Highland Children's House

8VAC20-780-340-F

“REPEAT VIOLATION Based on interview, the center failed to ensure that children under 10 years of age shall be within actual sight and sound supervision of staff. Evidence: 1. Staff 1 reported that during an evacuation drill on July 18, 2024, Child 1(age 5) did not follow the class outside to a safe area. Staff 1 stated that it was realized Child 1 was not with the class when a head count was conducted. 2. Staff 1 came inside to find Child 1 (age 5) back on cot trying to go back to sleep.”

22.1-289.035-A

“Based on record review, the center failed to ensure that all staff obtain criminal history search results every five years for all employees. Evidence: 1. The record of Staff 1 (DOH 07/29/2019) did not contain documentation of a repeat criminal history check. Staff 1 has been employed for more than 5 years. 2. The current criminal history check is dated 07/13/2019.”

8VAC20-780-340-F

“REPEAT VIOLATION Based on documentation and interviews, the center failed to ensure that staff were in actual sight and sound supervision of children under 10 years of age. Evidence: 1. When leaving the playground, two children (age 2) were left outside. 2. Staff 1 reported that once inside she began counting children and realized two children were missing. Staff 1 stated she ran outside to find Child 1 (age 2) being brought in by a volunteer. 3. Staff 1 further reported that the volunteer was unaware of Child 2 (age 2), also outside and walking behind the volunteer.”

8VAC20-780-340-F

“REPEAT VIOLATION Based on interview, the center failed to ensure that children under 10 years of age shall be within actual sight and sound supervision of staff. Evidence: 1. Staff 1 reported that during an evacuation drill on July 18, 2024, Child 1(age 5) did not follow the class outside to a safe area. Staff 1 stated that it was realized Child 1 was not with the class when a head count was conducted. 2. Staff 1 came inside to find Child 1 (age 5) back on cot trying to go back to sleep.”

22.1-289.035-A

“Based on record review, the center failed to ensure that all staff obtain criminal history search results every five years for all employees. Evidence: 1. The record of Staff 1 (DOH 07/29/2019) did not contain documentation of a repeat criminal history check. Staff 1 has been employed for more than 5 years. 2. The current criminal history check is dated 07/13/2019.”

8VAC20-780-340-F

“REPEAT VIOLATION Based on documentation and interviews, the center failed to ensure that staff were in actual sight and sound supervision of children under 10 years of age. Evidence: 1. When leaving the playground, two children (age 2) were left outside. 2. Staff 1 reported that once inside she began counting children and realized two children were missing. Staff 1 stated she ran outside to find Child 1 (age 2) being brought in by a volunteer. 3. Staff 1 further reported that the volunteer was unaware of Child 2 (age 2), also outside and walking behind the volunteer.”

63.2-1509-A* Complaint related: No

“REPEAT VIOLATION/SYSTEMIC VIOLATION Based on document review and interviews, staff who had reason to suspect that a child is abused or neglected failed to report the matter immediately to the local department of the county or city wherein the child resides or wherein the abuse or neglect is believed to have occurred or to the Departments toll-free child abuse and neglect hotline. Evidence: At least three staff members had knowledge that on 08/25/2023 four school-age children drew one picture of Staff 1, which included private body parts and body hair, and indicated to Staff 2 that they had seen this. Interview revealed that Staff 1 would take the children to the bathroom. These three staff members failed to report this incident to the local department, as required.”

8VAC20-790-600-F

“Based on record review, the provider failed to ensure that all staff will complete the department's annual health and safety update course. Evidence: 1. The record of Staff # 5 did not contain documentation of the department's health and safety update course, which is to be completed annually. 2. Administration confirmed that the 2023 3 hour annual update training was not in Staff #5's record.”

8VAC20-780-160-C

“Based on a review of staff records, the center failed to obtain results of a follow-up tuberculosis screening at least every two years from the date of the first initial screening. Evidence: 1. The record of Staff #1 (DOH 07.29.19) did not contain an updated tuberculosis screening. The tuberculosis documentation in the record was dated 01/19/2022.”

8VAC20-770-40-D-1-a

“Based on a review of records on February 22, 2024, the center did not ensure to obtain a Sworn Statement for each new officer when a change occurred from each Officer of the Board before the end of the 30 days after the change of officer. Evidence: 1. The record of Board Member #3 (office date: 05/01/2023) did not contain documentation of a Sworn statement or affirmation. 2. The administrator confirmed that there was not a Sworn statement if it was not in the record.”

8VAC20-790-600-F

“Based on record review, the provider failed to ensure that all staff will complete the department's annual health and safety update course. Evidence: 1. The record of Staff # 5 did not contain documentation of the department's health and safety update course, which is to be completed annually. 2. Administration confirmed that the 2023 3 hour annual update training was not in Staff #5's record.”

8VAC20-780-160-C

“Based on a review of staff records, the center failed to obtain results of a follow-up tuberculosis screening at least every two years from the date of the first initial screening. Evidence: 1. The record of Staff #1 (DOH 07.29.19) did not contain an updated tuberculosis screening. The tuberculosis documentation in the record was dated 01/19/2022.”

8VAC20-770-40-D-1-a

“Based on a review of records on February 22, 2024, the center did not ensure to obtain a Sworn Statement for each new officer when a change occurred from each Officer of the Board before the end of the 30 days after the change of officer. Evidence: 1. The record of Board Member #3 (office date: 05/01/2023) did not contain documentation of a Sworn statement or affirmation. 2. The administrator confirmed that there was not a Sworn statement if it was not in the record.”

63.2-1509-A* Complaint related: No

“REPEAT VIOLATION Based on document review and interviews, staff who had reason to suspect that a child is abused or neglected failed to report the matter immediately to the local department of the county or city wherein the child resides or wherein the abuse or neglect is believed to have occurred or to the Departments toll-free child abuse and neglect hotline. Evidence: 1. The Program Director received two photographs of bruises on both arms of Child 1 (five years of age) on June 30, 2023 that were reported as a possible result of Child 1 being grabbed while in care of the child day center. The Program Director and at least two other staff were aware of these bruises and failed to report the incident to the local department.”

8VAC20-780-400-B Complaint related: Yes

“COMPLAINT RELATED Based on document review and interviews, the center failed to ensure that behavioral guidance shall be constructive in nature, age and stage appropriate, and shall be intended to redirect children to appropriate behavior and resolve conflicts. Evidence: 1. On 11/06/2023, in response to Child 1 (age 2 years) biting, kicking, and hitting other children, Staff 1 forcefully lifted Child 1 by the arm, roughly moved the child across the room, and used a raised voice to threaten the child.”

63.2-1509-A Complaint related: Yes

“COMPLAINT RELATED Based on document review and interviews, staff who had reason to suspect that a child is abused or neglected failed to report the matter immediately to the local department of the county or city wherein the child resides or wherein the abuse or neglect is believed to have occurred or to the Department’s toll-free child abuse and neglect hotline. Evidence: 1. At least four staff members who had knowledge that on 11/06/2023, Staff 1 roughly grabbed Child 1 (age 2 years) by the arm, forcefully moved the child to the other side of the room, and threatened the child failed to report this incident to the local department.”

8VAC20-780-410-1 Complaint related: Yes

“COMPLAINT RELATED Based on document review and interviews, the center failed to ensure that threatening and roughly handling a child was forbidden. Evidence: 1. On 11/06/2023, Staff 1 forcefully lifted Child 1 (age 2 years) by the arm, roughly moved the child across the room, and used a raised voice to threaten the child.”

8VAC20-780-140-A

“REPEAT VIOLATION Based on a review of children’s records, the center failed to obtain documentation of a physical examination by or under the direction of a physician for each child before the child's attendance or within one month after attendance. Evidence: 1. The record of Child 2 (DOE 10/11/2023) did not contain documentation of a physical in the record. 2. The record of Child 1 (DOE 10/17/2022) contained documentation of a physical dated 01/03/2023.”

8VAC20-780-500-C

“Based on observation, the center failed to ensure toilet chairs were emptied promptly and cleaned and sanitized after each use. Evidence: 1. Two toilet training chairs located in the Older Toddler and Two's Classroom containing urine was observed at 11:38 am. All of the children and staff were outside on the playground at the time of observation.”

8VAC20-780-520-A

“Based on a review of diaper ointments, the center failed to ensure that all over-the-counter skins products shall not be kept beyond the expiration date. Evidence: 1. In the Older Toddler and Two's Classroom there was a tube of Desitin Diaper Cream that had expired in 03/23 and a tube of Vitamin A & D ointment that expired in 12/21. 2. Staff verified that Desitin Diaper Cream and Vitamin A & D had expired.”

8VAC20-780-140-A

“REPEAT VIOLATION Based on a review of children’s records, the center failed to obtain documentation of a physical examination by or under the direction of a physician for each child before the child's attendance or within one month after attendance. Evidence: 1. The record of Child 2 (DOE 10/11/2023) did not contain documentation of a physical in the record. 2. The record of Child 1 (DOE 10/17/2022) contained documentation of a physical dated 01/03/2023.”

8VAC20-780-500-C

“Based on observation, the center failed to ensure toilet chairs were emptied promptly and cleaned and sanitized after each use. Evidence: 1. Two toilet training chairs located in the Older Toddler and Two's Classroom containing urine was observed at 11:38 am. All of the children and staff were outside on the playground at the time of observation.”

8VAC20-780-520-A

“Based on a review of diaper ointments, the center failed to ensure that all over-the-counter skins products shall not be kept beyond the expiration date. Evidence: 1. In the Older Toddler and Two's Classroom there was a tube of Desitin Diaper Cream that had expired in 03/23 and a tube of Vitamin A & D ointment that expired in 12/21. 2. Staff verified that Desitin Diaper Cream and Vitamin A & D had expired.”

8VAC20-790-600-D-2

“Based on record review, the center failed to ensure that all staff who work directly with children shall have within 90 days of the date of employment current certification in first aid appropriate to the ages of children in care. Evidence: 1. The record of Staff 6 (DOH 03/14/2022) did not have documentation of certification in first aid. 2. Administration confirmed that Staff 6 did not have first aid certification.”

8VAC20-790-600-D-1

“Based on record review, the center failed to ensure that all staff who work directly with children shall have within 90 days of the date of employment a current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care. Evidence: 1. The record of Staff 6 (DOH 03/14/2022) did not have documentation of CPR certification. 2. Administration confirmed Staff 6 did not have CPR certification.”

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

“Based on interviews, the center failed to ensure children under 10 years of age always shall be within actual sight supervision of staff. Evidence: 1. Staff 2 stated that Child 1 was in a crib with a blanket over the side rail, preventing the child from seeing out of the crib and the staff seeing the child. 2. During staff interviews, Staff 1, Staff 3, Staff 4, Staff 7, and Staff 8 confirmed that there was a blanket placed over the side railing of Child 1's crib.”

8VAC20-780-245-A Complaint related: No

“Based on record review, the center shall ensure that staff complete annually a minimum of 16 hours of training appropriate to the age of children in care. Evidence: 1. The record of Staff 6 only had documentation of 10 hours of training for 2022-2023. 2. Administration confirmed that was the only training the employee received for the year.”

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

“Based on record review, the center failed to ensure that within the first 30 days of employment, staff must complete orientation training in first aid and cardiopulmonary resuscitation (CPR), as appropriate to the age of children in care. Evidence: 1. The record of Staff 6 had no documentation of first aid and cardiopulmonary resuscitation training within 30 days of employment.”

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

“Based on a review of staff records and interview, the center failed to ensure that staff complete the Virginia Department of Education sponsored orientation course within 90 calendar days of employment. Evidence: 1. The record of Staff 6 (hired on 03/11/2022) contained documentation of completed sponsored orientation on 03/09/2023.”

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

“Based on a review of records, the center failed to comply with the center's own policies and procedures for safe sleeping practices. Evidence: 1. Staff in Infant classroom hung a receiving blanket over the side railing of the crib of Child 1. 2. The center's safe sleeping policy states that "NO blankets, stuffed toys or pillows should ever be placed in a crib". 3. During interviews, Staff 1, Staff 2, Staff 3, Staff 4, Staff 7 and Staff 8 confirmed that a blanket was hanging over the side railing of the crib of Child 1.”

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

“Based on record review, the center did not ensure that all staff completed orientation training prior to staff member working alone with children and no later than seven days of the date of assuming job responsibilities. Evidence: 1. The records of Staff 6 (DOH 03/11/2022) did not contain documentation of orientation. 2. Administration confirmed that there was no orientation.”

8VAC20-790-600-D-2

“Based on record review, the center failed to ensure that all staff who work directly with children shall have within 90 days of the date of employment current certification in first aid appropriate to the ages of children in care. Evidence: 1. The record of Staff 6 (DOH 03/14/2022) did not have documentation of certification in first aid. 2. Administration confirmed that Staff 6 did not have first aid certification.”

8VAC20-790-600-D-1

“Based on record review, the center failed to ensure that all staff who work directly with children shall have within 90 days of the date of employment a current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care. Evidence: 1. The record of Staff 6 (DOH 03/14/2022) did not have documentation of CPR certification. 2. Administration confirmed Staff 6 did not have CPR certification.”

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

“Based on interviews, the center failed to ensure children under 10 years of age always shall be within actual sight supervision of staff. Evidence: 1. Staff 2 stated that Child 1 was in a crib with a blanket over the side rail, preventing the child from seeing out of the crib and the staff seeing the child. 2. During staff interviews, Staff 1, Staff 3, Staff 4, Staff 7, and Staff 8 confirmed that there was a blanket placed over the side railing of Child 1's crib.”

8VAC20-780-245-A Complaint related: No

“Based on record review, the center shall ensure that staff complete annually a minimum of 16 hours of training appropriate to the age of children in care. Evidence: 1. The record of Staff 6 only had documentation of 10 hours of training for 2022-2023. 2. Administration confirmed that was the only training the employee received for the year.”

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

“Based on record review, the center failed to ensure that within the first 30 days of employment, staff must complete orientation training in first aid and cardiopulmonary resuscitation (CPR), as appropriate to the age of children in care. Evidence: 1. The record of Staff 6 had no documentation of first aid and cardiopulmonary resuscitation training within 30 days of employment.”

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

“Based on a review of staff records and interview, the center failed to ensure that staff complete the Virginia Department of Education sponsored orientation course within 90 calendar days of employment. Evidence: 1. The record of Staff 6 (hired on 03/11/2022) contained documentation of completed sponsored orientation on 03/09/2023.”

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

“Based on a review of records, the center failed to comply with the center's own policies and procedures for safe sleeping practices. Evidence: 1. Staff in Infant classroom hung a receiving blanket over the side railing of the crib of Child 1. 2. The center's safe sleeping policy states that "NO blankets, stuffed toys or pillows should ever be placed in a crib". 3. During interviews, Staff 1, Staff 2, Staff 3, Staff 4, Staff 7 and Staff 8 confirmed that a blanket was hanging over the side railing of the crib of Child 1.”

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

“Based on record review, the center did not ensure that all staff completed orientation training prior to staff member working alone with children and no later than seven days of the date of assuming job responsibilities. Evidence: 1. The records of Staff 6 (DOH 03/11/2022) did not contain documentation of orientation. 2. Administration confirmed that there was no orientation.”

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

“Based on interview and record review, the center failed to ensure care and protection of children at all times. Evidence: 1. The record of Child 1 contains documentation of a physician's note that states, "From 2/9/2023 May Return On: 3/9/2023 Child 1 is well enough to attend daycare but due to reactive airway disease, please limit outside activities to 10 minutes due to coughing with cold air/activity". 2. In an interview, Staff 1 admitted that on 03/08/2023, Child 1 was left outside for 20 minutes more than the physician's orders. Staff 1 stated Child 1 was outside from 4:00 pm to 4:30 pm. 3. A review of messages from the parent to Staff 1 indicate that 50 degrees was considered to be cold weather. The child was only to be outside for the 10 minutes in 50 degrees or below. According to the weather app on 03/08/2023 at 4:00 pm, the temperature was 46 degrees outside.”

8VAC20-770-40-C-1-b

“Based on interview, the licensee did not ensure to obtain a copy of the results of a search of the central registry ( CPS ) or the Sworn Statement by the end of the 30th day of employment/service for new agents/board officers. Evidence: 1. Staff 1 confirmed Board Member 1 began as a board officer in December of 2022. 2. When LI arrived for inspection in February of 2023, Board Member 1 still had not completed Sworn Statement or Central Registry ( CPS ) check. 3. LI spoke with Board Member 1 and confirmed that background checks were not completed.”

22.1-289.036-B-2

“Based on interview, the licensee did not ensure to obtain a criminal records check prior to the end of the 30th day of employment/service for new agents/board officers. Evidence: 1. Staff 1 confirmed that Board Member 1's start date as a board officer was December of 2022. 2. When LI conducted an inspection in February of 2023, Board Member 1 still did not complete a criminal records check (fingerprinting). 3. LI spoke with Board Member 1 and confirmed that the background check (fingerprinting) had not been completed.”

8VAC20-780-140-A

“Based on record review and interview, it was determined the center did not ensure that each child had a physical examination by or under the direction of a physician within the required time frame. Evidence: 1. The record for Child D (enrolled 09/09/2021) did not contain documentation of a physical exam. 2. The director confirmed this documentation was not available during this inspection.”

8VAC20-780-160-A

“Based on record review, the center failed to ensure that documentation of a tuberculosis screening was obtained prior to staff coming into contact with children. Evidence: 1. Staff # 5's tuberculosis test/screening was dated 12/06/2022. First day of employment and being in contact with children was 10/05/2022.”

8VAC20-780-550-E

“Based on record review, the center did not ensure to practice shelter-in-place procedures a minimum of twice per year. Evidence: 1. The center had documentation showing that only one shelter-in-place drill was practiced during the year 2022. 2. The director confirmed that there was only one shelter-in-place drill that was practiced during 2022.”

8VAC20-780-550-F

“Based on record review, lockdown procedures were not practiced at least annually. Evidence: 1. The center did not practice a lockdown drill in 2022. 2. The director confirmed that they did not conduct a lockdown drill in 2022.”

8VAC20-770-40-C-1-b

“Based on interview, the licensee did not ensure to obtain a copy of the results of a search of the central registry ( CPS ) or the Sworn Statement by the end of the 30th day of employment/service for new agents/board officers. Evidence: 1. Staff 1 confirmed Board Member 1 began as a board officer in December of 2022. 2. When LI arrived for inspection in February of 2023, Board Member 1 still had not completed Sworn Statement or Central Registry ( CPS ) check. 3. LI spoke with Board Member 1 and confirmed that background checks were not completed.”

22.1-289.036-B-2

“Based on interview, the licensee did not ensure to obtain a criminal records check prior to the end of the 30th day of employment/service for new agents/board officers. Evidence: 1. Staff 1 confirmed that Board Member 1's start date as a board officer was December of 2022. 2. When LI conducted an inspection in February of 2023, Board Member 1 still did not complete a criminal records check (fingerprinting). 3. LI spoke with Board Member 1 and confirmed that the background check (fingerprinting) had not been completed.”

8VAC20-780-140-A

“Based on record review and interview, it was determined the center did not ensure that each child had a physical examination by or under the direction of a physician within the required time frame. Evidence: 1. The record for Child D (enrolled 09/09/2021) did not contain documentation of a physical exam. 2. The director confirmed this documentation was not available during this inspection.”

8VAC20-780-160-A

“Based on record review, the center failed to ensure that documentation of a tuberculosis screening was obtained prior to staff coming into contact with children. Evidence: 1. Staff # 5's tuberculosis test/screening was dated 12/06/2022. First day of employment and being in contact with children was 10/05/2022.”

8VAC20-780-550-E

“Based on record review, the center did not ensure to practice shelter-in-place procedures a minimum of twice per year. Evidence: 1. The center had documentation showing that only one shelter-in-place drill was practiced during the year 2022. 2. The director confirmed that there was only one shelter-in-place drill that was practiced during 2022.”

8VAC20-780-550-F

“Based on record review, lockdown procedures were not practiced at least annually. Evidence: 1. The center did not practice a lockdown drill in 2022. 2. The director confirmed that they did not conduct a lockdown drill in 2022.”

8VAC20-770-40-C-1-b

“Based on interview, the licensee did not ensure to obtain a copy of the results of a search of the central registry ( CPS ) or the Sworn Statement by the end of the 30th day of employment/service for new agents/board officers. Evidence: 1. Staff 1 confirmed Board Member 1 began as a board officer in December of 2022. 2. When LI arrived for inspection in February of 2023, Board Member 1 still had not completed Sworn Statement or Central Registry ( CPS ) check. 3. LI spoke with Board Member 1 and confirmed that background checks were not completed.”

22.1-289.036-B-2

“Based on interview, the licensee did not ensure to obtain a criminal records check prior to the end of the 30th day of employment/service for new agents/board officers. Evidence: 1. Staff 1 confirmed that Board Member 1's start date as a board officer was December of 2022. 2. When LI conducted an inspection in February of 2023, Board Member 1 still did not complete a criminal records check (fingerprinting). 3. LI spoke with Board Member 1 and confirmed that the background check (fingerprinting) had not been completed.”

8VAC20-780-140-A

“Based on record review and interview, it was determined the center did not ensure that each child had a physical examination by or under the direction of a physician within the required time frame. Evidence: 1. The record for Child D (enrolled 09/09/2021) did not contain documentation of a physical exam. 2. The director confirmed this documentation was not available during this inspection.”

8VAC20-780-160-A

“Based on record review, the center failed to ensure that documentation of a tuberculosis screening was obtained prior to staff coming into contact with children. Evidence: 1. Staff # 5's tuberculosis test/screening was dated 12/06/2022. First day of employment and being in contact with children was 10/05/2022.”

8VAC20-780-550-E

“Based on record review, the center did not ensure to practice shelter-in-place procedures a minimum of twice per year. Evidence: 1. The center had documentation showing that only one shelter-in-place drill was practiced during the year 2022. 2. The director confirmed that there was only one shelter-in-place drill that was practiced during 2022.”

8VAC20-780-550-F

“Based on record review, lockdown procedures were not practiced at least annually. Evidence: 1. The center did not practice a lockdown drill in 2022. 2. The director confirmed that they did not conduct a lockdown drill in 2022.”

8VAC20-780-280-B

“Based on observation, 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. In Classroom #1 there was a spray bottle marked "[name]" sitting on a half wall near the changing area. 2. Staff verified that the spray bottle marked "[name]" was not in a locked location that prevented access by the children.”

8VAC20-780-160-A

“Based on record review, center failed to ensure a staff member received documentation of a negative tuberculosis screening. Evidence: 1. Staff #7 date of hire was 07/05/2020 during the COVID pandemic. The leniency for TB tests ended 07/2021. 2. There was no documentation of a TB screening or test on file for Staff #7. 3. Director confirmed there was no TB document in the file.”

8VAC20-780-160-C

“Based on review of staff records and verification with the director, three staff members did not obtain their updated tuberculosis (TB) screening/test within two years of the most recent TB screening. Evidence: 1. The records of Staff #5, Staff #6, and Staff #7 contained updated negative TB screenings dated 01/19/2022. The most recent TB screenings for the three staff had been dated 07/24/2019. 2. The director stated she knew the TB screenings were late.”

8VAC20-770-40-D-1-a

“Based on a record review of the corporation's board officers and confirmation with the director, two new board officers had not completed a sworn statement as one of the required background checks. Evidence: 1. The records for Board Officer #1 and Board Officer #2 did not contain a completed sworn statement. The officers began serving on the board in January 2022. 2. The director confirmed the sworn statements had not been completed.”

8VAC20-780-140-A

“Based on review of children's records and discussion with the director, one child's physical examination record was obtained after the first 30 days of enrollment. Evidence: 1. The record for Child #2 contained a physical examination report that was signed by the physician on 02/03/2021. Date of enrollment for the child was 10/13/2021. 2. The director confirmed that the physical exam report was obtained late.”

8VAC20-780-500-B

“Based on observation and discussion with staff, one staff member failed to use the required procedure for cleaning and sanitizing the changing pad after changing a diaper. Evidence: 1. After Staff #3 changed a child's diaper, she sprayed the sanitizing spray on the changing pad without first cleaning the pad with a soap and water solution. She then wiped the changing pad with a paper towel without waiting the required time for the sanitizer to remain on the surface. 2. Staff #3 confirmed that she did not clean the pad with soap and water before spraying on the sanitizer, and she did not allow the sanitizer to air dry before wiping it.”

8VAC20-780-160-A-1

“Based on review of staff records and confirmation from the director, two new staff members did not obtain their tuberculosis (TB) screening/test at the time of hire and before coming in contact with children. Evidence: 1. The record of Staff #1 contained a TB screening dated 01/20/2022. Date of hire was 12/05/2021. 2. The record of Staff #3 contained a TB screening dated 01/19/2022. Date of hire was 10/13/2021. 3. The director reported she was aware the TB screenings were late.”

8VAC20-780-160-C

“Based on review of staff records and verification with the director, three staff members did not obtain their updated tuberculosis (TB) screening/test within two years of the most recent TB screening. Evidence: 1. The records of Staff #5, Staff #6, and Staff #7 contained updated negative TB screenings dated 01/19/2022. The most recent TB screenings for the three staff had been dated 07/24/2019. 2. The director stated she knew the TB screenings were late.”

8VAC20-770-40-D-1-a

“Based on a record review of the corporation's board officers and confirmation with the director, two new board officers had not completed a sworn statement as one of the required background checks. Evidence: 1. The records for Board Officer #1 and Board Officer #2 did not contain a completed sworn statement. The officers began serving on the board in January 2022. 2. The director confirmed the sworn statements had not been completed.”

8VAC20-780-140-A

“Based on review of children's records and discussion with the director, one child's physical examination record was obtained after the first 30 days of enrollment. Evidence: 1. The record for Child #2 contained a physical examination report that was signed by the physician on 02/03/2021. Date of enrollment for the child was 10/13/2021. 2. The director confirmed that the physical exam report was obtained late.”

8VAC20-780-500-B

“Based on observation and discussion with staff, one staff member failed to use the required procedure for cleaning and sanitizing the changing pad after changing a diaper. Evidence: 1. After Staff #3 changed a child's diaper, she sprayed the sanitizing spray on the changing pad without first cleaning the pad with a soap and water solution. She then wiped the changing pad with a paper towel without waiting the required time for the sanitizer to remain on the surface. 2. Staff #3 confirmed that she did not clean the pad with soap and water before spraying on the sanitizer, and she did not allow the sanitizer to air dry before wiping it.”

8VAC20-780-160-A-1

“Based on review of staff records and confirmation from the director, two new staff members did not obtain their tuberculosis (TB) screening/test at the time of hire and before coming in contact with children. Evidence: 1. The record of Staff #1 contained a TB screening dated 01/20/2022. Date of hire was 12/05/2021. 2. The record of Staff #3 contained a TB screening dated 01/19/2022. Date of hire was 10/13/2021. 3. The director reported she was aware the TB screenings were late.”