Main Street Baptist Church

8VAC20-780-550-C

“Emergency evacuation and shelter-in-place procedures or maps shall be posted in a location conspicuous to staff and children on each floor of each building. There were no emergency evacuation and shelter-in-place maps or procedures posted in the mission center room where children and staff were present.”

8VAC20-780-510-P

“When an authorization for medication expires, the facility shall notify parents that the medication must be picked up within 14 days of the authorization expiring or that a new authorization should be completed. Medication for Child #6 was onsite, but the medication authorization had expired over a month ago.”

8VAC20-780-70

“The center shall maintain a separate record for each staff with all required information. The records for Staff #1, #2, #3, #4 and #5 did not have documentation of start date of employment and job title.”

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 of children's allergies, sensitivities and dietary restrictions was not present in the mission center room where children were located.”

8VAC20-780-160-A

“(Repeat violation) Each staff member shall submit documentation of a negative tuberculosis screening at the time of employment, prior to coming into contact with the children and completed within the last 30 calendar days. The screening for Staff #1 was completed eight months prior to employment. The screening for Staff #3 was completed four months prior to employment.”

22.1-289.035-B-4

“The center is required to obtain background checks from any state in which the individual has resided in the preceding five years. The center did not request a search of the child abuse and neglect registry and sex offender search from one state for Staff #5, who has been employed for three weeks.”

8VAC20-780-245-J-3

“When a child is present that has been prescribed emergency medication, they shall always be in care of staff member who the requirements for being certified to administer the medication. One child was present with a prescribed emergency medication and there was not a staff person MAT certified.”

8VAC20-780-280-B

“Hazardous substances must be in a locked place that prevents access by children. Disinfectant wipes and hand sanitizer were stored on a shelf in an open storage room, out of reach of children.”

8VAC20-780-510-G

“Medication shall be labeled with the child's name, dosage amount and the time or times to be given. Two medications were observed and they were not labeled with the required information.”

8VAC20-780-510-L

“Medication, except for those prescriptions designated otherwise by written's physician's orders, shall be kept in a locked place using a safe locking method that prevents access by children. Two medications were stored on a shelf in an unlocked storage room, out of reach of children.”

8VAC20-780-540-B

“The first aid kit shall be easily accessible to staff but not to children. The first aid kit was stored on a shelf in a open storage room, within reach of children.”

8VAC20-780-550-E

“Shelter in place procedures shall be practiced a minimum of twice per year. One shelter in place drill was conducted in 2025.”

8VAC20-780-80-A

“For each group of children, the center shall maintain a written record of daily attendance that documents the arrival and departure of each child in care as it occurs. At approximately 10:25 a.m., there were 13 children present, but only 12 were marked present on the attendance record.”

8VAC20-780-130-A

“The center shall obtain documentation that each child has received the immunizations required by the State Board of Health before the child can attend the center. Child #1, who had been attending for two weeks, did not have documentation of an immunization record on file.”

8VAC20-780-150-B

“Immunization records are required to be signed and dated by a physician, his designee, or an official of the local health department. The immunization records for child #2 and child #3 were not signed.”

8VAC20-780-160-A

“Each staff member shall submit documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with the children. The screening for Staff #5 was completed two weeks after hire.”

22.1-289.035-B-3

“(Repeat violation) The center must request a search of the central registry prior to the employee's first day of employment. The records for Staff #1 (employed for two months), Staff #2 (employed for two months), Staff #3 (employed for three months), Staff #4 (employed for a year), and Staff #7 (employed for two months) did not have a central registry search requested.”

8VAC20-780-60-A

“(Repeat violation) 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 five months, and Child #2, enrolled for three months, did not have both parent's employment phone numbers.”

8VAC20-780-70

“(Repeat violation) The center shall maintain a record for each staff with required information. The record #6 did not have documentation to demonstrate the individual possesses the education, certification and experience required by the job position.”

8VAC20-780-330-B

“Playground equipment with moving parts or climbing apparatus must have resilient surfacing in all appropriate fall zones that encompass sufficient area to include the child's trajectory in the event of a fall. The fall zones around the perimeter of the play structure with swings, rock climbing wall and yellow slide were not sufficient. There was less than 10' in front of and behind the slides when there should be 16'. There was less than 5' from the rock climbing wall and chain ladder when there should be at least 6'. There was less than 8' from the exit of the yellow slide chute when there should be 9'.”

8VAC20-780-560-F

“(Repeat violation) When centers choose to provide meals or snacks, they shall follow the most recent, age-appropriate nutritional requirements of the Child and Adult Care Food Program of the United States Department of Agriculture (USDA). According to the menu and staff, milk is not being served daily for lunch.”

22.1-289.035-B-3

“(Repeat violation) The center must request a search of the central registry prior to the employee's first day of employment. The records for Staff #1 (employed for two months), Staff #2 (employed for two months), Staff #3 (employed for three months), Staff #4 (employed for a year), and Staff #7 (employed for two months) did not have a central registry search requested.”

8VAC20-780-60-A

“(Repeat violation) 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 five months, and Child #2, enrolled for three months, did not have both parent's employment phone numbers.”

8VAC20-780-70

“(Repeat violation) The center shall maintain a record for each staff with required information. The record #6 did not have documentation to demonstrate the individual possesses the education, certification and experience required by the job position.”

8VAC20-780-330-B

“Playground equipment with moving parts or climbing apparatus must have resilient surfacing in all appropriate fall zones that encompass sufficient area to include the child's trajectory in the event of a fall. The fall zones around the perimeter of the play structure with swings, rock climbing wall and yellow slide were not sufficient. There was less than 10' in front of and behind the slides when there should be 16'. There was less than 5' from the rock climbing wall and chain ladder when there should be at least 6'. There was less than 8' from the exit of the yellow slide chute when there should be 9'.”

8VAC20-780-560-F

“(Repeat violation) When centers choose to provide meals or snacks, they shall follow the most recent, age-appropriate nutritional requirements of the Child and Adult Care Food Program of the United States Department of Agriculture (USDA). According to the menu and staff, milk is not being served daily for lunch.”

8VAC20-780-60-A-8

“A written care plan is required for each child with a diagnosed food allergy, to include instructions from a physician regarding the food to which the child is allergic and the steps to be taken in the event of a suspected or confirmed allergic reaction. Child #2, who was present on this date, has a diagnosed food allergy and did not have a written care plan in their file.”

8VAC20-780-260-A

“(Repeat Violation) The center shall provide an annual fire inspection report. The most recent fire inspection report available was overdue four months.”

8VAC20-780-280-B

“(Repeat Violation) Hazardous substances must be in a locked place that prevents access by children. Hand sanitizer was stored on a table, within reach of children.”

8VAC20-780-70

“(Repeat Violation Systemic Deficiency) Staff records shall be kept for each staff person and shall contain all required information. The record for Staff #2 did not have documentation that two or more references as to character and reputation were checked, documentation to demonstrate the individual possesses the education, certification and experienced required by the job position and documentation of orientation training. The record for Staff #3 did not have documentation of orientation training. The record for Staff #5 did not have documentation that two or more references as to character and reputation were checked, documentation to demonstrate the individual possesses the education, certification and experienced required by the job position and documentation of orientation training.”

8VAC20-780-240-A

“(Repeat Violation Systemic Violation) The Virginia Department of Education-sponsored orientation course shall be completed within 90 calendar days of employment. Staff #2 and Staff #3, both employed for over a year, did not have documentation of completing this course.”

8VAC20-780-160-C

“A tuberculosis (TB) screening is required every two years from the last screening. Staff # 4 updated screening was due more than a month ago. The updated screening has not yet been completed.”

8VAC20-780-160-A

“(Repeat Violation Systemic Violation) The center is required to obtain documentation of a negative tuberculosis (TB) screening at the time of employment, prior to coming into contact with children, and shall have been completed within the last 30 days of the date of employment. Staff #5, currently working with children, has no documentation of a negative TB screening.”

22.1-289.035-B-3

“(Repeat Violation Systemic Violation) The center must request a search of the central registry prior to the employee's first day of employment. The records for Staff #2 and #3, both employed over a year, did not have a central registry search requested. The record for Staff #5, employed for less than a week, did not have a central registry search requested.”

8VAC20-780-60-A

“(Repeat Violation Systemic Deficiency) 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, present during inspection, was missing parent home address, parents' employment information, physician information, two emergency contacts and first date of attendance. The record for Child #2, present during inspection, was missing first date of attendance and documentation of viewing proof of child's identity. The record for Child #3, present during inspection, was missing parent's employment phone number, emergency contact addresses, first date of attendance and documentation of viewing proof of child's identity. The record for Child #4, present during inspection, was missing first date of attendance.”

22.1-289.035-B-2

“(Repeat Violation Systemic Violation) Providers must obtain a completed national criminal background check prior to the employee's first day of employment. Staff #2, who has been working for more than a year, Staff #3, who has been working for more than a year and Staff #5, who has been employed less than a week, did not have a completed national criminal background check.”

8VAC20-780-150-B

“(Repeat Violation) Each immunization and physical examination report shall include the date of the physical examination and dates immunizations were received and shall be signed by a physician, his designee, or an official of a local health department. The record for Child #3 had a physical examination and immunization report that were not signed.”

8VAC20-790-600-D-2

“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. Staff #2, employed for twenty-three months, Staff #3, employed for ten months, and Staff #4, employed for six months, did not have current certification in First Aid.”

8VAC20-790-600-F

“Staff who work directly with children shall annually attend the department's health and safety update course. Staff #1, employed for eleven years, did not attend the 2023 or 2024 annual training. Staff #2, employed for twenty-three months, did not attend the 2024 annual training.”

8VAC20-790-600-D-1

“All staff who work directly with children shall have within 90 days of the date of employment current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care. Staff #2, employed for twenty-three months, Staff #3, employed for ten months, and Staff #4, employed for six months, did not have current certification in CPR.”

8VAC20-780-340-C

“During the stated hours of operation, there always shall be on the premises when one or more children are present one staff member who meets the qualifications of a program leader or program director. There was no one program leader or program director qualified on the premises.”

8VAC20-780-290-A-3

“In areas used by children of preschool age or younger electrical outlets shall have protective covers. There were four outlets with out protective covers in the area where children were present.”

8VAC20-780-40-H

“The sponsor shall maintain public liability insurance for bodily injury for each center. Documentation of public liability insurance was not available for review.”

8VAC20-780-260-A

“The center shall provide an annual fire inspection report. The most recent fire inspection report available was completed thirteen months ago.”

8VAC20-780-245-A

“Staff shall complete annually a minimum of 16 hours of training appropriate to the age of children in care. Staff #1 completed 6 of the 16 required hours of training in 2024. Staff #2 completed 4 of the 16 required hours of training in 2024.”

8VAC20-780-240-A

“(Repeat Violation) The Virginia Department of Education-sponsored orientation course shall be completed within 90 calendar days of employment. Staff #3, employed for ten months, and Staff #4, employed for over six months, did not have documentation of completing this course.”

8VAC20-780-200-A

“The center shall 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. There is currently no staff member that is program director qualified.”

8VAC20-780-550-F

“Lockdown procedures shall be practiced at least annually. There was no lockdown procedure practiced in 2024.”

8VAC20-780-560-F

“When centers choose to provide meals or snacks the following shall apply: -Centers shall follow the most recent, age-appropriate nutritional requirements of the Child and Adult Care Food Program of the United States Department of Agriculture (USDA). Punch, described by staff as watered down kool-aid, was served in place of milk at lunch. -A menu listing foods to be served for meals and snacks during the current one-week period shall be dated and list any substituted food. The menu that was posted was not dated and did not include the substituted food being served during lunch time.”

22.1-289.011-F

“The license and any other documents required by the Superintendent shall be posted in a conspicuous place on the licensed premises. The most recent inspection posted was dated over a year ago and was not the most recent inspection conducted.”

22.1-289.035-B-1

“The center is required to obtain a completed sworn statement prior to the employee's first day of employment. There is no sworn statement for Staff #5, who is currently working.”

22.1-289.035-B-2

“(Repeat Violation Systemic Deficiency) Providers must obtain a completed national criminal background check prior to the employee's first day of employment. Staff #3, #4, and #5, currently working with children, did not have a completed national criminal background check.”

22.1-289.035-B-3

“The center must request a search of the central registry prior to the employee's first day of employment. Staff #3, #4, and #5, currently working with children, did not have a central registry search requested.”

22.1-289.057-A

“The program is required to submit to VDH and implement a plan to test potable water for lead. The program did not have evidence of a testing plan submitted to VDH and/or the program did not have evidence of the implementation of the required testing plan.”

22.1-289.058

“Child day programs that serve preschool-age children shall be equipped with at least one carbon monoxide detector. There was no carbon monoxide detector.”

8VAC20-780-150-B

“(Repeat Violation) Each immunization and physical examination report shall include the date of the physical examination and dates immunizations were received and shall be signed by a physician, his designee, or an official of a local health department. The physical examination and immunization report were not signed.”

8VAC20-780-60-A

“(Repeat Violation Systemic Deficiency) Each center shall maintain and keep at the center a separate record for each child enrolled that contains all of the required information. The records for Child #1 and Child #4 were missing name home address and home phone number of parents, work phone number and place of employment of each parent, name and phone number of child's physician, name address and phone number of two designated people to call in an emergency, names of persons authorized to pick up the child, written agreements between the parent and the center, previous child day care and schools attended, first date of attendance, and documentation of viewing proof of child's identity and age. The record for Child #3, enrolled for more than two years, was missing work phone number and place of employment of each parent. The record for Child #5 was missing the name of child's physician, and the address for one of the designated people to call in an emergency.”

8VAC20-780-160-A

“The center is required to obtain documentation of a negative tuberculosis (TB) screening at the time of employment, prior to coming into contact with children, and shall have been completed within the last 30 days of the date of employment. Staff #3, currently working with children, TB was dated one month after the date of employment and Staff #5, currently working with children, has no documentation of a negative TB screening.”

8VAC20-780-280-B

“Hazardous substances must be in a locked place that prevents access by children. Hand sanitizer and disinfectant wipes were on a table, within reach of children and there were multiple bottles of disinfectant spray on a shelf in an unlocked and open adjoining storage room within reach of children.”

8VAC20-780-70

“(Repeat Violation Systemic Deficiency) Staff records shall be kept for each staff person and shall contain all required information. The record for Staff #2 was missing the name, address, and telephone number of a person to be notified in an emergency. The records for Staff #3 and Staff #4 were missing job title, date of employment, verification of age, name, address, and telephone number of a person to be notified in an emergency, documentation that two or more references as to character and reputation as well as competency were checked before employment, documentation to demonstrate that the individual possesses the education, certification, and experience required by the job position, and orientation and training as required. There was no record for Staff #5.”

8VAC20-780-530-C

“There shall be at least two staff members who have current certification in CPR and First Aid present on the premises during the center's hours of operation, on fieldtrips, and wherever children are in care. One staff is currently CPR and First Aid certified.”

8VAC20-780-540-E

“(Repeat Violation) The center is required to have one working, battery-operated radio in each building used by children. There was no battery-operated radio.”

8VAC20-780-550-D

“The center shall implement a monthly practice evacuation drill. There were no evacuation drills practiced during the last 9 months.”

8VAC20-780-550-E

“Shelter in place procedures shall be practiced a minimum of twice per year. There were no shelter in place drills practiced in 2024.”

8VAC20-790-600-D-2

“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. Staff #2, employed for twenty-three months, Staff #3, employed for ten months, and Staff #4, employed for six months, did not have current certification in First Aid.”

8VAC20-790-600-F

“Staff who work directly with children shall annually attend the department's health and safety update course. Staff #1, employed for eleven years, did not attend the 2023 or 2024 annual training. Staff #2, employed for twenty-three months, did not attend the 2024 annual training.”

8VAC20-790-600-D-1

“All staff who work directly with children shall have within 90 days of the date of employment current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care. Staff #2, employed for twenty-three months, Staff #3, employed for ten months, and Staff #4, employed for six months, did not have current certification in CPR.”

8VAC20-780-340-C

“During the stated hours of operation, there always shall be on the premises when one or more children are present one staff member who meets the qualifications of a program leader or program director. There was no one program leader or program director qualified on the premises.”

8VAC20-780-290-A-3

“In areas used by children of preschool age or younger electrical outlets shall have protective covers. There were four outlets with out protective covers in the area where children were present.”

8VAC20-780-40-H

“The sponsor shall maintain public liability insurance for bodily injury for each center. Documentation of public liability insurance was not available for review.”

8VAC20-780-260-A

“The center shall provide an annual fire inspection report. The most recent fire inspection report available was completed thirteen months ago.”

8VAC20-780-245-A

“Staff shall complete annually a minimum of 16 hours of training appropriate to the age of children in care. Staff #1 completed 6 of the 16 required hours of training in 2024. Staff #2 completed 4 of the 16 required hours of training in 2024.”

8VAC20-780-240-A

“(Repeat Violation) The Virginia Department of Education-sponsored orientation course shall be completed within 90 calendar days of employment. Staff #3, employed for ten months, and Staff #4, employed for over six months, did not have documentation of completing this course.”

8VAC20-780-200-A

“The center shall 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. There is currently no staff member that is program director qualified.”

8VAC20-780-550-F

“Lockdown procedures shall be practiced at least annually. There was no lockdown procedure practiced in 2024.”

8VAC20-780-560-F

“When centers choose to provide meals or snacks the following shall apply: -Centers shall follow the most recent, age-appropriate nutritional requirements of the Child and Adult Care Food Program of the United States Department of Agriculture (USDA). Punch, described by staff as watered down kool-aid, was served in place of milk at lunch. -A menu listing foods to be served for meals and snacks during the current one-week period shall be dated and list any substituted food. The menu that was posted was not dated and did not include the substituted food being served during lunch time.”

22.1-289.011-F

“The license and any other documents required by the Superintendent shall be posted in a conspicuous place on the licensed premises. The most recent inspection posted was dated over a year ago and was not the most recent inspection conducted.”

22.1-289.035-B-1

“The center is required to obtain a completed sworn statement prior to the employee's first day of employment. There is no sworn statement for Staff #5, who is currently working.”

22.1-289.035-B-2

“(Repeat Violation Systemic Deficiency) Providers must obtain a completed national criminal background check prior to the employee's first day of employment. Staff #3, #4, and #5, currently working with children, did not have a completed national criminal background check.”

22.1-289.035-B-3

“The center must request a search of the central registry prior to the employee's first day of employment. Staff #3, #4, and #5, currently working with children, did not have a central registry search requested.”

22.1-289.057-A

“The program is required to submit to VDH and implement a plan to test potable water for lead. The program did not have evidence of a testing plan submitted to VDH and/or the program did not have evidence of the implementation of the required testing plan.”

22.1-289.058

“Child day programs that serve preschool-age children shall be equipped with at least one carbon monoxide detector. There was no carbon monoxide detector.”

8VAC20-780-150-B

“(Repeat Violation) Each immunization and physical examination report shall include the date of the physical examination and dates immunizations were received and shall be signed by a physician, his designee, or an official of a local health department. The physical examination and immunization report were not signed.”

8VAC20-780-60-A

“(Repeat Violation Systemic Deficiency) Each center shall maintain and keep at the center a separate record for each child enrolled that contains all of the required information. The records for Child #1 and Child #4 were missing name home address and home phone number of parents, work phone number and place of employment of each parent, name and phone number of child's physician, name address and phone number of two designated people to call in an emergency, names of persons authorized to pick up the child, written agreements between the parent and the center, previous child day care and schools attended, first date of attendance, and documentation of viewing proof of child's identity and age. The record for Child #3, enrolled for more than two years, was missing work phone number and place of employment of each parent. The record for Child #5 was missing the name of child's physician, and the address for one of the designated people to call in an emergency.”

8VAC20-780-160-A

“The center is required to obtain documentation of a negative tuberculosis (TB) screening at the time of employment, prior to coming into contact with children, and shall have been completed within the last 30 days of the date of employment. Staff #3, currently working with children, TB was dated one month after the date of employment and Staff #5, currently working with children, has no documentation of a negative TB screening.”

8VAC20-780-280-B

“Hazardous substances must be in a locked place that prevents access by children. Hand sanitizer and disinfectant wipes were on a table, within reach of children and there were multiple bottles of disinfectant spray on a shelf in an unlocked and open adjoining storage room within reach of children.”

8VAC20-780-70

“(Repeat Violation Systemic Deficiency) Staff records shall be kept for each staff person and shall contain all required information. The record for Staff #2 was missing the name, address, and telephone number of a person to be notified in an emergency. The records for Staff #3 and Staff #4 were missing job title, date of employment, verification of age, name, address, and telephone number of a person to be notified in an emergency, documentation that two or more references as to character and reputation as well as competency were checked before employment, documentation to demonstrate that the individual possesses the education, certification, and experience required by the job position, and orientation and training as required. There was no record for Staff #5.”

8VAC20-780-530-C

“There shall be at least two staff members who have current certification in CPR and First Aid present on the premises during the center's hours of operation, on fieldtrips, and wherever children are in care. One staff is currently CPR and First Aid certified.”

8VAC20-780-540-E

“(Repeat Violation) The center is required to have one working, battery-operated radio in each building used by children. There was no battery-operated radio.”

8VAC20-780-550-D

“The center shall implement a monthly practice evacuation drill. There were no evacuation drills practiced during the last 9 months.”

8VAC20-780-550-E

“Shelter in place procedures shall be practiced a minimum of twice per year. There were no shelter in place drills practiced in 2024.”

22.1-289.035-A

“Based on review, facility did not ensure required background checks are updated every 5 years. Evidence: The record for staff #4 had most recent fingerprinting letter and central registry search dated 2018 which is beyond 5 years old. Missing information was confirmed by director.”

22.1-289.035-B-2

“Based on review, facility did not ensure 1 of 5 staff have a completed fingerprinting letter of eligibility prior to beginning employment. Evidence: The record for staff #1 (start date 4/21/2024) did not have a fingerprinting letter of eligibility. Missing information was confirmed by director.”

8VAC20-770-60-C-2

“Based on review, facility did not ensure 1 of 5 staff have a completed central registry search. Evidence: The record for staff #1 (start date 4/24/2024) did not have a completed central registry search. Missing information was confirmed by director.”

8VAC20-780-150-A

“Based on review, facility did not ensure 2 of 5 child record physical examinations are signed by a physician, designee or health department official. Evidence: The records for child #1 and child #2 had physicals that were not signed.”

8VAC20-780-150-B

“Based on review, facility did not ensure 1 of 5 child record immunizations are signed by a physician, designee or health department official. Evidence: The record for child #2 had an immunization record that was not signed.”

8VAC20-780-60-A

“Based on review, facility did not ensure 5 of 5 child records have documentation of required information. Evidence: The following was found during record review: 1. The record for child #1 (start date 9/6/2023) did not have an immunization record. 2. The record for child #2 did not have documentation of start date and parent employment phone numbers. 3. The record for child #3 (start date 10/3/2023) did not have parent employment phones numbers and emergency contact addresses. 4. The record for child #4 (start date 11/13/2023) did not have 2nd emergency contact address, physical examination and immunization record. 5. The record for child #5 (start date 4/17/2023) did not have one parent's home address, phone number and employment information. 6. Missing information was confirmed by director.”

8VAC20-780-70

“Based on interview, facility did not ensure 1 of 5 staff have a record with required information. Evidence: The record for staff #2 was not available for review. Director reported she could not locate the file.”

8VAC20-780-80-A

“Based on observation and review, facility did not ensure for each group of children there is written record of daily attendance that documents the arrival and departure of each child in care as it occurs. Evidence: The attendance noted electronically showed 12 children present however 11 children were observed in the group. Director confirmed the attendance was not accurate at that time.”

8VAC20-780-240-A

“Based on review, facility did not ensure 2 of 5 staff complete the Virginia Department of Education (VDOE)-sponsored orientation course within 90 calendar days of employment. Evidence: The record for staff #1 (start date 4/21/2024) and staff #3 (start date 6/24/2023) did not have documentation of completing the VDOE-sponsored orientation course. Staff confirmed the training has not been done.”

8VAC20-780-330-B

“Based on observation, facility did not ensure where playground equipment is provided, resilient surfacing shall comply with the minimum safety standards in accordance with the American Society for Testing and Materials (ASTM). There shall be sufficient resilient surfacing in the fall zones under and around equipment with climbing and/or moving parts. Evidence: There is not sufficient fall zones and resilient surfacing under and around the two composite pieces of play equipment on the outside playground. The pieces have slides and swings. The borders are within fall zones and grass has grown to impair the surfacing. One piece of composite equipment with a red circular slide is labeled for use by children ages 9-12 years.”

8VAC20-780-550-G

“Based on review, facility did not ensure there is documentation of emergency evacuation drills. Evidence: There was not documentation of evacuation drills conducted in June and August 2024.”

8VAC20-780-540-E

“Based on observation, facility did not ensure the required nonmedical emergency supplies are available. Evidence: The radio was not operable with batteries.”

22.1-289.035-A

“Based on review, facility did not ensure required background checks are updated every 5 years. Evidence: The record for staff #4 had most recent fingerprinting letter and central registry search dated 2018 which is beyond 5 years old. Missing information was confirmed by director.”

22.1-289.035-B-2

“Based on review, facility did not ensure 1 of 5 staff have a completed fingerprinting letter of eligibility prior to beginning employment. Evidence: The record for staff #1 (start date 4/21/2024) did not have a fingerprinting letter of eligibility. Missing information was confirmed by director.”

8VAC20-770-60-C-2

“Based on review, facility did not ensure 1 of 5 staff have a completed central registry search. Evidence: The record for staff #1 (start date 4/24/2024) did not have a completed central registry search. Missing information was confirmed by director.”

8VAC20-780-150-A

“Based on review, facility did not ensure 2 of 5 child record physical examinations are signed by a physician, designee or health department official. Evidence: The records for child #1 and child #2 had physicals that were not signed.”

8VAC20-780-150-B

“Based on review, facility did not ensure 1 of 5 child record immunizations are signed by a physician, designee or health department official. Evidence: The record for child #2 had an immunization record that was not signed.”

8VAC20-780-60-A

“Based on review, facility did not ensure 5 of 5 child records have documentation of required information. Evidence: The following was found during record review: 1. The record for child #1 (start date 9/6/2023) did not have an immunization record. 2. The record for child #2 did not have documentation of start date and parent employment phone numbers. 3. The record for child #3 (start date 10/3/2023) did not have parent employment phones numbers and emergency contact addresses. 4. The record for child #4 (start date 11/13/2023) did not have 2nd emergency contact address, physical examination and immunization record. 5. The record for child #5 (start date 4/17/2023) did not have one parent's home address, phone number and employment information. 6. Missing information was confirmed by director.”

8VAC20-780-70

“Based on interview, facility did not ensure 1 of 5 staff have a record with required information. Evidence: The record for staff #2 was not available for review. Director reported she could not locate the file.”

8VAC20-780-80-A

“Based on observation and review, facility did not ensure for each group of children there is written record of daily attendance that documents the arrival and departure of each child in care as it occurs. Evidence: The attendance noted electronically showed 12 children present however 11 children were observed in the group. Director confirmed the attendance was not accurate at that time.”

8VAC20-780-240-A

“Based on review, facility did not ensure 2 of 5 staff complete the Virginia Department of Education (VDOE)-sponsored orientation course within 90 calendar days of employment. Evidence: The record for staff #1 (start date 4/21/2024) and staff #3 (start date 6/24/2023) did not have documentation of completing the VDOE-sponsored orientation course. Staff confirmed the training has not been done.”

8VAC20-780-330-B

“Based on observation, facility did not ensure where playground equipment is provided, resilient surfacing shall comply with the minimum safety standards in accordance with the American Society for Testing and Materials (ASTM). There shall be sufficient resilient surfacing in the fall zones under and around equipment with climbing and/or moving parts. Evidence: There is not sufficient fall zones and resilient surfacing under and around the two composite pieces of play equipment on the outside playground. The pieces have slides and swings. The borders are within fall zones and grass has grown to impair the surfacing. One piece of composite equipment with a red circular slide is labeled for use by children ages 9-12 years.”

8VAC20-780-550-G

“Based on review, facility did not ensure there is documentation of emergency evacuation drills. Evidence: There was not documentation of evacuation drills conducted in June and August 2024.”

8VAC20-780-540-E

“Based on observation, facility did not ensure the required nonmedical emergency supplies are available. Evidence: The radio was not operable with batteries.”