Right at School, LLC- Bethel Manor

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. The record for Child #4 and Child #5 who had been attending for 3 weeks did not have documentation of immunizations.”

8VAC20-780-40-J

“Repeat Violation Injury prevention procedures shall be updated at least annually based on documentation of injuries and a review of the activities and services. There was not annual update available to review.”

8VAC20-780-550-P

“The center shall maintain a written record of children's serious and minor injuries in which entries are made on the day of occurrence. Injury reports were reviewed and 4 out of 6 were missing information to include the date and time the parent was notified of the injury, and the second required signature.”

8VAC20-780-150-B

“Repeat Violation 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, Child #4 and Child #7 were not signed. Child #2 has been enrolled for 11 months, Child #4 has been enrolled for 3 weeks, and Child #7 has been enrolled for 14 months.”

8VAC20-780-70

“Documentation shall be kept at the center for each staff member regarding a name, address, and telephone number of a person to be notified in an emergency and any health problems that may interfere with fulfilling the job responsibilities. Staff #1, Staff #3, Staff #4, Staff #5, Staff #6 and Staff #7 did not have emergency contact information or health related information at the center.”

8VAC20-780-420-E-3

“Staff shall request at least annually parent confirmation that the required information in the child's record is up to date. Up-to-date information is required to be requested from the parent for each child's record at least annually. The information in the record of Child #6 had not been updated in over 18 months which is overdue by 6 months and information for Child #7 had not been updated in over 14 months which is overdue by 2 months.”

8VAC20-780-510-I

“Prescription medication may be administered if the parent has completed a written authorization. Three medications were administered to Child #8 without parent authorization. Medication A and medication B were administered 3 separate days in July and medication C was administered 2 separate days in July, the parent authorization on file had expired June 30, 2025.”

8VAC20-780-510-P

“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. Child #6 had 2 medications (medication D and E) with an expired authorization by12 months, and the medication had not been sent home or disposed as required.”

8VAC20-780-550-D

“The center shall implement a monthly practice evacuation drill. There was not documentation of drills conducted in April, May and June 2025.”

8VAC20-780-140-A

“Physical examinations completed by a physician shall be obtained prior to the first day of attendance or within 30 days after the first day of attendance. There was no physical examination in the record of Child #1, who had been enrolled for 11 months and Child #7 who had been enrolled for 14 months.”

8VAC20-780-60-A

“Repeat Violation The record for Child #1, enrolled for 11 months, was missing the second emergency contact name, their address and phone number.”

8VAC20-780-150-B

“Repeat Violation 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, Child #4 and Child #7 were not signed. Child #2 has been enrolled for 11 months, Child #4 has been enrolled for 3 weeks, and Child #7 has been enrolled for 14 months.”

8VAC20-780-70

“Documentation shall be kept at the center for each staff member regarding a name, address, and telephone number of a person to be notified in an emergency and any health problems that may interfere with fulfilling the job responsibilities. Staff #1, Staff #3, Staff #4, Staff #5, Staff #6 and Staff #7 did not have emergency contact information or health related information at the center.”

8VAC20-780-420-E-3

“Staff shall request at least annually parent confirmation that the required information in the child's record is up to date. Up-to-date information is required to be requested from the parent for each child's record at least annually. The information in the record of Child #6 had not been updated in over 18 months which is overdue by 6 months and information for Child #7 had not been updated in over 14 months which is overdue by 2 months.”

8VAC20-780-510-I

“Prescription medication may be administered if the parent has completed a written authorization. Three medications were administered to Child #8 without parent authorization. Medication A and medication B were administered 3 separate days in July and medication C was administered 2 separate days in July, the parent authorization on file had expired June 30, 2025.”

8VAC20-780-510-P

“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. Child #6 had 2 medications (medication D and E) with an expired authorization by12 months, and the medication had not been sent home or disposed as required.”

8VAC20-780-550-D

“The center shall implement a monthly practice evacuation drill. There was not documentation of drills conducted in April, May and June 2025.”

8VAC20-780-140-A

“Physical examinations completed by a physician shall be obtained prior to the first day of attendance or within 30 days after the first day of attendance. There was no physical examination in the record of Child #1, who had been enrolled for 11 months and Child #7 who had been enrolled for 14 months.”

8VAC20-780-60-A

“Repeat Violation The record for Child #1, enrolled for 11 months, was missing the second emergency contact name, their address and phone number.”

8VAC20-790-600-F

“Staff who work directly with children shall annually complete the health and safety update course. Staff #4's record did not contain documentation for the 2024 health and safety update course.”

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 list was not dated and was not current because it was missing the name of a child with a known allergy.”

22.1-289.035-B-2

“Providers must obtain a completed national criminal background check prior to the employee's first day of employment. Staff #4, was dated 11 days after their employment.”

8VAC20-780-550-E

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

8VAC20-780-60-A

“Centers must keep a separate record for each child enrolled that contains all of the required information. Child 2's record was missing one custodial parent's work phone number and the phone number of the child's physician. Child 3's record was missing both custodial parent's work phone numbers.”

8VAC20-780-150-B

“Each immunization report shall include dates immunizations were received and shall be signed by a physician, his designee, or an official of a local health department. The record's for child #1, 2, and 5 were not signed.”

8VAC20-780-160-C

“A tuberculosis (TB) screening is required every two years from the last screening. Staff #2 updated screening was due 5 months ago.”

8VAC20-790-600-F

“Staff who work directly with children shall annually complete the health and safety update course. Staff #4's record did not contain documentation for the 2024 health and safety update course.”

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 list was not dated and was not current because it was missing the name of a child with a known allergy.”

22.1-289.035-B-2

“Providers must obtain a completed national criminal background check prior to the employee's first day of employment. Staff #4, was dated 11 days after their employment.”

8VAC20-780-550-E

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

8VAC20-780-60-A

“Centers must keep a separate record for each child enrolled that contains all of the required information. Child 2's record was missing one custodial parent's work phone number and the phone number of the child's physician. Child 3's record was missing both custodial parent's work phone numbers.”

8VAC20-780-150-B

“Each immunization report shall include dates immunizations were received and shall be signed by a physician, his designee, or an official of a local health department. The record's for child #1, 2, and 5 were not signed.”

8VAC20-780-160-C

“A tuberculosis (TB) screening is required every two years from the last screening. Staff #2 updated screening was due 5 months ago.”

8VAC20-790-600-F

“Based on a review of 8 staff records and staff interviews, the vendor did not ensure staff completed who work directly with children shall have completed the departments health and safety update course. Evidence: Staff #3, Staff #5 and Staff #8 do not have the annual updated health and safety course.”

8VAC20-780-550-P

“Based on center documentation review and staff interviews, the licensee did not ensure the center shall maintain a written record of children's serious and minor injuries in which entries are made the day of occurrence that includes all required information. Evidence: Injury reports were reviewed and 6 out of 7 were missing some information related to the date, time and how the parent was notified of the injury.”

8VAC20-780-40-M

“Based on observation and staff interviews, the licensee did not ensure the center shall maintain, in a way that is accessible to all staff who work with children, a current written list of all children's allergies, sensitivities, and dietary restrictions. This list shall be dated and kept confidential in each room or area where children are present. Evidence: The current written list of all children's allergies, sensitivities, and dietary restrictions did not include the information for Child #2 who has a restriction of pork.”

8VAC20-780-40-J

“Based on center documentation review and staff interview the licensee did not ensure the injury prevention procedures shall be updated at least annually based on documentation of injuries and a review of the activities and services. Evidence: Senior Program Manager confirmed they did not have an updated injury prevention plan.”

8VAC20-780-510-P

“Based on review of documentation and staff interviews, the licensee did not ensure when an authorization for medication expires, the parent shall be notified 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: 1.Child #4 had a medication (Epi-pen) and the medication authorization designated expiration at the end of the 2023- 2024 school year . 2.Child #1 had a medication (Albuterol) and the medication authorization expired July 1, 2024. 3.These medications had not been sent home to the parents or disposed of as required.”

8VAC20-780-245-A

“(Repeat Violation) Based on a review of 8 staff records and staff interviews, the licensee did not ensure staff completed 16 hours of annual training. Evidence: Staff #5?s and Staff #8?s record did not include documentation of 16 hours of training.”

8VAC20-780-240-C

“Based on record review and staff interviews, the licensee did not ensure each staff member had completed orientation training in all required facility specific topics. Evidence: Staff #5 did not have documentation they had not obtained orientation training related to prevention of abusive head trauma.”

8VAC20-780-60-A

“(Repeat Violation) Based on record review and staff interviews, the licensee did not ensure each center shall maintain and keep at the center a separate record for each child enrolled which shall contain all required information. Evidence: 1. Records for Child #7 and Child #6 did not include complete emergency contact information to include the city, state and zip code for the emergency contacts listed. 2. Records Child #1, #2, #3,#4,#5,#7 and #8 did not include proof of identity.”

8VAC20-790-600-F

“Based on a review of 8 staff records and staff interviews, the vendor did not ensure staff completed who work directly with children shall have completed the departments health and safety update course. Evidence: Staff #3, Staff #5 and Staff #8 do not have the annual updated health and safety course.”

8VAC20-780-550-P

“Based on center documentation review and staff interviews, the licensee did not ensure the center shall maintain a written record of children's serious and minor injuries in which entries are made the day of occurrence that includes all required information. Evidence: Injury reports were reviewed and 6 out of 7 were missing some information related to the date, time and how the parent was notified of the injury.”

8VAC20-780-40-M

“Based on observation and staff interviews, the licensee did not ensure the center shall maintain, in a way that is accessible to all staff who work with children, a current written list of all children's allergies, sensitivities, and dietary restrictions. This list shall be dated and kept confidential in each room or area where children are present. Evidence: The current written list of all children's allergies, sensitivities, and dietary restrictions did not include the information for Child #2 who has a restriction of pork.”

8VAC20-780-40-J

“Based on center documentation review and staff interview the licensee did not ensure the injury prevention procedures shall be updated at least annually based on documentation of injuries and a review of the activities and services. Evidence: Senior Program Manager confirmed they did not have an updated injury prevention plan.”

8VAC20-780-510-P

“Based on review of documentation and staff interviews, the licensee did not ensure when an authorization for medication expires, the parent shall be notified 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: 1.Child #4 had a medication (Epi-pen) and the medication authorization designated expiration at the end of the 2023- 2024 school year . 2.Child #1 had a medication (Albuterol) and the medication authorization expired July 1, 2024. 3.These medications had not been sent home to the parents or disposed of as required.”

8VAC20-780-245-A

“(Repeat Violation) Based on a review of 8 staff records and staff interviews, the licensee did not ensure staff completed 16 hours of annual training. Evidence: Staff #5?s and Staff #8?s record did not include documentation of 16 hours of training.”

8VAC20-780-240-C

“Based on record review and staff interviews, the licensee did not ensure each staff member had completed orientation training in all required facility specific topics. Evidence: Staff #5 did not have documentation they had not obtained orientation training related to prevention of abusive head trauma.”

8VAC20-780-60-A

“(Repeat Violation) Based on record review and staff interviews, the licensee did not ensure each center shall maintain and keep at the center a separate record for each child enrolled which shall contain all required information. Evidence: 1. Records for Child #7 and Child #6 did not include complete emergency contact information to include the city, state and zip code for the emergency contacts listed. 2. Records Child #1, #2, #3,#4,#5,#7 and #8 did not include proof of identity.”

8VAC20-780-550-G

“Based on staff interviews and review of documentation, the licensee did not ensure to maintain documentation of monthly emergency evacuation drills. Evidence: Staff #4 confirmed they did not have documentation of evacuation drills conducted in December 2023.”

8VAC20-780-245-A

“Based on a record review and staff interviews, the licensee did not ensure staff obtained a minimum of 16 hours of annual training related to the care of children. Evidence: The records for Staff #1 and Staff #4 did not include documentation of 16 hours of training.”

22.1-289.035-B-4

“Based on record review and licensee interviews, the licensee did not ensure to a obtain the out of state criminal records check prior to employment. The out of state background checks are required for any person who has lived outside of Virginia within the last five years. Evidence: Staff #4?s criminal record results ( CRC ) for Texas was dated 11-27-23 after employment began. Staff #2 began employment on 11-8-23.”

8VAC20-780-60-A

“Repeat Violation Based on record review and staff interviews, license did not ensure that children’s records contained all required information. Evidence: The record for Child #3 was missing the employment phone numbers for both parents listed, the name, phone number and address for second emergency contact and the previous programs attended.”

8VAC20-780-70

“Repeat Violation Based on record review and staff interviews, the licensee did not ensure each staff record contained all required documentation. Evidence: The record for Staff #4, (designated Program Director) did not include documentation to demonstrate they possess the education, and certification required by the job position.”

8VAC20-780-550-G

“Based on staff interviews and review of documentation, the licensee did not ensure to maintain documentation of monthly emergency evacuation drills. Evidence: Staff #4 confirmed they did not have documentation of evacuation drills conducted in December 2023.”

8VAC20-780-245-A

“Based on a record review and staff interviews, the licensee did not ensure staff obtained a minimum of 16 hours of annual training related to the care of children. Evidence: The records for Staff #1 and Staff #4 did not include documentation of 16 hours of training.”

22.1-289.035-B-4

“Based on record review and licensee interviews, the licensee did not ensure to a obtain the out of state criminal records check prior to employment. The out of state background checks are required for any person who has lived outside of Virginia within the last five years. Evidence: Staff #4?s criminal record results ( CRC ) for Texas was dated 11-27-23 after employment began. Staff #2 began employment on 11-8-23.”

8VAC20-780-60-A

“Repeat Violation Based on record review and staff interviews, license did not ensure that children’s records contained all required information. Evidence: The record for Child #3 was missing the employment phone numbers for both parents listed, the name, phone number and address for second emergency contact and the previous programs attended.”

8VAC20-780-70

“Repeat Violation Based on record review and staff interviews, the licensee did not ensure each staff record contained all required documentation. Evidence: The record for Staff #4, (designated Program Director) did not include documentation to demonstrate they possess the education, and certification required by the job position.”

8VAC20-790-600-F

“Based on staff record review and staff interviews, the vendor did not ensure that staff who work directly with children shall have completed the departments health and safety update course. Evidence: The record for Staff #3 did not include the required annual 3-hour health and safety update course. The most recent was dated 2-19-2017.”

8VAC20-780-150-B

“Based on record review and provider interview, the licensee did not ensure the physical examination and dates of immunizations shall include the signature of a physician, his designee, or an official of a local health department Evidence: The immunization documents in the record for Child #4 did not include a physician or designated individual’s signature.”

8VAC20-780-70

“Based on record review and staff interviews, the licensee did not ensure each staff record contained all required documentation. Evidence: The record for Staff #3, (designated as a program leader/educator ) did not include documentation to demonstrate they possess the education, certification, and experience required by the job position.”

8VAC20-780-60-A

“Based on record review and staff interviews, license did not ensure that children’s records contained all required information. Evidence: The following records were missing information as listed below; 1.Child #2 was missing the city, state, and zip code for both emergency contacts listed. 2.Child #3 was missing the physicians phone number and the phone number for one emergency contact listed.”