KinderCare Learning Centers #631

8VAC20-780-270-A

“REPEAT VIOLATION Areas inside of the center were not maintained in a safe condition. There were areas of chipped paint in four classrooms inspected.”

8VAC20-780-290-A-3

“In areas used by preschool age or younger children, electrical outlets shall have protective covers. In the two's room, there were two broken outlet covers.”

8VAC20-780-260-B

“The center shall obtain annual approval from the health department for meeting requirements for water supply and sewage disposal system. The center does not have an environmental sanitation inspection completed.”

8VAC20-780-240-I

“Documentation of orientation training shall be kept by the center in a manner that allows for identification by individual staff member, is considered part of the staff member's record, and shall include date of training. Staff #5, who has been actively working at the center for the past 9 months, did not have the date of orientation training and the entity or individual providing training documented.”

8VAC20-780-280-B

“Hazardous substances must be in a locked place that prevents access by children. In the multi-age classroom, petroleum jelly and bug spray were kept in cubbies, within reach of children.”

8VAC20-780-40-M

“The center is required to keep a current list of all known allergies, sensitivities, and dietary restrictions in each room or area where children are present. The list must be dated and kept confidential. The allergy list in the toddler's classroom was dated 26 days ago and included Child #2, who has a food allergy. During the inspection, the administration stated that Child #2 had left the program. However, the allergy list had not been updated to reflect the change.”

8VAC20-780-520-B

“The facility did not ensure that sunscreen was inaccessible to children under 5 years old. In the multi-age classroom, sunscreen was kept in cubbies, within reach of children.”

8VAC20-780-340-D

“Each grouping of children shall have at least one staff regularly present who meets lead teacher qualifications. Staff #5, who did not meet lead teacher qualifications, was alone with a group of children during a time of the inspection. Staff #2 stated they are the lead teacher in the infant classroom, but they do not meet the lead teacher qualifications.”

8VAC20-780-90-A

“A written agreement between the parent and the center shall be in each child's record by the first day of the child's attendance.. The record for Child #1, enrolled for 14 months, was missing the following required components: An authorization for emergency medical care, a statement that the center will notify the parent when the child becomes ill, and a statement that the parent will inform the center within 24 hours or the next business day after his child or any member of the immediate household has developed any reportable communicable disease.”

8VAC20-780-60-A

“Each center shall maintain and keep at the center a separate record for each child enrolled that contains all of the required information. The record for Child #1, enrolled for 14 months, was missing the following required components: documentation of viewing proof of the child's identity and age, annual update confirming the child's information in the child's record was up-to-date, and previous school attended. The record for Child #3, enrolled for 10 months, was missing the following required components: emergency contacts and annual update confirming the child's information in the child's record was up-to-date.”

8VAC20-780-70

“Documentation of at least 2 references to character, reputation, and competency are to be checked prior to employment. Staff #5, who has been actively working at the center for the past 9 months, did not have any completed reference verifications on file. Staff #1, who has been actively working at the center for the past 5 months, did not document the date of contact and signature of the person taking the references for two of their references.”

8VAC20-780-160-A

“Documentation of a negative tuberculosis (TB) screening must be submitted at the time of employment, before coming into contact with children, and shall have been completed within the last 30 days of the date of employment. Staff #5 had no documentation and had been employed for 9 months, and Staff #1 TB was dated 2 months prior to date of employment and has been employed for 5 months.”

8VAC20-780-380-A-2

“Based on record review and staff inteview, centers operating five or more hours per day failed to have a designated rest period for at least one hour but no more than two hours. Evidence: 1. The toddler classroom's rest period is documented on their daily schedule as 12:30 pm to 2:30 pm. However, on June 13, 2024, 7 out of 10 students exceeded the two-hour rest period. 2. According to a staff member, the rest period on June 13, 2024, began between 11:30 am and 11:45 am and ended at 3 pm, when Staff #1 arrived. 3. A staff member stated that the reason for the earlier rest period is that lunch is now served earlier.”

8VAC20-780-510-P

“Based on staff interview and record review, the center did not ensure 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. Medications that are not picked up by the parent within 14 days will be disposed of by the center by either dissolving the medication down the sink or flushing it down the toilet. Evidence: On June 10, 2024, Child #3's medication authorization form expired on 02/28/2024 and the emergency medication was still being stored at the center.”

8VAC20-780-270-A

“Based on observation, Areas and equipment outside were not maintained in a clean, safe and operable condition. Evidence: A stroller located on the toddler playground had a compartment that had standing water and a black trash bag inside.”

8VAC20-780-510-P

“Based on review of medications, the center did not ensure that when an authorization for a medication expires that the parent is notified to pick up the medication within 14 days or that any medications not picked up within 14 days after medication authorization expiration are disposed of by the center. Evidence: 1. Child #3 had emergency medication on site at the time of the inspection and the authorization expired on 7/28/2023. 2. The emergency medication was not return to the parent or disposed of within 14 days.”

63.2-1509-A

“Based on interviews, staff failed to report suspected child abuse and neglect in a timely manner. Evidence: 1. Staff #1 stated that they were notified by Staff #2 on Monday, November 6, 2023, that the parent of Child #1 reported that Staff #3 had hit their child on the back of the head with a bag of styrofoam bowls. 2. Staff #1 stated they reported the incident to CPS on Monday, November 13, 2023.”

8VAC20-780-350-B-5

“Based on the review of the CSR (child supervision record) and interviews, the center failed to ensure that the staff-to-child ratios are required whenever children are in care. Evidence: 1. The CSR (child supervision record) used to track student attendance and transitions, documented the group being over ratio on Monday, November 6, 2023, during the following approximate times: 3:02 pm- 3:50 pm. There were 19 children between the ages of 5 years old to school-age with 1 staff exceeding the 1:18 ratio in the school-age room. 2. The ratio between the approximate hours of 3:02 pm- 3:50 pm should have been 1:18.”

8VAC20-780-40-E

“Based on staff interviews and record review, it was determined the center failed to comply with its own policies and procedures as it relates to maintaining supervision. Evidence: 1. The CSR (child supervision record) used to track student attendance, name-to-face, name-to-face transitions, and teacher/staff attendance was not fully completed. 2. On Monday, November 6, 2023, The name-to-face checks were not completed at the approximate hours of 12:00 pm, 2:00 pm, 4:00 pm, and 5:00 pm, based on the school-age CSR. During this time, children were in care. 3. On Monday, November 6, 2023, The name-to-face transitions for the school-age classroom were not completed during the transition from the playground, and no documentation was put on the CSR detailing what time the children transitioned and which students transitioned back to the classroom from the playground. 4. On Monday, November 6, 2023, The school-age CSR reported that a time-out for Staff #4 was missing, Staff #3's time-out was scribbled through, and a new time-out was not written in.”

8VAC20-780-580-B

“Based on observation and interview, 2 of 2 vehicles used by the center for the transportation of children did not meet the safety standards set by the Department of Motor Vehicles to ensure the safety of children. Evidence: 1. Vehicle #1's Virginia registration expired in June 2022. 2. Vehicle #2's Virginia registration expired in June 2023.”

8VAC20-780-140-A

“Based on record review and staff interview, 1 of 5 children's records indicated the center failed to ensure that all physical examination records were obtained before the child's attendance or within 30 days after attendance. Evidence: There was no documentation of a physical examination for Child #3 whose first date of attendance is 3/31/2019.”

8VAC20-780-240-A

“Based on record review and staff interview, 1 of 4 staff did not complete the Virginia Department of Education-sponsored orientation course within 90 calendar days of employment. Evidence: Staff #3 (DOH: 7/19/2023) had not completed the Virginia Department of Education-sponsored orientation course within 90 calendar days of employment.”

8VAC20-780-550-D

“Based on record review and staff interview, evacuation drills were not practiced monthly. Evidence: The September 2023 evacuation drill had not been practiced.”

8VAC20-780-580-B

“Based on observation and interview, 2 of 2 vehicles used by the center for the transportation of children did not meet the safety standards set by the Department of Motor Vehicles to ensure the safety of children. Evidence: 1. Vehicle #1's Virginia registration expired in June 2022. 2. Vehicle #2's Virginia registration expired in June 2023.”

8VAC20-780-140-A

“Based on record review and staff interview, 1 of 5 children's records indicated the center failed to ensure that all physical examination records were obtained before the child's attendance or within 30 days after attendance. Evidence: There was no documentation of a physical examination for Child #3 whose first date of attendance is 3/31/2019.”

8VAC20-780-240-A

“Based on record review and staff interview, 1 of 4 staff did not complete the Virginia Department of Education-sponsored orientation course within 90 calendar days of employment. Evidence: Staff #3 (DOH: 7/19/2023) had not completed the Virginia Department of Education-sponsored orientation course within 90 calendar days of employment.”

8VAC20-780-550-D

“Based on record review and staff interview, evacuation drills were not practiced monthly. Evidence: The September 2023 evacuation drill had not been practiced.”

8VAC20-780-160-A

“REPEAT VIOLATION Based on record review and interview, the facility did not ensure that each staff member submitted documentation of negative tuberculosis screening within the last 30 calendar days of the date of employment and prior to coming into contact with children. Evidence: There was no documentation of a tuberculosis test on file for staff #1. The start date for Staff #1 is listed as 06/23/2023.”

8VAC20-780-270-A

“REPEAT VIOLATION Based on observation and interview, areas and equipment of the center, inside and outside, were not maintained in a clean, safe, and operable condition. Evidence: 1. In the Discovery room, the white edge around the student cubbies is peeling and chipped in several areas, exposing the wood. 2. In the Pre-K room, the white edge around the student cubbies is peeling and chipped in several areas, exposing the wood.”

8VAC20-780-330-B

“Based on observation and interview, the center failed to have adequate resilient surfacing as required in the fall zones underneath and surrounding equipment. Evidence: 1. There was no resilient surfacing at the bottom of the toddler playground slide. 2. There was no resilient surfacing at the bottom of the preschool playground slide. 3. The Director confirmed that the playground needs mulch and has spoken with maintenance about the need for it.”

8VAC20-780-280-B

“REPEAT VIOLATION Based on observation and interview, hazardous substances such as cleaning materials, insecticides, and pesticides were not kept in a locked place using a safe locking method that prevents access by children. Evidence: In the Discovery classroom, two bottles of disinfectant cleaner were found under the diaper changing table unlocked.”

8VAC20-780-280-D

“Based on observation and interview, cleaning and sanitizing materials were located above food, food equipment, utensils or single-service articles and were not stored in areas physically separate from food. Evidence: Disinfectant cleaner was located on a shelf in a cabinet above plates, utensils, and Cheerios cereal.”

8VAC20-780-320-B

“Based on observation and interview, the center was not equipped with soap, toilet paper, and disposable towels, or an air dryer within reach of children. Evidence: There were no disposable towels in the girls' hallway bathroom.”

8VAC20-780-70

“REPEAT VIOLATION: Based on record review and interview, the center failed to ensure all staff records had all required documentation. Evidence: 1. There was no documentation of education for Staff #1. 2. There was no verification of programmatic experience and employment dates for Staff #1. 3. 1 of 4 reference checks for Staff #1 did not list the company name contacted. 4. 3 of 4 reference checks for Staff #1 did not list the results of the reference checks. 5. 3 of 4 reference checks for Staff #1 were not signed by the person taking the reference. 6. 3 of 4 reference checks for Staff #1 did not have the dates of contact.”

8VAC20-780-340-D

“REPEAT VIOLATION Based on record review and interview, the center did not ensure that all staff met the qualifications to be a program leader. Evidence: 1. Staff #1 in the three's classroom does not meet the lead teacher qualifications.”

8VAC20-780-240-E

“Based on record review and staff interview, the center did not ensure within 30 days of the first day of employment, staff must complete orientation training in first aid and cardiopulmonary resuscitation (CPR), as appropriate to the age of the children in care. Evidence: There was no documentation of first aid and CPR orientation for staff #1.”

22.1-289.011-F

“Based on record review and interview, not all required documentation was posted as required. Evidence: On the date of inspection, the findings of the most recent inspection of the facility (07/27/2023) were not posted.”

8VAC20-780-350-B-4

“Based on review of attendance records and interviews, the center failed to ensure that the staff-to-child ratios are required whenever children are in care: 3-year-olds up to school age - ratio 1:10 (staff: children) Evidence: The CSR (child supervision record) used to track student attendance and transitions, documented the group being over ratio on August 17, 2023, during the following approximate times: 8:34 am-9:30 am. There were 27 children between the ages of 4-12 years old with 1 staff in the fours classroom. 2. The ratio of the youngest age must be followed in a mixed-age grouping such as this.”

8VAC20-780-350-B-5

“Based on review of attendance records and interviews, the center failed to ensure that the staff-to-child ratios are required whenever children are in care: School age eligible up to 9 years- ratio 1:18 (staff: children) Evidence: 1. The CSR (child supervision record) used to track student attendance and transitions, documented the group being over ratio on July 14, 2023, during the following approximate times: 1:20 pm- 2:20 pm. There were 19 children with 1 staff in the school-age room. 2. The CSR (child supervision record) used to track student attendance and transitions, documented the group being over ratio on July 17, 2023, during the following approximate times: 1:29 pm- 4:23 pm. There were 19 children with 1 staff in the school-age room. 3. The CSR (child supervision record) used to track student attendance and transitions, documented the group being over ratio on July 20, 2023, during the following approximate times: 1:20 pm- 3:47 pm. There were 19 children with 1 staff in the school-age room.”

8VAC20-780-340-D

“Based on record review, each grouping of children does not have at least one staff member who meets the qualifications of a program leader regularly present. Evidence: Staff #2 is the lead teacher for the school-age classroom. The Director and Staff #1 confirmed that Staff #2 is the lead teacher of the school-age classroom. Staff #2 does not meet program leader qualifications.”

8VAC20-780-160-A

“REPEAT VIOLATION Based on record review and interview, 1 of 5 staff files indicated that the facility has not ensured that each staff member has submitted documentation of a negative tuberculosis screening within the last 30 calendar days of the date of employment. Evidence: 1. The TB documentation on file for staff #1 was dated 03/13/2023. 2. The start date for Staff #1 is 05/15/2023.”

8VAC20-780-160-C

“Based on record review and interview, 1 of 5 staff files indicated that it has been more than 2 years from the date of the last tuberculosis (TB) documentation kept on file. Evidence: 1. The TB documentation on file for Staff #4 was dated - 07/18/2019. 2. A more current TB documentation was not available at the time of inspection.”

8VAC20-780-280-B

“REPEAT VIOLATION Based on observation and interview, hazardous substances such as cleaning materials, insecticides, and pesticides were not kept in a locked place using a safe locking method that prevents access by children. Evidence: 1. 6 gallons of bleach were found in an unlocked cabinet next to the classroom sink and bookcase in the school-age room. 2. 1 bottle of disinfectant was found in an unlocked cabinet between sleeping cots and cubbies in the Discover classroom.”

22.1-289.035-A

“REPEAT VIOLATION Based on record review and interview, 2 of 5 background checks were not repeated every five years. Evidence: 1. Staff #4's central registry finding is dated 06/15/2016 and expired on 06/15/2021. 2. Staff #5's criminal history check results is dated 06/28/2018 and expired on 6/28/2023.”

8VAC20-770-60-C-2

“REPEAT VIOLATION Based on record review and interview, 1 of 5 staff files indicated that the facility did not obtain the results of a central registry check by the end of the 30th day of employment. Evidence: 1. There was no documentation of central registry results for staff #1. 2. The start date for Staff #1 is 05/15/2023.”

8VAC20-780-560-P

“Based on record review and staff interview, the center did not ensure that a child with a diagnosed food allergy was not served any food identified in the required written care plan. Evidence: 1. Child #1 (three-years-old) has a written care plan stating that the child is allergic to eggs, and the child also has emergency medication on site. 2. On April 10, 2023, at approximately, 11:30 am, Staff #1 placed coleslaw containing mayonnaise (the main ingredient being eggs) on child #1?s plate for lunch. 3. Child #1 was administered the emergency medication by Staff #3 due to an allergic reaction and transported by EMS for medical care. 4. Staff #1, who was caring for the child, and Staff #2, who prepared the food, confirmed that they were aware of Child #1's allergy to eggs.”

8VAC20-780-240-I

“Based on a review of six records and staff interviews, the center did not ensure that documentation of orientation training included all required elements for two staff. Evidence: Staff #1 and Staff #2?s documentation of orientation training, presented at the time of the inspection, was missing the training delivery method, the entity or individual providing training, and the date of the training.”

8VAC20-780-510-I

“Based on record review and staff interview, the center did not ensure that prescription medication was administered by a staff member who meets the requirements in 8VAC20-780-245 J related to Medication Administration Training (MAT). Evidence: 1. Staff #3 confirmed that they administered Child #1's emergency medication to the child on Monday, April 10, 2023, as a result of Child #1's allergic reaction to the coleslaw served for lunch. 2. The most recent MAT certification on file for Staff #3 expired on 3/6/2023.”

8VAC20-780-550-P

“Based on record review and staff interview, the center did not maintain a written record of children's serious injuries in which entries are made the day of the occurrence. Evidence: 1. There was no documentation of an injury report for Child #1, who suffered an allergic reaction requiring the administration of an emergency medication and EMS being called on Monday, April 10, 2023, after being served a known food allergen. 2. Staff #3 confirmed that there was no injury report on file for Child #1 related to the incident.”

8VAC20-780-510-N

“Based on record review and staff interview, the center failed to keep a record of all medications given to a child including the child's name, the amount and type of medication, the date and time of administration, the name of the administering staff member, or any adverse reactions to the medication. Evidence: Staff #3 confirmed that they administered Child #1's emergency medication on April 10, 2023, in response to an allergic reaction, but did not document the occurrence.”

8VAC20-780-340-A

“Based on a review of documentation and staff interviews, the center did not ensure their care and protection, when a child with a documented food allergy was served food that contained a known allergen. 1. Child #1 (three-years-old) has a written care plan stating that the child is allergic to eggs. 2. On Monday, April 10, 2023, Staff #2 prepared coleslaw containing mayonnaise (the main ingredient being eggs) and distributed it to the three-year-old classroom for lunch. 3. Staff #2 stated they neglected to provide an alternative food item for Child #1 as they typically would and forgot to remind Staff #1 that Child #1 could not have the coleslaw. 4. Staff #2 confirmed that they were aware of Child #1's egg allergy. 5. Staff #1 reported that on April 10, 2023, at approximately 11:30 am, they placed a small portion of coleslaw containing mayonnaise on Child #1?s plate for lunch. 6. At approximately 11:45 am, Child #1 finished their lunch and went down for a nap. Staff #1 reported that Child #1 began coughing repeatedly during naptime. 7. At approximately 12:30 pm, Staff #1 stated that they realized Child#1's coughing could be due to them eating the coleslaw given to them for lunch and immediately alerted Staff #3. 8. Multiple staff reported that Child #1?s breathing was normal. However, the child was coughing, scratching at their mouth, and started to develop a rash on both cheeks. 9. Multiple staff reported that the emergency medication was administered by Staff#3, at approximately 12:35 pm, in concurrence with Staff #4 calling 911, and Staff #5 calling the parents of Child #1. 10. Child #1 was transported to the nearby hospital and was accompanied by Staff #3 until the parents arrived.”

8VAC20-790-600-D-1

“Based on record review and interview, all staff did not have current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care within 90 days of employment. Evidence: Staff #2 (DOH: 12/19/2022) and staff #5 (DOH: 11/14/2022) did not have documentation of current CPR certification.”

8VAC20-790-600-D-2

“Based on record review and interview, all staff did not have current certification in first aid appropriate to the ages of children in care within 90 days of employment. Evidence: Staff #2 (DOH: 12/19/2022) and staff #5 (DOH: 11/14/2022) did not have documentation of current first aid certification.”

8VAC20-780-160-A

“Based on a record review and interview, two of five staff records did not contain documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with children. Evidence: The record for staff #2 (DOH: 12/19/2022) and staff #5 (DOH: 11/14/2022) did not contain documentation of a negative tuberculosis screening.”

8VAC20-780-270-A

“Based on observation, areas and equipment of the center, inside and outside were not maintained in a clean, safe and operable condition. Evidence: 1. The gate used as a barrier between the infant and toddler classroom had several areas of peeling paint around its frame. 2. In the outdoor breezeway of the infant and two's classrooms, a medium-sized unanchored bookcase was leaning against a wall.”

8VAC20-780-245-J-3

“Based on record review and interview, the center failed to ensure that a staff person was onsite with MAT training when emergency medication was present. Evidence: Staff #1's MAT (medication administration training) certification expired on 3/6/2023. During the inspection, there was no documentation of another staff member on site with current MAT certification. There were two emergency medications on-site during the inspection.”

8VAC20-770-60-C-2

“Based on record review and interview, the center did not obtain the results of a central registry check by end of the 30th day of employment. Evidence: There was no documentation of central registry results for staff #1 (DOH: 12/27/2021), staff #3 (DOH: 11/14/2004) staff #4 (DOH: 6/15/2022), staff #5 (DOH: 11/14/2022), and staff #6 (DOH: 3/16/2022).”

8VAC20-770-60-B

“Based on record review and interview, a sworn statement was not completed prior to first day of employment. Evidence: There was no documentation of a sworn statement for staff #5 (DOH: 11/14/2022).”

22.1-289.035-A

“Based on record review and interview, it was determined that not all background checks were repeated every five years. Evidence: 1. The most recent sworn statement on file for Staff #3 is dated 9/21/2017.”

8VAC20-780-70

“Based on record review and interview, staff records were missing two references. Evidence: Staff #1 (DOH: 12/27/2021), staff #2 (DOH: 12/19/2022), and staff #3 (DOH: 11/14/2004) records were missing documentation that two or more references as to character and reputation as well as competency were checked before employment.”

8VAC20-780-60-A

“Based on record review, the center did not obtain all the required information for each child's record. Evidence: Child #5 is missing proof of identity.”

8VAC20-780-280-B

“Based on observation and interview, hazardous substances such as cleaning materials, insecticides, and pesticides were not kept in a locked place using a safe locking method that prevents access by children. Evidence: In the Infant room, spray bottles of sanitizer, disintectant, and glass cleaner were kept in an unlocked cabinet under the diaper changing table.”

8VAC20-780-550-H

“Based on review of the emergency drill log, the facility did not maintain a record of the dates of the monthly practiced evacuation drills for one year. Evidence: There was no documentation of a practiced emergency evacuation drill for August 2022 through December 2022.”

8VAC20-780-560-P

“Based on record review and staff interview, the center did not ensure that a child with a diagnosed food allergy was not served any food identified in the required written care plan. Evidence: 1. Child #1 (three-years-old) has a written care plan stating that the child is allergic to eggs, and the child also has emergency medication on site. 2. On April 10, 2023, at approximately, 11:30 am, Staff #1 placed coleslaw containing mayonnaise (the main ingredient being eggs) on child #1?s plate for lunch. 3. Child #1 was administered the emergency medication by Staff #3 due to an allergic reaction and transported by EMS for medical care. 4. Staff #1, who was caring for the child, and Staff #2, who prepared the food, confirmed that they were aware of Child #1's allergy to eggs.”

8VAC20-780-240-I

“Based on a review of six records and staff interviews, the center did not ensure that documentation of orientation training included all required elements for two staff. Evidence: Staff #1 and Staff #2?s documentation of orientation training, presented at the time of the inspection, was missing the training delivery method, the entity or individual providing training, and the date of the training.”

8VAC20-780-510-I

“Based on record review and staff interview, the center did not ensure that prescription medication was administered by a staff member who meets the requirements in 8VAC20-780-245 J related to Medication Administration Training (MAT). Evidence: 1. Staff #3 confirmed that they administered Child #1's emergency medication to the child on Monday, April 10, 2023, as a result of Child #1's allergic reaction to the coleslaw served for lunch. 2. The most recent MAT certification on file for Staff #3 expired on 3/6/2023.”

8VAC20-780-550-P

“Based on record review and staff interview, the center did not maintain a written record of children's serious injuries in which entries are made the day of the occurrence. Evidence: 1. There was no documentation of an injury report for Child #1, who suffered an allergic reaction requiring the administration of an emergency medication and EMS being called on Monday, April 10, 2023, after being served a known food allergen. 2. Staff #3 confirmed that there was no injury report on file for Child #1 related to the incident.”

8VAC20-780-510-N

“Based on record review and staff interview, the center failed to keep a record of all medications given to a child including the child's name, the amount and type of medication, the date and time of administration, the name of the administering staff member, or any adverse reactions to the medication. Evidence: Staff #3 confirmed that they administered Child #1's emergency medication on April 10, 2023, in response to an allergic reaction, but did not document the occurrence.”

8VAC20-780-340-A

“Based on a review of documentation and staff interviews, the center did not ensure their care and protection, when a child with a documented food allergy was served food that contained a known allergen. 1. Child #1 (three-years-old) has a written care plan stating that the child is allergic to eggs. 2. On Monday, April 10, 2023, Staff #2 prepared coleslaw containing mayonnaise (the main ingredient being eggs) and distributed it to the three-year-old classroom for lunch. 3. Staff #2 stated they neglected to provide an alternative food item for Child #1 as they typically would and forgot to remind Staff #1 that Child #1 could not have the coleslaw. 4. Staff #2 confirmed that they were aware of Child #1's egg allergy. 5. Staff #1 reported that on April 10, 2023, at approximately 11:30 am, they placed a small portion of coleslaw containing mayonnaise on Child #1?s plate for lunch. 6. At approximately 11:45 am, Child #1 finished their lunch and went down for a nap. Staff #1 reported that Child #1 began coughing repeatedly during naptime. 7. At approximately 12:30 pm, Staff #1 stated that they realized Child#1's coughing could be due to them eating the coleslaw given to them for lunch and immediately alerted Staff #3. 8. Multiple staff reported that Child #1?s breathing was normal. However, the child was coughing, scratching at their mouth, and started to develop a rash on both cheeks. 9. Multiple staff reported that the emergency medication was administered by Staff#3, at approximately 12:35 pm, in concurrence with Staff #4 calling 911, and Staff #5 calling the parents of Child #1. 10. Child #1 was transported to the nearby hospital and was accompanied by Staff #3 until the parents arrived.”

8VAC20-790-600-D-1

“Based on record review and interview, all staff did not have current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care within 90 days of employment. Evidence: Staff #2 (DOH: 12/19/2022) and staff #5 (DOH: 11/14/2022) did not have documentation of current CPR certification.”

8VAC20-790-600-D-2

“Based on record review and interview, all staff did not have current certification in first aid appropriate to the ages of children in care within 90 days of employment. Evidence: Staff #2 (DOH: 12/19/2022) and staff #5 (DOH: 11/14/2022) did not have documentation of current first aid certification.”

8VAC20-780-160-A

“Based on a record review and interview, two of five staff records did not contain documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with children. Evidence: The record for staff #2 (DOH: 12/19/2022) and staff #5 (DOH: 11/14/2022) did not contain documentation of a negative tuberculosis screening.”

8VAC20-780-270-A

“Based on observation, areas and equipment of the center, inside and outside were not maintained in a clean, safe and operable condition. Evidence: 1. The gate used as a barrier between the infant and toddler classroom had several areas of peeling paint around its frame. 2. In the outdoor breezeway of the infant and two's classrooms, a medium-sized unanchored bookcase was leaning against a wall.”

8VAC20-780-245-J-3

“Based on record review and interview, the center failed to ensure that a staff person was onsite with MAT training when emergency medication was present. Evidence: Staff #1's MAT (medication administration training) certification expired on 3/6/2023. During the inspection, there was no documentation of another staff member on site with current MAT certification. There were two emergency medications on-site during the inspection.”

8VAC20-770-60-C-2

“Based on record review and interview, the center did not obtain the results of a central registry check by end of the 30th day of employment. Evidence: There was no documentation of central registry results for staff #1 (DOH: 12/27/2021), staff #3 (DOH: 11/14/2004) staff #4 (DOH: 6/15/2022), staff #5 (DOH: 11/14/2022), and staff #6 (DOH: 3/16/2022).”

8VAC20-770-60-B

“Based on record review and interview, a sworn statement was not completed prior to first day of employment. Evidence: There was no documentation of a sworn statement for staff #5 (DOH: 11/14/2022).”

22.1-289.035-A

“Based on record review and interview, it was determined that not all background checks were repeated every five years. Evidence: 1. The most recent sworn statement on file for Staff #3 is dated 9/21/2017.”

8VAC20-780-70

“Based on record review and interview, staff records were missing two references. Evidence: Staff #1 (DOH: 12/27/2021), staff #2 (DOH: 12/19/2022), and staff #3 (DOH: 11/14/2004) records were missing documentation that two or more references as to character and reputation as well as competency were checked before employment.”

8VAC20-780-60-A

“Based on record review, the center did not obtain all the required information for each child's record. Evidence: Child #5 is missing proof of identity.”

8VAC20-780-280-B

“Based on observation and interview, hazardous substances such as cleaning materials, insecticides, and pesticides were not kept in a locked place using a safe locking method that prevents access by children. Evidence: In the Infant room, spray bottles of sanitizer, disintectant, and glass cleaner were kept in an unlocked cabinet under the diaper changing table.”

8VAC20-780-550-H

“Based on review of the emergency drill log, the facility did not maintain a record of the dates of the monthly practiced evacuation drills for one year. Evidence: There was no documentation of a practiced emergency evacuation drill for August 2022 through December 2022.”

8VAC20-780-560-P

“Based on record review and staff interview, the center did not ensure that a child with a diagnosed food allergy was not served any food identified in the required written care plan. Evidence: 1. Child #1 (three-years-old) has a written care plan stating that the child is allergic to eggs, and the child also has emergency medication on site. 2. On April 10, 2023, at approximately, 11:30 am, Staff #1 placed coleslaw containing mayonnaise (the main ingredient being eggs) on child #1?s plate for lunch. 3. Child #1 was administered the emergency medication by Staff #3 due to an allergic reaction and transported by EMS for medical care. 4. Staff #1, who was caring for the child, and Staff #2, who prepared the food, confirmed that they were aware of Child #1's allergy to eggs.”

8VAC20-780-240-I

“Based on a review of six records and staff interviews, the center did not ensure that documentation of orientation training included all required elements for two staff. Evidence: Staff #1 and Staff #2?s documentation of orientation training, presented at the time of the inspection, was missing the training delivery method, the entity or individual providing training, and the date of the training.”

8VAC20-780-510-I

“Based on record review and staff interview, the center did not ensure that prescription medication was administered by a staff member who meets the requirements in 8VAC20-780-245 J related to Medication Administration Training (MAT). Evidence: 1. Staff #3 confirmed that they administered Child #1's emergency medication to the child on Monday, April 10, 2023, as a result of Child #1's allergic reaction to the coleslaw served for lunch. 2. The most recent MAT certification on file for Staff #3 expired on 3/6/2023.”

8VAC20-780-550-P

“Based on record review and staff interview, the center did not maintain a written record of children's serious injuries in which entries are made the day of the occurrence. Evidence: 1. There was no documentation of an injury report for Child #1, who suffered an allergic reaction requiring the administration of an emergency medication and EMS being called on Monday, April 10, 2023, after being served a known food allergen. 2. Staff #3 confirmed that there was no injury report on file for Child #1 related to the incident.”

8VAC20-780-510-N

“Based on record review and staff interview, the center failed to keep a record of all medications given to a child including the child's name, the amount and type of medication, the date and time of administration, the name of the administering staff member, or any adverse reactions to the medication. Evidence: Staff #3 confirmed that they administered Child #1's emergency medication on April 10, 2023, in response to an allergic reaction, but did not document the occurrence.”

8VAC20-780-340-A

“Based on a review of documentation and staff interviews, the center did not ensure their care and protection, when a child with a documented food allergy was served food that contained a known allergen. 1. Child #1 (three-years-old) has a written care plan stating that the child is allergic to eggs. 2. On Monday, April 10, 2023, Staff #2 prepared coleslaw containing mayonnaise (the main ingredient being eggs) and distributed it to the three-year-old classroom for lunch. 3. Staff #2 stated they neglected to provide an alternative food item for Child #1 as they typically would and forgot to remind Staff #1 that Child #1 could not have the coleslaw. 4. Staff #2 confirmed that they were aware of Child #1's egg allergy. 5. Staff #1 reported that on April 10, 2023, at approximately 11:30 am, they placed a small portion of coleslaw containing mayonnaise on Child #1?s plate for lunch. 6. At approximately 11:45 am, Child #1 finished their lunch and went down for a nap. Staff #1 reported that Child #1 began coughing repeatedly during naptime. 7. At approximately 12:30 pm, Staff #1 stated that they realized Child#1's coughing could be due to them eating the coleslaw given to them for lunch and immediately alerted Staff #3. 8. Multiple staff reported that Child #1?s breathing was normal. However, the child was coughing, scratching at their mouth, and started to develop a rash on both cheeks. 9. Multiple staff reported that the emergency medication was administered by Staff#3, at approximately 12:35 pm, in concurrence with Staff #4 calling 911, and Staff #5 calling the parents of Child #1. 10. Child #1 was transported to the nearby hospital and was accompanied by Staff #3 until the parents arrived.”

8VAC20-790-600-D-1

“Based on record review and interview, all staff did not have current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care within 90 days of employment. Evidence: Staff #2 (DOH: 12/19/2022) and staff #5 (DOH: 11/14/2022) did not have documentation of current CPR certification.”

8VAC20-790-600-D-2

“Based on record review and interview, all staff did not have current certification in first aid appropriate to the ages of children in care within 90 days of employment. Evidence: Staff #2 (DOH: 12/19/2022) and staff #5 (DOH: 11/14/2022) did not have documentation of current first aid certification.”

8VAC20-780-160-A

“Based on a record review and interview, two of five staff records did not contain documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with children. Evidence: The record for staff #2 (DOH: 12/19/2022) and staff #5 (DOH: 11/14/2022) did not contain documentation of a negative tuberculosis screening.”

8VAC20-780-270-A

“Based on observation, areas and equipment of the center, inside and outside were not maintained in a clean, safe and operable condition. Evidence: 1. The gate used as a barrier between the infant and toddler classroom had several areas of peeling paint around its frame. 2. In the outdoor breezeway of the infant and two's classrooms, a medium-sized unanchored bookcase was leaning against a wall.”

8VAC20-780-245-J-3

“Based on record review and interview, the center failed to ensure that a staff person was onsite with MAT training when emergency medication was present. Evidence: Staff #1's MAT (medication administration training) certification expired on 3/6/2023. During the inspection, there was no documentation of another staff member on site with current MAT certification. There were two emergency medications on-site during the inspection.”

8VAC20-770-60-C-2

“Based on record review and interview, the center did not obtain the results of a central registry check by end of the 30th day of employment. Evidence: There was no documentation of central registry results for staff #1 (DOH: 12/27/2021), staff #3 (DOH: 11/14/2004) staff #4 (DOH: 6/15/2022), staff #5 (DOH: 11/14/2022), and staff #6 (DOH: 3/16/2022).”

8VAC20-770-60-B

“Based on record review and interview, a sworn statement was not completed prior to first day of employment. Evidence: There was no documentation of a sworn statement for staff #5 (DOH: 11/14/2022).”

22.1-289.035-A

“Based on record review and interview, it was determined that not all background checks were repeated every five years. Evidence: 1. The most recent sworn statement on file for Staff #3 is dated 9/21/2017.”

8VAC20-780-70

“Based on record review and interview, staff records were missing two references. Evidence: Staff #1 (DOH: 12/27/2021), staff #2 (DOH: 12/19/2022), and staff #3 (DOH: 11/14/2004) records were missing documentation that two or more references as to character and reputation as well as competency were checked before employment.”

8VAC20-780-60-A

“Based on record review, the center did not obtain all the required information for each child's record. Evidence: Child #5 is missing proof of identity.”

8VAC20-780-280-B

“Based on observation and interview, hazardous substances such as cleaning materials, insecticides, and pesticides were not kept in a locked place using a safe locking method that prevents access by children. Evidence: In the Infant room, spray bottles of sanitizer, disintectant, and glass cleaner were kept in an unlocked cabinet under the diaper changing table.”

8VAC20-780-550-H

“Based on review of the emergency drill log, the facility did not maintain a record of the dates of the monthly practiced evacuation drills for one year. Evidence: There was no documentation of a practiced emergency evacuation drill for August 2022 through December 2022.”

8VAC20-780-350-Q

“Based on record review and staff statement, children were moved to maintain ratio. Evidence: 1.On the CSR used to track attendance and transitions, Child #2 was moved from the Infant A classroom at 9:38am to the toddler classroom and was moved back to Infant A at 10:39am. Multiple staff stated this was to maintain ratio in the Infant room. 2. Multiple staff stated that moving children from Infant A to Toddlers was done routinely to maintain ratios in both classrooms.”

8VAC20-780-340-F

“Based on staff interviews and statements, a child under 10 years of age was not within actual sight and sound supervision of staff. Evidence: 1.On the morning of July 19, 2022, an 18-month old toddler (child #1) was left on the playground and was not in sight and sound by the supervision of staff sometime between 10:00 am-10:30am. 2. Child #1 was discovered after Staff #3 went outside to speak to a staff member on the adjacent preschool playground. 3. Through multiple interviews it was reported, they did not know that Child #1 had been left outside on the playground until Staff #3 knocked on the window of the classroom door and notified them. 4. According to staff interviews and a record review, it was determined that Child #1 was left outside for approximately 20 minutes.”

8VAC20-780-40-E

“Based on staff statement and record review, it was determined the center failed to comply with its' own policies and procedures as it relates to maintaining supervision. Evidence: 1. Through multiple interviews it was determined that the CSR (child supervision record) used to track student attendance and transitions was not completed during the transition between entering and exiting the playground on the morning of July 19, 2022. 2. A Name-to-Face check was not completed on the CSR for Child #2 while in the Toddlers classroom.”

8VAC20-780-340-A

“Based on staff interviews and statements, staff failed to ensure care, protection, and guidance while supervising children. Evidence: Child #1 was left outside on the playground for approximately 20 minutes without supervision, care, protection, and guidance.”

8VAC20-780-350-C

“Based on staff interview and statement, staff failed to adhere to the staff-to-children ratio and group size applicable to the youngest child in the group. Evidence: 1. Multiple staff stated that while on the playground in the morning, Staff #1 walked a feeding tray to the Infant A classroom, leaving Staff #2 alone with the Toddlers. 2. Multiple staff stated Staff #4, who was on the older children's playground that is separated by a fence, went to the bathroom around the same time Staff #1 left the playground area to pass a feeding tray to the Infant A classroom, leaving Staff #2 alone with 21 children from the Toddlers and Pre-K classrooms.”

8VAC20-780-570-E

“Based on observation, bottles were not refrigerated, dated, and labeled with the child's name. Evidence: An infant bottle that was found on the playground was not refrigerated, dated, and labeled with the child's name.”

8VAC20-780-350-Q

“Based on record review and staff statement, children were moved to maintain ratio. Evidence: 1.On the CSR used to track attendance and transitions, Child #2 was moved from the Infant A classroom at 9:38am to the toddler classroom and was moved back to Infant A at 10:39am. Multiple staff stated this was to maintain ratio in the Infant room. 2. Multiple staff stated that moving children from Infant A to Toddlers was done routinely to maintain ratios in both classrooms.”

8VAC20-780-340-F

“Based on staff interviews and statements, a child under 10 years of age was not within actual sight and sound supervision of staff. Evidence: 1.On the morning of July 19, 2022, an 18-month old toddler (child #1) was left on the playground and was not in sight and sound by the supervision of staff sometime between 10:00 am-10:30am. 2. Child #1 was discovered after Staff #3 went outside to speak to a staff member on the adjacent preschool playground. 3. Through multiple interviews it was reported, they did not know that Child #1 had been left outside on the playground until Staff #3 knocked on the window of the classroom door and notified them. 4. According to staff interviews and a record review, it was determined that Child #1 was left outside for approximately 20 minutes.”

8VAC20-780-40-E

“Based on staff statement and record review, it was determined the center failed to comply with its' own policies and procedures as it relates to maintaining supervision. Evidence: 1. Through multiple interviews it was determined that the CSR (child supervision record) used to track student attendance and transitions was not completed during the transition between entering and exiting the playground on the morning of July 19, 2022. 2. A Name-to-Face check was not completed on the CSR for Child #2 while in the Toddlers classroom.”

8VAC20-780-340-A

“Based on staff interviews and statements, staff failed to ensure care, protection, and guidance while supervising children. Evidence: Child #1 was left outside on the playground for approximately 20 minutes without supervision, care, protection, and guidance.”

8VAC20-780-350-C

“Based on staff interview and statement, staff failed to adhere to the staff-to-children ratio and group size applicable to the youngest child in the group. Evidence: 1. Multiple staff stated that while on the playground in the morning, Staff #1 walked a feeding tray to the Infant A classroom, leaving Staff #2 alone with the Toddlers. 2. Multiple staff stated Staff #4, who was on the older children's playground that is separated by a fence, went to the bathroom around the same time Staff #1 left the playground area to pass a feeding tray to the Infant A classroom, leaving Staff #2 alone with 21 children from the Toddlers and Pre-K classrooms.”

8VAC20-780-570-E

“Based on observation, bottles were not refrigerated, dated, and labeled with the child's name. Evidence: An infant bottle that was found on the playground was not refrigerated, dated, and labeled with the child's name.”

8VAC20-770-60-C-2

“Based on review of documentation, the licensed or registered child day program or family day system does not have a central registry finding within 30 days of employment or volunteer service. Evidence: 1. Staff #3's record (Date of hire-03/16/2022) does not have a Central Registry Results in the record. 2. Staff #4's record (Date of hire-12/27/2021) does not have a Central Registry Results in the record.”

8VAC20-780-160-A-1

“Based on review of documentation, staff did not have documentation of the Tuberculosis (TB) screening submitted at the time of employment and prior to coming into contact with children. Evidence: 1. Staff #1's (Date of hire-02/21/2022) record did not contain documentation of a TB screening at the time of employment in the record.”

8VAC20-770-60-B

“Based on review of documentation, an employee did not have a completed sworn statement or affirmation. Evidence: 1. Staff #1's record (Date of hire-02/21/2022) contained a signed sworn statement after the first day of employment dated 03/01/2022.”

8VAC20-780-40-K

“Based on review of documentation, the center did not develop written procedures for prevention of shaken baby syndrome or abusive head trauma, including coping with crying babies, safe sleeping practices, and sudden infant death syndrome awareness. Evidence: 1. The center did not have documentation for prevention of shaken baby syndrome or abusive head trauma, including coping with crying babies, safe sleeping practices, and sudden infant death syndrome awareness.”

8VAC20-780-550-G

“Based on review of documentation, documentation was not maintained for evacuation, shelter in place, and lockdown drills. Evidence: 1. The Evacuation Drill log was missing the following information: notification method, number of staff, weather conditions, and problems encountered, if any.”

8VAC20-780-440-B

“Based on observation, cots were not identified for use by a specific child. Evidence: 1. The cots in the 3's classroom were not labeled for individual use.”

8VAC20-780-290-A-3

“Based on observation, electrical outlets did not have protective covers that are of a size that cannot be swallowed by children. Evidence: 1. In the Toddler room, four electrical outlets were not covered with protective covers.”

8VAC20-780-280-B

“Based on observation, hazardous substances were not kept in a locked place using a safe method that prevents access to children. Evidence: 1. A bottle of hand sanitizer was located on a shelf in the preschool classroom.”

8VAC20-780-60-A

“Based on record review, children's records did not contain required information. Evidence: 1. Child #2's and Child #3's record did not contain documentation of an annual update.”

8VAC20-770-60-C-2

“Based on review of documentation, the licensed or registered child day program or family day system does not have a central registry finding within 30 days of employment or volunteer service. Evidence: 1. Staff #3's record (Date of hire-03/16/2022) does not have a Central Registry Results in the record. 2. Staff #4's record (Date of hire-12/27/2021) does not have a Central Registry Results in the record.”

8VAC20-780-160-A-1

“Based on review of documentation, staff did not have documentation of the Tuberculosis (TB) screening submitted at the time of employment and prior to coming into contact with children. Evidence: 1. Staff #1's (Date of hire-02/21/2022) record did not contain documentation of a TB screening at the time of employment in the record.”

8VAC20-770-60-B

“Based on review of documentation, an employee did not have a completed sworn statement or affirmation. Evidence: 1. Staff #1's record (Date of hire-02/21/2022) contained a signed sworn statement after the first day of employment dated 03/01/2022.”

8VAC20-780-40-K

“Based on review of documentation, the center did not develop written procedures for prevention of shaken baby syndrome or abusive head trauma, including coping with crying babies, safe sleeping practices, and sudden infant death syndrome awareness. Evidence: 1. The center did not have documentation for prevention of shaken baby syndrome or abusive head trauma, including coping with crying babies, safe sleeping practices, and sudden infant death syndrome awareness.”

8VAC20-780-550-G

“Based on review of documentation, documentation was not maintained for evacuation, shelter in place, and lockdown drills. Evidence: 1. The Evacuation Drill log was missing the following information: notification method, number of staff, weather conditions, and problems encountered, if any.”

8VAC20-780-440-B

“Based on observation, cots were not identified for use by a specific child. Evidence: 1. The cots in the 3's classroom were not labeled for individual use.”

8VAC20-780-290-A-3

“Based on observation, electrical outlets did not have protective covers that are of a size that cannot be swallowed by children. Evidence: 1. In the Toddler room, four electrical outlets were not covered with protective covers.”

8VAC20-780-280-B

“Based on observation, hazardous substances were not kept in a locked place using a safe method that prevents access to children. Evidence: 1. A bottle of hand sanitizer was located on a shelf in the preschool classroom.”

8VAC20-780-60-A

“Based on record review, children's records did not contain required information. Evidence: 1. Child #2's and Child #3's record did not contain documentation of an annual update.”

22VAC40-185-140-A Complaint related: No

“Based on record review, each child did not have a physical examination by or under the direction of a physician. Evidence: 1. Child # 1's record (Start date-09/05/2021) did not have documentation of a completed physical examination.”

22VAC40-185-60-A Complaint related: No

“Based on record review, children's records did not contain required information. Evidence: 1. Child #1's record (Start date-09/05/2021) did not contain documentation of viewing proof of the child's identity and age.”

22VAC40-185-130-A Complaint related: No

“Based on record review, the center did not obtain documentation that each child has received the immunizations required by the State Board of Health before the child can attend the center. Evidence: 1. Child #1's record (Start date 09/05/2021) did not have documentation of immunizations in the record.”

22VAC40-185-340-F Complaint related: Yes

“Based on staff interviews, the center did not ensure that children under 10 years of age always shall be within actual sight and sound supervision of staff. Evidence: 1. On 11/09/2021 during playground time, Child #1 (4 years old) asked Staff #1 (Date of hire-11/17/2004) if they could go to get some water. Child #1 left the playground area alone and walked through the classroom to go to the water fountain while Staff #1 watched them through the classroom windows from the playground. After getting water, Child #1 proceeded to the restroom located around the corner of the water fountain and out of sight and supervision. Child #1 was alone for approximately one minute. 2. Staff #1 confirmed that Child #1 was sent inside of the building alone. Staff #1 stated that the child asked for water, but went to the bathroom too. 3. Staff #2 (Date of hire-09/21/2021) confirmed that Child #1 went inside of the building alone without supervision for approximately one minute. 4. Staff #3 (Date of hire-07/20/2021) confirmed that Child #1 was inside of the bathroom alone unsupervised by staff.”

22VAC40-191-60-C-2 Complaint related: No

“Based on record review, the center did not obtain Central Registry results for staff. Evidence: 1. Staff #1's record (Date of hire-11/17/2004) contained an expired Central Registry Search results dated 06/27/2016. There was no documentation of a new completed Central Registry Search completed.”

22VAC40-185-550-M

“Based on documentation review, the center did not maintain a written record of three of five children's serious and minor injuries in which entries are made the day of occurrence and include all required information. Evidence: 1. Three of five injury reports reviewed did not contain how the parent was notified and the time the parent was notified.”

22VAC40-191-60-C-2

“Based on record review and interview, the center did not obtain Central Registry( CPS ) Results by the end of the 30th day of employment. Evidence: 1. Staff #2's record (Date of hire-07/26/2021) did not contain documentation of a CPS finding. There was documentation that the CPS Search was mailed on 07/30/2021, but no results in the record. There was no documentation of follow up with CPS 30 days after employment. There was documentation of follow up by email dated 11/02/2021. 2. Staff #3's record (Date of hire-04/26/2021) did not contain documentation of a CPS finding in the record. There was documentation of a CPS search that was mailed on 06/30/2021, over 60 days after the first day of employment. There was documentation of follow up with CPS dated 11/02/2021. 3. Staff #5 stated that the documentation was not available for review and follow up with CPS was done on November 2, 2021.”

22VAC40-185-550-M

“Based on documentation review, the center did not maintain a written record of three of five children's serious and minor injuries in which entries are made the day of occurrence and include all required information. Evidence: 1. Three of five injury reports reviewed did not contain how the parent was notified and the time the parent was notified.”

22VAC40-191-60-C-2

“Based on record review and interview, the center did not obtain Central Registry( CPS ) Results by the end of the 30th day of employment. Evidence: 1. Staff #2's record (Date of hire-07/26/2021) did not contain documentation of a CPS finding. There was documentation that the CPS Search was mailed on 07/30/2021, but no results in the record. There was no documentation of follow up with CPS 30 days after employment. There was documentation of follow up by email dated 11/02/2021. 2. Staff #3's record (Date of hire-04/26/2021) did not contain documentation of a CPS finding in the record. There was documentation of a CPS search that was mailed on 06/30/2021, over 60 days after the first day of employment. There was documentation of follow up with CPS dated 11/02/2021. 3. Staff #5 stated that the documentation was not available for review and follow up with CPS was done on November 2, 2021.”