Lakeside Presbyterian Preschool

8VAC20-780-140-A

“Based on a review of seven child records and interview, the center did not ensure that two children had a physical examination by or under the direction of a physician: 1. Before the child's attendance; or 2. Within 30 days after the first day of attendance. Evidence: 1. The record of child #6 (date of attendance: 8/21/2023) did not contain a physical record. The record of child #7 (date of attendance: 11/7/2023) did not contain a physical record. 2. Administration acknowledged that they had not received a physical record for the children.”

8VAC20-780-130-A

“Based on a review of seven child records and interview, the center did not ensure to obtain documentation that one child had received the immunizations required by the State Board of Health before the first date of attendance as required. Evidence: 1.The record of child #4 (date of attendance: 8/22/2023) contained an immunization record dated 9/7/2023. 2. Administration acknowledged that the immunization record was reviewed after the first date of attendance.”

8VAC20-780-70

“Based on a review of seven staff records and interview, the center did not ensure that one record was kept that contained the required information. Evidence: 1. The record of staff #7 (date of employment: 8/28/2023) contained two references dated 8/29/2023. Staff records are required to contain documentation that two or more references as to character and reputation as well as competency were checked before employment. 2. Administration acknowledged that the references were obtained after the start of employment.”

8VAC20-770-60-B

“REPEAT VIOLATION Based on a review of seven staff records and interview, the center did not ensure that one staff completed a sworn statement background check prior to employment as required. Evidence: 1. The record of staff # 7 (date of employment: 8/28/2023) contained a sworn statement dated 8/29/2023. 2. Administration acknowledged that the sworn statement was not completed prior to employment.”

8VAC20-780-60-A

“REPEAT VIOLATION Based on a review of seven child records and interview, the center did not ensure that two records contained the required information. Evidence: 1. The record of child #3 (date of attendance: 2/5/2024) was missing two emergency contact addresses. The record of child #4 (date of attendance: 8/22/2023) was missing one emergency contact address. Child records are required to contain the name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached. 2. Administration acknowledged that the records were incomplete.”

8VAC20-780-60-A

“Based on record review, the center did not ensure two of ten children’s records contained documentation of viewing proof of the child’s identity and age. Evidence: The record of child #1 (enrollment date: 3/13/2023) did not have documentation of viewing proof of the child’s identity and age.”

8VAC20-780-520-C

“Based on observation and record review, the center did not ensure that used diaper creams had written parent authorizations. Evidence: Two out of five diaper creams did not have parent authorizations in the child’s record.”

8VAC20-780-500-B

“Based on observation, the center did not ensure disposable diapers were disposed in a leak-proof or plastic-lined storage system that is either foot-operated or used in such a way that neither the staff member's hand nor the soiled diaper touches an exterior surface of the storage system during disposal. Evidence: The toddler classroom diapering area located in both the purple and yellow room, had a broken step trashcan that was used by the teachers to dispose of soiled diapers. The trashcan was not operable which caused the teachers to lift the lid of the trashcan to dispose of the diapers.”

8VAC20-780-570-A

“Based on observation, the center did not ensure to place children in high chairs with the protective belt fastened securely. Evidence: There were eight infants whose protective belts were not fastened securely while sitting in high chairs during meal time.”

8VAC20-780-290-A-3

“Based on observation the center did not ensure electrical outlets had protective covers in areas used by children of preschool age or younger. Evidence: 1. The Pre-K classroom had three uncovered electrical outlets located on an extension cord within the reach of children in care. 2. The 2A classroom had five uncovered electrical outlets located on an extension cord out of the reach of children in care.”

22.1-289.035-B-2

“Based on record review, the provider did not ensure 3 of 17 staff records contained documentation of fingerprint based national criminal history search results prior to employment. Evidence: 1. The record of staff #2 (start date: 9/14/22) had documentation of fingerprint based national criminal history search results dated 10/3/2022. 2. The record of staff #7 (start date: 3/28/22) had documentation of fingerprint based national criminal history search results dated 9/28/2022.”

8VAC20-770-60-C-2

“Based on record review, the provider did not ensure 3 of 17 staff records had documentation of central registry results within 30 days of employment. Evidence: 1. The record of staff #1 (start date: 10/17/22) had documentation of central registry results dated 11/22/22. 2. The record of staff #4 (start date: 10/17/22) had documentation of central registry results dated 11/22/22. 3. The record of staff #7 (start date: 3/28/22) had documentation of central registry results dated 1/2/23.”

8VAC20-770-60-B

“Based on record review, the provider did not ensure 3 of 17 staff records had documentation of a completed sworn statement or affirmation prior to employment. Evidence: 1. The record of staff #2 (start date: 9/14/22) had documentation of a completed sworn statement or affirmation dated 11/18/22. 2. The record of staff #5 (start date: 11/15/22) had documentation of a completed sworn statement or affirmation dated 11/18/22. 3. The record of staff #7 (start date: 3/28/22) had documentation of a completed sworn statement or affirmation dated 9/20/22.”

8VAC20-780-70

“Based on a review of eight staff records, the center did not ensure seven staff records contained the required information. Evidence: 1) The following staff records did not contain documentation that two or more references as to character and reputation as were checked before employment or volunteering ? Staff #1, employed 09/12/22; Staff #3, employed 08/26/22; and Staff #7, employed 03/28/22. 2) The following staff records, whose references were taken over the phone, did not contain the date of contact, results, and signature of person making the call ? Staff #2, employed 07/25/22; Staff #5, employed 03/28/22; and Staff #6, employed 04/26/22. 3) The record for Staff #8, employed 03/28/22, did not contain documentation of orientation training no later than seven days of the date of assuming job responsibilities.”

8VAC20-780-200-A

“Based on interview and observation, the center did not have a qualified program director or a qualified back-up program director who meets one of the director qualifications who shall regularly be on site at least 50% of the center’s hours of operation. Evidence: 1) Staff #9 was identified as the Program Director that is on site at least 50% of the center’s hours of operation and was present during the renewal inspection. 2) During interview, Staff #9 reported she did not have the complete education background required to meet director qualifications. Staff #9 reported there are no other staff members that meet director qualifications.”

8VAC20-780-240-A

“Based on a review of eight staff records and interview, the center did not ensure one staff completed the Virginia Department of Education-sponsored orientation course within 90 calendar days of employment. Evidence: 1) The record for Staff #8, employed 03/28/22, did not contain a certificate for the Virginia Department of Education-sponsored orientation course. 2) During interview, Staff #9 confirmed Staff #8 has not completed the required orientation course.”

8VAC20-780-510-F

“Based on a review of five medications, the center did not ensure the medication authorizations for four medications were available to staff during the entire time they were effective. Evidence: 1) On 09/20/22, two medications were observed on site for Child #5, but the authorizations to administer the medications were not on available on site. 2) On 09/21/2022, two medications were observed on site for Child #10, but the authorizations to administer the medications were not on available on site.”

8VAC20-780-130-E

“Based on a review of eight children's records and interview, the center did not obtain documentation of additional immunizations once every six months for children under the age of two years. Evidence: 1) The immunizations in the record for Child #4 (11 months old), date of attendance 03/28/22, were dated 01/28/22. 2) During interview, a member of management reported there were no additional immunizations in the record for Child #4.”

8VAC20-770-60-B

“Based on a review of eight staff records and interview, the center did not obtain a completed sworn statement or affirmation for three staff members prior to employment. Evidence: 1) The record for Staff #4, employed 08/01/22, contained a completed sworn statement dated 09/10/19. 2) The record for Staff #5, employed 03/28/22, contained a completed sworn statement dated 07/23/19. 3) During interview, Staff #9 reported Staff #4 and Staff #5 did not complete a new sworn statement prior to employment with the current employer. 4) The sworn statement in the record for Staff #8, employed 03/28/22, was not complete. The sworn statement was missing the date it was completed.”

22.1-289.035-B-2

“Based on a review of eight staff records and interview, the center did not ensure three staff obtained a national criminal background check prior to employment. Evidence: 1) The record for Staff #4, employed 08/01/22, did not contain the results of a national criminal background check by the current employer. The record for Staff #4 contained a national criminal background check dated 06/18/18, this background check was conducted by a different center. National criminal background checks cannot be transferred from center to center unless both centers are sponsored by the same business entity. New results should have been obtained prior to employment. 2) The record for Staff #7, employed 03/28/22, did not contain the results of a national criminal background check. 3) The record for Staff #8, employed 03/28/22, did not contain the results of a national criminal background check. 4) During interview, Staff #9 reported the background checks were requested, but the results have not been received.”

8VAC20-780-130-A

“Based on a review of eight children’s records and interview, the center did not obtain documentation that one child had received the immunizations required by the State Board of Health before the child attended the center. Evidence: 1) The immunizations in the record for Child #3, date of attendance 05/31/22, were dated 06/27/22. 2) During interview, a member of management confirmed the immunizations for Child #3 were not obtained before the child attended the center.”

8VAC20-770-60-C-2

“Based on a review of eight staff records and interview, the center did not ensure that five staff members had a central registry finding within 30 days of employment. Evidence: 1) The following staff records did not have the results of a central registry finding ? Staff #3 (employed 08/26/22); Staff #4 (employed 08/01/22); Staff #6 (employed 04/26/22); Staff #7 (employed 03/28/22); and Staff #8 (employed 03/28/22). 2) During interview, Staff #9 reported the central registry searches were sent, but have not been received to date.”

8VAC20-780-160-A

“Based on a review of eight staff records, the center did not ensure eight staff submitted documentation of a negative tuberculosis (TB) screening within the required timeframe. Evidence: 1) The following staff members did not submit documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with children ? The TB screening in the record for Staff #1, employed 09/12/22, was dated 09/15/22; the TB screening in the record for Staff #3, employed 08/26/22, was dated 09/06/22; the TB screening in the record for Staff #4, employed 08/01/22, was dated 09/06/22; and the TB screening in the record for Staff #6, employed 04/26/22, was dated 07/06/22. 2) The TB screenings in the record for the following staff members were not completed within the last 30 calendar days of the date of employment ? The TB screening in the record for Staff #2, employed 07/25/22, was dated 02/23/22; the TB screening in the record for Staff #5, employed 03/28/22, was dated 02/14/22; the TB screening in the record for Staff #7, employed 03/28/22, was dated 02/14/22; and the TB screening in the record for Staff #8, employed 03/28/22, was dated 02/16/22.”

8VAC20-780-60-A

“Based on record review, the center did not ensure two of ten children’s records contained documentation of viewing proof of the child’s identity and age. Evidence: 1. The record of child #3 (start date: 4/4/2022) did not have documentation of viewing proof of the child’s identity and age. 2. The record of child #7 (start date: 3/28/2022) did not have documentation of viewing proof of the child’s identity and age.”

8VAC20-780-140-A

“Based on record review, the center did not ensure one of ten children’s records contained documentation of a physical examination before the child’s attendance or within 30 days after the first day of attendance. Evidence: 1. The record of child #8 (start date: 3/28/2022) did not have documentation of a physical examination.”

22.1-289.035-B-2

“Based on record review, the provider did not ensure 24 of 33 staff records contained documentation of fingerprint based national criminal history search results prior to employment. Evidence: 1. The record of staff #2 (start date: 3/28/22) did not have documentation of fingerprint based national criminal history search results. 2. The record of staff #4 (start date: 3/28/22) did not have documentation of fingerprint based national criminal history search results. 3. The record of staff #5 (start date: 3/28/22) did not have documentation of fingerprint based national criminal history search results. 4. The record of staff #6 (start date: 3/28/22) did not have documentation of fingerprint based national criminal history search results. 5. The record of staff #7 (start date: 3/28/22) did not have documentation of fingerprint based national criminal history search results. 6. The record of staff #8 (start date: 3/28/22) did not have documentation of fingerprint based national criminal history search results. 7. The record of staff #10 (start date: 3/28/22) did not have documentation of fingerprint based national criminal history search results. 8. The record of staff #11 (start date: 3/28/22) did not have documentation of fingerprint based national criminal history search results. 9. The record of staff #12 (start date: 3/28/22) did not have documentation of fingerprint based national criminal history search results. 10. The record of staff #14 (start date: 3/28/22) did not have documentation of fingerprint based national criminal history search results. 11. The record of staff #15 (start date: 3/28/22) did not have documentation of fingerprint based national criminal history search results. 12. The record of staff #16 (start date: 3/28/22) did not have documentation of fingerprint based national criminal history search results. 13. The record of staff #17 (start date: 3/28/22) did not have documentation of fingerprint based national criminal history search results. 14. The record of staff #18 (start date: 3/28/22) did not have documentation of fingerprint based national criminal history search results. 15. The record of staff #19 (start date: 3/28/22) did not have documentation of fingerprint based national criminal history search results. 16. The record of staff #23 (start date: 3/28/22) did not have documentation of fingerprint based national criminal history search results. 17. The record of staff #24 (start date: 3/28/22) did not have documentation of fingerprint based national criminal history search results. 18. The record of staff #26 (start date: 3/28/22) did not have documentation of fingerprint based national criminal history search results. 19. The record of staff #27 (start date: 3/28/22) did not have documentation of fingerprint based national criminal history search results. 20. The record of staff #28 (start date: 3/28/22) did not have documentation of fingerprint based national criminal history search results. 21. The record of staff #29 (start date: 3/28/22) did not have documentation of fingerprint based national criminal history search results. 22. The record of staff #31 (start date: 3/28/22) did not have documentation of fingerprint based national criminal history search results. 23. The record of staff #32 (start date: 3/28/22) did not have documentation of fingerprint based national criminal history search results. 24. The record of staff #33 (start date: 3/28/22) did not have documentation of fingerprint based national criminal history search results.”

22.1-289.035-B-4

“Based on record review, the center did not ensure one of 33 staff records contained documentation of criminal history record results, sex offender registry check results and a child abuse and neglect search request from any state in which the individual has resided in the past five years. Evidence: The record of staff #8 (start date: 3/28/2022) did not have documentation of criminal history record results, sex offender registry check results and a child abuse and neglect search request from any state in which the individual has resided in the past five years.”

8VAC20-770-60-B

“Based on record review, the provider did not ensure 25 of 33 staff records had documentation of central registry results within 30 days of employment. Evidence: 1. The record of staff #2 (start date: 3/28/22) did not have documentation of central registry results. 2. The record of staff #3 (start date: 3/28/22) did not have documentation of central registry results. 3. The record of staff #4 (start date: 3/28/22) did not have documentation of central registry results. 4. The record of staff #5 (start date: 3/28/22) did not have documentation of central registry results. 5. The record of staff #6 (start date: 3/28/22) did not have documentation of central registry results. 6. The record of staff #7 (start date: 3/28/22) did not have documentation of central registry results. 7. The record of staff #8 (start date: 3/28/22) did not have documentation of central registry results. 8. The record of staff #9 (start date: 3/28/22) did not have documentation of central registry results. 9. The record of staff #10 (start date: 3/28/22) did not have documentation of central registry results. 10. The record of staff #11 (start date: 3/28/22) did not have documentation of central registry results. 11. The record of staff #12 (start date: 3/28/22) did not have documentation of central registry results. 12. The record of staff #14 (start date: 3/28/22) did not have documentation of central registry results. 13. The record of staff #16 (start date: 3/28/22) did not have documentation of central registry results. 14. The record of staff #17 (start date: 3/28/22) did not have documentation of central registry results. 15. The record of staff #18 (start date: 3/28/22) did not have documentation of central registry results. 16. The record of staff #19 (start date: 3/28/22) did not have documentation of central registry results. 17. The record of staff #20 (start date: 4/11/22) did not have documentation of central registry results. 18. The record of staff #21 (start date: 3/28/22) did not have documentation of central registry results. 19. The record of staff #23 (start date: 3/28/22) did not have documentation of central registry results. 20. The record of staff #24 (start date: 3/28/22) did not have documentation of central registry results. 21. The record of staff #28 (start date: 3/28/22) did not have documentation of central registry results. 22. The record of staff #29 (start date: 3/28/22) did not have documentation of central registry results. 23. The record of staff #31 (start date: 3/28/22) did not have documentation of central registry results. 24. The record of staff #32 (start date: 3/28/22) did not have documentation of central registry results. 25. The record of staff #33 (start date: 3/28/22) did not have documentation of central registry results.”

8VAC20-770-60-C-2

“Based on record review, the provider did not ensure 13 of 33 staff records had documentation of a completed sworn statement or affirmation prior to employment. Evidence: 1. The record of staff #6 (start date: 3/28/22) did not have documentation of a completed sworn statement or affirmation. 2. The record of staff #8 (start date: 3/28/22) did not have documentation of a completed sworn statement or affirmation. 3. The record of staff #10 (start date: 3/28/22) did not have documentation of a completed sworn statement or affirmation. 4. The record of staff #14 (start date: 3/28/22) did not have documentation of a completed sworn statement or affirmation. 5. The record of staff #15 (start date: 3/28/22) did not have documentation of a completed sworn statement or affirmation. 6. The record of staff #18 (start date: 3/28/22) did not have documentation of a completed sworn statement or affirmation. 7. The record of staff #21 (start date: 3/28/22) did not have documentation of a completed sworn statement or affirmation. 8. The record of staff #23 (start date: 3/28/22) did not have documentation of a completed sworn statement or affirmation. 9. The record of staff #24 (start date: 3/28/22) did not have documentation of a completed sworn statement or affirmation. 10. The record of staff #26 (start date: 3/28/22) did not have documentation of a completed sworn statement or affirmation. 11. The record of staff #27 (start date: 3/28/22) did not have documentation of a completed sworn statement or affirmation. 12. The record of staff #28 (start date: 3/28/22) did not have documentation of a completed sworn statement or affirmation. 13. The record of staff #33 (start date: 3/28/22) did not have documentation of a completed sworn statement or affirmation.”

8VAC20-780-330-B

“Based on observation, the center did not ensure that where play equipment is provided, resilient surfacing complied with minimum safety standards described in the American Society for Testing and Materials. Evidence: 1. Both slides located on the center's toddler playground did not have enough resilient surfacing throughout the entire fall zone. There must be at least six inches of resilient surfacing throughout the fall zone. The center had about 1 inch of wooden mulch and decomposed mulch/dirt in the fall zone.”

8VAC20-780-270-A

“Based on observation, the center did not ensure areas and equipment of the center, inside, were maintained in a clean, save and operable condition. Evidence: 1. There was a rope, about 2 feet long, hanging from a window covering located near a crib presenting an entanglement hazard. 2. The Blue/Purple Room’s bathroom sink had begun to rust and there were two rusted screws sticking up, about 2 inches high, from the bottom of the toilet presenting a puncture hazard. 3. The Red/Yellow Room’s bathroom had two rusted screws sticking up, about 2 inches high, from the bottom of the toilet presenting a puncture hazard. 4. The Preschool bathroom had two rusted screws sticking up, about 2 inches high, from the bottom of the toilets presenting a puncture hazard.”

8VAC20-780-280-B

“Based on observation, the center did not ensure hazardous substances such as cleaning materials were kept in a locked place using a safe locking method that prevents access by children. Evidence: 1. The unlocked staff break room had several cleaners located in unlocked cabinets out of the reach of children in care. 2. The Red Room had several cleaners located in an unlocked cabinet within the reach of children in care. 3. The Pre-K classroom had an unlocked closet with two cleaners located in it.”

8VAC20-780-70

“Based on record review, the center did not ensure one of ten staff records had documentation to demonstrate that the individual possesses the education and training as required by their assigned job position. Evidence: 1. The record of staff #8 (start date: 3/28/2022) did not have documentation showing that the staff member possesses the education and training required by the job position. 2. The record of staff #10 (start date: 3/28/2022) did not have documentation showing that the staff member possesses the education required by the job position.”

8VAC20-770-40-C-1-a

“Based on record review, the center's applicant did not have documentation of central registry results. Evidence: The record of the applicant did not have documentation of central registry results.”

8VAC20-780-550-A

“Based on record review, the center did not ensure that the emergency plan was developed in consultation with local or state authorities. Evidence: The center's emergency plan was not developed in consultation with local or state authorities.”

8VAC20-780-500-B

“Based on observation, the center did not ensure that the diapering area had a sink with running warm water not to exceed 120?F. Evidence: The Orange Infant room had a sink with hot running water that measured 168?F.”

8VAC20-780-330-B

“Based on observation, it was determined that where playground equipment is provided, resilient surfacing did not comply with minimum safety standards when tested in accordance with the procedures described in the American Society for Testing and Materials standard F1292-99. Evidence: Resilient surfacing under the blue portable slide was not compliant with the requirements in the standards. The center had very little mulch scattered on top of compacted dirt in various places around the slide and on the playground.”

8VAC20-780-550-B

“Based on record review, the center did not ensure the emergency plan contained all of the procedural components. Evidence: The center's emergency plan did not contain all of the required procedural components.”