

“Based on observation, the center did not ensure that staff sanitized before and after each use for feeding. Evidence: In room# 6, staff did not sanitize the table before the children sat down to eat snack. As children were finishing snack and getting cleaned up, child B arrived for snack and sat at the table where child A had just finished eating. The table was not sanitized when child B was finished or when child A began to eat snack.”

8VAC20-780-270-A

“Based on observation, the center did not ensure that areas and equipment of the center were maintained in a clean, safe and operable condition. Evidence: 1. In room #1, the children’s blue sofa had tears in the material on the back and arms, on wall near exit door was a crack approximately one foot, and the molding near windows was coming away from the wall. 2. In room #2, ten rest mats had tears and in room #3, eight rest mats had tears. 3. In room #3, one outlet near exit door was damaged and drywall was exposed. 4. In room #6, rust was observed on the vent.”

8VAC20-780-500-A

“Based on observation, the center did not ensure that staff washed their hands with soap and running water before preparing and serving food. Evidence: In room #6, three teachers were serving snack and did not wash their hands with soap and running water before preparing or serving food or beverages.”

8VAC20-780-350-B-2 Complaint related: Yes

“Based on observation, the facility failed to maintain the required ratio of one staff for every 5 children ages 16 months to two years. Evidence: On 10/05/2022 there were 6 children ages 23 months to 2 1/2 years with one staff.”

8VAC20-780-160-A

“Based on a review of staff records, the center did not ensure that each staff member shall submit documentation of a negative tuberculosis screening (TB) at the time of employment and prior to coming in contact with children. Evidence: 1. The record for staff # 7 (employed 8/29/22) had documentation of a TB screening/test on 9/05/22. Documentation of screening shall e submitted at the time of employment and prior to coming into contact with children. 2. The record for staff #8 (employed 5/09/22) did not have a dated documentation of a TB screening or test.”

8VAC20-780-560-J

“Based on observation, the center did not ensure that staff sanitized before and after each use for feeding. Evidence: In room# 6, staff did not sanitize the table before the children sat down to eat snack. As children were finishing snack and getting cleaned up, child B arrived for snack and sat at the table where child A had just finished eating. The table was not sanitized when child B was finished or when child A began to eat snack.”

8VAC20-780-270-A

“Based on observation, the center did not ensure that areas and equipment of the center were maintained in a clean, safe and operable condition. Evidence: 1. In room #1, the children’s blue sofa had tears in the material on the back and arms, on wall near exit door was a crack approximately one foot, and the molding near windows was coming away from the wall. 2. In room #2, ten rest mats had tears and in room #3, eight rest mats had tears. 3. In room #3, one outlet near exit door was damaged and drywall was exposed. 4. In room #6, rust was observed on the vent.”

8VAC20-780-500-A

“Based on observation, the center did not ensure that staff washed their hands with soap and running water before preparing and serving food. Evidence: In room #6, three teachers were serving snack and did not wash their hands with soap and running water before preparing or serving food or beverages.”

8VAC20-780-350-B-2 Complaint related: Yes

“Based on observation, the facility failed to maintain the required ratio of one staff for every 5 children ages 16 months to two years. Evidence: On 10/05/2022 there were 6 children ages 23 months to 2 1/2 years with one staff.”

8VAC20-780-160-A

“Based on a review of staff records, the center did not ensure that each staff member shall submit documentation of a negative tuberculosis screening (TB) at the time of employment and prior to coming in contact with children. Evidence: 1. The record for staff # 7 (employed 8/29/22) had documentation of a TB screening/test on 9/05/22. Documentation of screening shall e submitted at the time of employment and prior to coming into contact with children. 2. The record for staff #8 (employed 5/09/22) did not have a dated documentation of a TB screening or test.”

8VAC20-780-560-J

“Based on observation, the center did not ensure that staff sanitized before and after each use for feeding. Evidence: In room# 6, staff did not sanitize the table before the children sat down to eat snack. As children were finishing snack and getting cleaned up, child B arrived for snack and sat at the table where child A had just finished eating. The table was not sanitized when child B was finished or when child A began to eat snack.”

8VAC20-780-270-A

“Based on observation, the center did not ensure that areas and equipment of the center were maintained in a clean, safe and operable condition. Evidence: 1. In room #1, the children’s blue sofa had tears in the material on the back and arms, on wall near exit door was a crack approximately one foot, and the molding near windows was coming away from the wall. 2. In room #2, ten rest mats had tears and in room #3, eight rest mats had tears. 3. In room #3, one outlet near exit door was damaged and drywall was exposed. 4. In room #6, rust was observed on the vent.”

8VAC20-780-500-A

“Based on observation, the center did not ensure that staff washed their hands with soap and running water before preparing and serving food. Evidence: In room #6, three teachers were serving snack and did not wash their hands with soap and running water before preparing or serving food or beverages.”

8VAC20-780-350-B-2 Complaint related: Yes

“Based on observation, the facility failed to maintain the required ratio of one staff for every 5 children ages 16 months to two years. Evidence: On 10/05/2022 there were 6 children ages 23 months to 2 1/2 years with one staff.”

8VAC20-780-160-A

“Based on a review of staff records, the center did not ensure that each staff member shall submit documentation of a negative tuberculosis screening (TB) at the time of employment and prior to coming in contact with children. Evidence: 1. The record for staff # 7 (employed 8/29/22) had documentation of a TB screening/test on 9/05/22. Documentation of screening shall e submitted at the time of employment and prior to coming into contact with children. 2. The record for staff #8 (employed 5/09/22) did not have a dated documentation of a TB screening or test.”

8VAC20-780-560-J

“Based on observation, the center did not ensure that staff sanitized before and after each use for feeding. Evidence: In room# 6, staff did not sanitize the table before the children sat down to eat snack. As children were finishing snack and getting cleaned up, child B arrived for snack and sat at the table where child A had just finished eating. The table was not sanitized when child B was finished or when child A began to eat snack.”

8VAC20-780-270-A

“Based on observation, the center did not ensure that areas and equipment of the center were maintained in a clean, safe and operable condition. Evidence: 1. In room #1, the children’s blue sofa had tears in the material on the back and arms, on wall near exit door was a crack approximately one foot, and the molding near windows was coming away from the wall. 2. In room #2, ten rest mats had tears and in room #3, eight rest mats had tears. 3. In room #3, one outlet near exit door was damaged and drywall was exposed. 4. In room #6, rust was observed on the vent.”

8VAC20-780-500-A

“Based on observation, the center did not ensure that staff washed their hands with soap and running water before preparing and serving food. Evidence: In room #6, three teachers were serving snack and did not wash their hands with soap and running water before preparing or serving food or beverages.”

8VAC20-780-350-B-2 Complaint related: Yes

“Based on observation, the facility failed to maintain the required ratio of one staff for every 5 children ages 16 months to two years. Evidence: On 10/05/2022 there were 6 children ages 23 months to 2 1/2 years with one staff.”

8VAC20-780-550-P Complaint related: Yes

“Based on a review of the facility's injury reports, all required information was not documented. Evidence: Injury reports for the month of August 2022 were reviewed; nine injury reports did not have any future action to prevent reoccurrence of the injury, seven did not have documentation of how parent was notified, and three did not contain staff and parent signatures or two staff signatures.”

8VAC20-780-40-E Complaint related: Yes

“Based on a review of documentation and interviews the center did not maintain compliance with the center's own policies and procedures that are required by these standards. Evidence: 1. The center's own policy and procedures for incident reporting states "Any accident, injury, illness or behavior observation involving children, regardless of severity, must be documented on an INCIDENT REPORT. The original copy of the INCIDENT REPORT must be kept in the child's file." 2. Administrator #1 stated that child #1 was injured. The center did not have documentation of the injury for child #1.”

8VAC20-790-600-D-2

“Based on a review of five staff records and interview, the vendor did not ensure that one staff had current certification in first aid appropriate to the ages of children in care within 90 days of the date of employment as required. Evidence: 1. The record of staff #4 (DOH:12/1/2021) did not contain a current first aid certification. 2. Administration acknowledged that the certification had not been obtained.”

8VAC20-790-600-D-1

“Based on a review of five staff records and interview, the vendor did not ensure that one staff had current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care within 90 days of the date of employment as required. Evidence: 1. The record of staff #4 (DOH:12/1/2021) did not contain a current CPR certification. 2. Administration acknowledged that the certification had not been obtained.”

8VAC20-790-600-F

“Based on record review and interview, the vendor did not ensure that all staff who work directly with children annually complete the department's health and safety update course as required. Evidence: 1. The record of staff #1 (DOH: 4/22/2019) did not contain documentation of a 2021 annual health and safety update. 2. Administration acknowledged that it was not completed.”

8VAC20-770-60-C-2

“Based on a review of five staff records and interview, two did not contain documentation of a central registry background check finding within 30 days of employment or volunteer service as required. Evidence: 1. The record of staff #2 (DOH:2/7/2022) did not contain documentation of a central registry background check. 2. The record of staff #4 (DOH: 12/1/2021) contained a central registry dated 1/16/2022. 3. Administration acknowledged that the background checks were not received within the required time frame.”

8VAC20-780-160-A-1

“Based on a review of five staff records and interview, the center did not ensure that two staff had documentation of a tuberculosis screening at the time of employment and prior to coming into contact with children. Evidence: 1. The record of staff #2 (DOH:2/7/2022) contained documentation of a tuberculosis screening dated 2/10/2022. 2. The record of staff #3 (DOH:3/30/2022) contained documentation of a tuberculosis screening dated 3/31/2022. 2. Administration acknowledged that the screenings were received after the start of employment.”

8VAC20-780-70

“Based on a review of five staff records and interview, the center did not ensure that three records contained the required information. Evidence: 1. The records of staff #2 (DOH: 2/7/2022) and staff #4 (DOH:12/1/2021) contained two references that were taken over the phone but did not contain dates of contact. The record of staff #5 (DOH: 4/5/2022) contained one reference that was missing a date. If a reference check is taken over the phone, documentation shall include: a. Dates of contact; b. Names of persons contacted; c. The firms contacted; d. Results; and e. Signature of person making call. 2. Administration acknowledged that the references were missing dates of contact.”

8VAC20-780-270-A

“Based on observation and interview, the center did not ensure that all areas and equipment of the center, inside and outside, were maintained in a clean, safe and operable condition. Evidence: 1. On 4/7/2022, 3 areas of metal fencing around the twos and school age playgrounds were observed to be loose and posed a risk of head entrapment. The same areas were observed to contain rust and sharp points that could entangle clothing or snag skin. 2. Administration acknowledged that the areas were not maintained in a safe and operable condition.”

8VAC20-790-600-D-2

“Based on a review of five staff records and interview, the vendor did not ensure that one staff had current certification in first aid appropriate to the ages of children in care within 90 days of the date of employment as required. Evidence: 1. The record of staff #4 (DOH:12/1/2021) did not contain a current first aid certification. 2. Administration acknowledged that the certification had not been obtained.”

8VAC20-790-600-D-1

“Based on a review of five staff records and interview, the vendor did not ensure that one staff had current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care within 90 days of the date of employment as required. Evidence: 1. The record of staff #4 (DOH:12/1/2021) did not contain a current CPR certification. 2. Administration acknowledged that the certification had not been obtained.”

8VAC20-790-600-F

“Based on record review and interview, the vendor did not ensure that all staff who work directly with children annually complete the department's health and safety update course as required. Evidence: 1. The record of staff #1 (DOH: 4/22/2019) did not contain documentation of a 2021 annual health and safety update. 2. Administration acknowledged that it was not completed.”

8VAC20-770-60-C-2

“Based on a review of five staff records and interview, two did not contain documentation of a central registry background check finding within 30 days of employment or volunteer service as required. Evidence: 1. The record of staff #2 (DOH:2/7/2022) did not contain documentation of a central registry background check. 2. The record of staff #4 (DOH: 12/1/2021) contained a central registry dated 1/16/2022. 3. Administration acknowledged that the background checks were not received within the required time frame.”

8VAC20-780-160-A-1

“Based on a review of five staff records and interview, the center did not ensure that two staff had documentation of a tuberculosis screening at the time of employment and prior to coming into contact with children. Evidence: 1. The record of staff #2 (DOH:2/7/2022) contained documentation of a tuberculosis screening dated 2/10/2022. 2. The record of staff #3 (DOH:3/30/2022) contained documentation of a tuberculosis screening dated 3/31/2022. 2. Administration acknowledged that the screenings were received after the start of employment.”

8VAC20-780-70

“Based on a review of five staff records and interview, the center did not ensure that three records contained the required information. Evidence: 1. The records of staff #2 (DOH: 2/7/2022) and staff #4 (DOH:12/1/2021) contained two references that were taken over the phone but did not contain dates of contact. The record of staff #5 (DOH: 4/5/2022) contained one reference that was missing a date. If a reference check is taken over the phone, documentation shall include: a. Dates of contact; b. Names of persons contacted; c. The firms contacted; d. Results; and e. Signature of person making call. 2. Administration acknowledged that the references were missing dates of contact.”

8VAC20-780-270-A

“Based on observation and interview, the center did not ensure that all areas and equipment of the center, inside and outside, were maintained in a clean, safe and operable condition. Evidence: 1. On 4/7/2022, 3 areas of metal fencing around the twos and school age playgrounds were observed to be loose and posed a risk of head entrapment. The same areas were observed to contain rust and sharp points that could entangle clothing or snag skin. 2. Administration acknowledged that the areas were not maintained in a safe and operable condition.”

8VAC20-790-600-D-2

“Based on a review of five staff records and interview, the vendor did not ensure that one staff had current certification in first aid appropriate to the ages of children in care within 90 days of the date of employment as required. Evidence: 1. The record of staff #4 (DOH:12/1/2021) did not contain a current first aid certification. 2. Administration acknowledged that the certification had not been obtained.”

8VAC20-790-600-D-1

“Based on a review of five staff records and interview, the vendor did not ensure that one staff had current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care within 90 days of the date of employment as required. Evidence: 1. The record of staff #4 (DOH:12/1/2021) did not contain a current CPR certification. 2. Administration acknowledged that the certification had not been obtained.”

8VAC20-790-600-F

“Based on record review and interview, the vendor did not ensure that all staff who work directly with children annually complete the department's health and safety update course as required. Evidence: 1. The record of staff #1 (DOH: 4/22/2019) did not contain documentation of a 2021 annual health and safety update. 2. Administration acknowledged that it was not completed.”

8VAC20-770-60-C-2

“Based on a review of five staff records and interview, two did not contain documentation of a central registry background check finding within 30 days of employment or volunteer service as required. Evidence: 1. The record of staff #2 (DOH:2/7/2022) did not contain documentation of a central registry background check. 2. The record of staff #4 (DOH: 12/1/2021) contained a central registry dated 1/16/2022. 3. Administration acknowledged that the background checks were not received within the required time frame.”

8VAC20-780-160-A-1

“Based on a review of five staff records and interview, the center did not ensure that two staff had documentation of a tuberculosis screening at the time of employment and prior to coming into contact with children. Evidence: 1. The record of staff #2 (DOH:2/7/2022) contained documentation of a tuberculosis screening dated 2/10/2022. 2. The record of staff #3 (DOH:3/30/2022) contained documentation of a tuberculosis screening dated 3/31/2022. 2. Administration acknowledged that the screenings were received after the start of employment.”

8VAC20-780-70

“Based on a review of five staff records and interview, the center did not ensure that three records contained the required information. Evidence: 1. The records of staff #2 (DOH: 2/7/2022) and staff #4 (DOH:12/1/2021) contained two references that were taken over the phone but did not contain dates of contact. The record of staff #5 (DOH: 4/5/2022) contained one reference that was missing a date. If a reference check is taken over the phone, documentation shall include: a. Dates of contact; b. Names of persons contacted; c. The firms contacted; d. Results; and e. Signature of person making call. 2. Administration acknowledged that the references were missing dates of contact.”

8VAC20-780-270-A

“Based on observation and interview, the center did not ensure that all areas and equipment of the center, inside and outside, were maintained in a clean, safe and operable condition. Evidence: 1. On 4/7/2022, 3 areas of metal fencing around the twos and school age playgrounds were observed to be loose and posed a risk of head entrapment. The same areas were observed to contain rust and sharp points that could entangle clothing or snag skin. 2. Administration acknowledged that the areas were not maintained in a safe and operable condition.”

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

“Based on observation and interview, the center did not ensure to maintain the required staff to child ratios whenever children are in care. Evidence: 1. On 1/11/2022, 3 classrooms were observed that did not meet the ratio requirements. 2. The pre-kindergarten classroom had 17 children ranging in age from 4-5 years with 1 staff. The required ratio for 3 year olds up to school age eligibility is 1:10. 3. The infant classroom had 12 children ranging in age from 2 months-10 months with 2 staff. The required ratio for birth up to 16 months is 1:4. 4. The toddler classroom had 14 children ranging in age from 16 months-24 months with 2 staff. The required ratio for 16 months up to 24 months is 1:5. 5. Administration acknowledged that the center had been running out of ratio due to recent staffing issues.”