Right at School, LLC.-Grafton Bethel

8VAC20-780-600-B

“Based on record reviews and staff interviews, the vendor did not ensure staff who work directly with children shall have completed Virginia Preservice Training. Evidence: The record for Staff #1 (hire date 9-30-2021) did not include documentation of completing the required updated training. The most recent training available for review was dated 10-20-2019.”

8VAC20-780-240-A

“Based on a record review and staff interviews, the licensee did not ensure that staff have completed the Virginia Department of Education-sponsored orientation course within 90 calendar days of employment. Evidence: Staff #5?s date of hire was 5-30-2023 and there was not documentation available of completing the required Virginia Department of Education-sponsored orientation.”

8VAC20-780-60-A

“Repeat 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 second parents? employment information (location and phone number) and the second emergency contacts complete home address (no city, state, and zip code). 2.Child #3 was missing the physicians phone number and the phone number for one emergency contact listed. 3.Staff #1 verified the record for Child #5 was missing and not available for review for review.”

8VAC20-780-540-E

“Based on equipment review and staff interview the licensee did not ensure the nonmedical emergency supplies were required. Evidence: Staff #1 verified they did not have a working battery-operated radio.”

8VAC20-780-70

“Based on a record review and staff interviews, the licensee did not ensure that staff have all required documentation in their record. Evidence: The following records are missing information; 1.The record for Staff #1 is a designated at Program Director and does not have documentation to demonstrate they have the education and certification required by the job position. 2. The record for Staff #5 is a designated Program Leader/ Educator and does not have documentation to demonstrate they have the education and certification required by the job position. 3. The record for Staff #3 and Staff #4 did not have their emergency contact information and required health related information at the center as required.”

8VAC20-780-160-A

“Based on record review and staff interviews, the licensee did not ensure that each staff member shall submit documentation of a negative tuberculosis screening prior to employment and coming in contact with children. Evidence: The records for Staff #2 did not include documentation of TB screenings. Staff #2 was observed working during the inspection.”

8VAC20-790-600-D-1

“Based on a review of 3 staff records and staff interviews, the vendor did not ensure staff completed who work directly with children shall have obtained within 90 days of the date of hire a current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care. The training shall include an in- person competency demonstration. Evidence: The record for Staff #1 (hire date 8-29-2022) did not include documentation of CPR certification.”

8VAC20-790-600-D-2

“Based on a review of 3 staff records and staff interviews, the vendor did not ensure staff completed who work directly with children shall have obtained within 90 days of the date of hire a current certification in first aid appropriate to the ages of children in care. Evidence: The record for Staff #1 (hire date 8-29-2022) did not include documentation of First Aid certification.”

8VAC20-780-240-E

“Based on staff record review and staff interviews, the licensee did not ensure each staff member had obtained within 30 days of the first day of employment, training in first aid and cardiopulmonary resuscitation (CPR), as appropriate to the age of the children in care. Evidence: Staff #3 (hire date 3-16-23) and Staff #4 (hire date 11-30-22) did not have documentation of CPR / First Aid orientation.”

8VAC20-780-130-A

“Based on record review and staff interviews, the licensee did not ensure to obtain documentation that each child has received the immunizations required by the State Board of Health before the child can attend the center. Evidence: The record for Child #5 (Staff #1 verified Child #5 started in October 2022) did not include documentation of required immunizations.”

22.1-289.035-B-4

“Based on record review and staff interviews, the licensee did not ensure, all staff had obtained an out of state criminal history name check ( CRC ) prior to the first day of employment and an out of state child abuse and neglect search ( CPS ) was request by the 30th day of employment Evidence: Staff #3?s record did not include an out of state CRC for Alaska where they had lived within the last five years from hire date, 4-6-2023. Staff #5 confirmed the missing information.”

8VAC20-780-140-A

“Based on record review and staff interviews, the licensee did not ensure to obtain documentation that each child has received a physical examination by or under the direction of a physician, before the child's attendance; or within 30 days after the first day of attendance. Evidence: The record for Child #5 (Staff #1 verified Child #5 started in October 2022) did not include documentation of a physical.”

8VAC20-790-600-D-1

“Based on a review of 3 staff records and staff interviews, the vendor did not ensure staff completed who work directly with children shall have obtained within 90 days of the date of hire a current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care. The training shall include an in- person competency demonstration. Evidence: The record for Staff #1 (hire date 8-29-2022) did not include documentation of CPR certification.”

8VAC20-790-600-D-2

“Based on a review of 3 staff records and staff interviews, the vendor did not ensure staff completed who work directly with children shall have obtained within 90 days of the date of hire a current certification in first aid appropriate to the ages of children in care. Evidence: The record for Staff #1 (hire date 8-29-2022) did not include documentation of First Aid certification.”

8VAC20-780-240-E

“Based on staff record review and staff interviews, the licensee did not ensure each staff member had obtained within 30 days of the first day of employment, training in first aid and cardiopulmonary resuscitation (CPR), as appropriate to the age of the children in care. Evidence: Staff #3 (hire date 3-16-23) and Staff #4 (hire date 11-30-22) did not have documentation of CPR / First Aid orientation.”

8VAC20-780-130-A

“Based on record review and staff interviews, the licensee did not ensure to obtain documentation that each child has received the immunizations required by the State Board of Health before the child can attend the center. Evidence: The record for Child #5 (Staff #1 verified Child #5 started in October 2022) did not include documentation of required immunizations.”

22.1-289.035-B-4

“Based on record review and staff interviews, the licensee did not ensure, all staff had obtained an out of state criminal history name check ( CRC ) prior to the first day of employment and an out of state child abuse and neglect search ( CPS ) was request by the 30th day of employment Evidence: Staff #3?s record did not include an out of state CRC for Alaska where they had lived within the last five years from hire date, 4-6-2023. Staff #5 confirmed the missing information.”

8VAC20-780-140-A

“Based on record review and staff interviews, the licensee did not ensure to obtain documentation that each child has received a physical examination by or under the direction of a physician, before the child's attendance; or within 30 days after the first day of attendance. Evidence: The record for Child #5 (Staff #1 verified Child #5 started in October 2022) did not include documentation of a physical.”

8VAC20-780-40-E

“Based on a review of video footage, center documentation and staff interviews, the licensee did not ensure the operational responsibilities of the center's activities, services, and facilities are maintained in compliance with these standards, the center's own policies and procedures that are required by these standards, and the terms of the current license issued by the department. Evidence: The Center did not ensure all staff followed the policies and procedures for supervision of children. 1) On January 16, 2023 between approximately 3:45 pm to 4:15 pm, there were 2 staff members and 28 school age children. Two children, Child #1 (age 8) and Child #2 (age 7) were able to engage in inappropriate touching periodically for about 20 minutes without staff intervention due to a staff member, Staff #2 not providing focused attention and observation of children. 2) Staff #2 verified they know ?they are supposed to watch the children at all times? but they were on their phone during this time. Staff #2 said ?I made a mistake and haven?t been on my phone since?. Staff #2 did not follow the center's supervision policy that includes ?Maintaining focused attention and observation (sight and sound) of children at all times? And ?abstaining from use of personal phones or other devices or activities that may impact the ability to ensure focused and active supervision?.”

8VAC20-780-340-A

“Based on a review of video footage, center documentation and staff interviews, the licensee did not ensure when staff are supervising children, they shall always ensure their care, protection, and guidance. Evidence: On January 16, 2023, between approximately 3:45 pm to 4:15 pm, there were 2 staff members and 28 school age children. Two children (Child #1- age 8 and Child #2-age 7) were able to engage in inappropriate touching periodically for about 20 minutes without staff intervention due to a staff member not providing supervision as required. 1) The children were sitting in the school cafeteria at the cafeteria tables watching a movie. 2) Child #1 and Child #2 were sitting facing each other and on the same side of the cafeteria table with a coat covering both of their laps. 3) Staff #1 was near the entrance door on one side of the cafeteria and was walking back and forth from the door greeting parents while monitoring children who were watching a movie. 4) Staff #2 was observed sitting at a cafeteria table, opposite side of the cafeteria from Staff #1 and was sitting behind the children and near doors that led to the school’s hallway. Although Staff #2 was sitting at the cafeteria table and facing the children who were watching the movie, Staff #2?s head was down off and on as it was confirmed by Staff #2 that they were watching a video and social media on their phone. 5) After about 5 minutes into the movie, Staff #2 reports that Child #1 and Child #2 asked to go to the restroom. Staff #2 gave them permission to walk down the school hallway to the restroom. 6) When Child #1 and Child #2 left the cafeteria for the restroom, Staff #2 then stood in the cafeteria’s entrance to the school hallway so that they could see (Child #1 and Child #2) walk down the hallway to the restroom. However, Staff #2 stood in the doorway and then immediately put their head down and again began watching a video on their phone their back was to all the other children in the cafeteria. 7) After approximately 2 to 3 minutes Staff #2 walked down the hallway to check on Child #1 and Child #2. Staff #2 verified as they approached the restroom, they did not hear anything unusual in the restroom. 8) After Child #1 and Child #2 returned from the restroom they returned to their seats in the cafeteria and sat facing each other again with a coat covering their laps. After about another 5 to 7 minutes Staff #2 observed Child #1 and Child #2 giggling and then they Staff #2 noticed they Child #1 and Child #2 OR the children were both moving their hands in a back-and-forth motion underneath the coat. Staff #2 got up from their seat in the cafeteria and walked towards Child #1 and Child #2. Staff #2 observed that the pants of Child #2 were unbuttoned and unzipped. Both children said to Staff #2, `?they were trying to keep their hands warm?.”

8VAC20-780-350-B-5

“Based on observation, interviews and a review of documentation the licensee did not ensure that the required child to staff ratio was met. The required ratio for school age children from 5 years to 9 years old is 1 staff for every 18 children. Evidence: On December 19, 2022 the license failed to meet the required child to staff ratio is listed below; 1) At approximately 3:31 pm, 47 children arrived at the after-school program and there were only 2 staff members (Staff #1 and Staff #2) onsite providing supervision. 2) At 3:43 pm another staff member (Staff #3) arrived on site and then immediately Staff #2 left the center. This was confirmed by Staff #3 and Staff #1. 3) At approximately 3:57 pm a third staff member, Staff #4 arrived onsite and now there were approximately 47 children with 3 staff. This was confirmed by Staff #4. 4) From approximately 3:31 pm until 3:57 pm there were only 2 staff members with 47 children 5)The age range of children in care was 5 to 11. Staff #1 stated that 2 staff had called out and they were short staffed.”

8VAC20-790-600-F

“Based on a review of 5 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: The following records did not include the required annual 3 hour health and safety update course. 1.The most recent Health and Safety course available for review for Staff #1 was dated 6-18-2019. 2.The most recent Health and Safety course available for review for Staff #2 was 8-22-2017.”

8VAC20-780-160-A

“Based on review of 5 staff records and staff interviews, the licensee did not ensure that each staff member shall submit documentation of a negative tuberculosis screening and the documentation shall have been completed within the last 30 calendar days of the date of employment and be signed by a physician, physician's designee, or an official of the local health department. Evidence: The following TB screenings/ test were not conducted within the required timeframe. 1.The TB screening/ test available for review for Staff #3 was not conducted in the required timeframe as it is dated 10-11-2022 and the first date of employment was 8-15-2022. 2. The TB screening/ test available for review for Staff #5 was not conducted in the required timeframe as it is dated 1-28-2022 and the first date of employment was 1-21-2022.”

8VAC20-780-40-K

“Based on review of center documentation and staff interviews, the licensee did not ensure the center shall develop written procedures for abusive head trauma. Evidence: Staff #1 confirmed there was not a policy available for review related to head trauma.”

8VAC20-820-120-E-2

“Based on observation and staff interviews, the licensee did not ensure the license and any other documents required by the Superintendent were posted in a conspicuous place on the licensed premises. Evidence: The most recent inspection results dated 9-26-2022 were not posted in a conspicuous place.”

8VAC20-780-60-A

“Based on review of 5 children’s records and staff interviews, the licensee did not ensure that each child shall maintain and keep at the center a separate record for each child enrolled which shall contain the required information. Evidence: The following information is missing from 4 out of 5 of the children’s records reviewed. 1. Child #1 did not have the address for 1 emergency contact listed, the home addresses, home phone number or place of employment for one of the parents listed. Child #1 did not have an immunization record that was signed by a physician, his designee, or an official of a local health department. 2. Child #2 did not have the addresses for both emergency contacts listed. 2. Child #3 did not have a physician name or phone number. 3. Child #4 did not have the address for 1 emergency contact listed.”

8VAC20-770-60-C-2

“Based on a review of 5 staff records and staff interviews, the licensee did not ensure each staff member had obtained by the end of the 30th day of hire the results of the Central Registry ( CPS ) finding for the state of Virginia. Evidence: Staff # 4?s date of hire 9-13-2022 does not have documentation of a CPS check conducted. Area Manger confirmed the CPS check was mailed on 10-10-2022. Staff #4 was observed working on the day of the day of the inspection.”

8VAC20-780-340-G

“Based on interviews with staff and other parties involved, the licensee failed to ensure children 10 years of age and older shall be within actual sight and sound supervision of staff except when specific requirements are met. Evidence: On September 7, 2022 between approximately 5:47 pm and 5:50 pm, Child #1 (age 10), was left alone on the playground without staff supervision. 1) Staff #1 and Staff #2 both reported it was at the end of the day and they took the remaining 3 children outside to the playground, directly located outside the center's entrance door. 2) At approximately 5:45 pm the parent of Child #2 and Child #3 arrived and Staff #1, Child #2, Child #3 and the parent went inside the building. 3) Child #2 and Child #3 were signed out of the program at approximately 5:47pm by their parent. 4) Staff #2 reports they were outside near the playground and the center’s entrance door and after Child #2, Child #3 and Staff #1 went into the building they called out towards the playground, ?Is there anyone else from Right at School here?? and then they went into the center. 5) Staff #2 confirms they did not know Child #1 was still on the playground when they went into the center. 6) Witness #1 reported they arrived at the center and Child #1 was on the playground by themselves. Child #1 was signed out of the center at approximately 5:50 pm by Witness #1.”

8VAC20-780-340-A

“Based on a review of the center's documentation and interviews, the licensee did not ensure when staff are supervising children, they shall always ensure their care, protection, and guidance. Evidence: 1) On September 7, 2022 between approximately 5:47 pm and 5:50 pm, Child#1 (age 10), was left alone on the playground without staff supervision. 2) The center’s entrance door and playground gate open to an elementary school parking lot located in a neighborhood and the road has a speed limit of 25.”

8VAC20-780-40-E

“Based on a review of the center's documentation and interviews, the licensee did not ensure the operational responsibilities of the licensee shall include ensuring that the center's activities, services, and facilities are maintained in compliance with the center's own policies and procedures that are required by these standards, and the terms of the current license issued by the department. Evidence: The center staff did not follow their own policy related to supervision of children. 1) Staff #2 confirms they did not follow the center's supervision policy that includes; ?Maintaining focused attention and observation (sight and sound) of children at all times.? 2) Staff #1 and Staff #2 confirm they did not follow the center's supervision policy that includes; "Maintaining the Name-To-Face form and process as intended, including documentation at each transition.? 3) Staff #1, Staff #2 and Staff #3 (center director) confirms there was not a Name-To-Face form available at that time for Staff #1 and Staff #2 to use to document transitions from the center to the playground and from the playground to the center.”

8VAC20-780-60-A-8

“Based on observation and record review, the licensee did not ensure there was a written care plan 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. Evidence: The physical signed by a physician for Child #2 confirms they have a food allergy/intolerance to strawberries and shellfish. There was not a written allergy care plan available for review.”

22.1-289-036-B-4

“Based on record review and licensee interviews, the licensee did not ensure to a obtain a sex offender check prior to the end of the 30th day of employment /service for new agents/board officers. The out of state background checks are required for any person who has lived out side of Virginia within the last five years. Evidence: Area Manager confirmed, there was not criminal record result available for review for Agent #1 who lived in New Jersey within the last five years. Agent #1, start date 1-1-2022.”

22.1-289.036-B-2

“Based on record review and licensee interviews, the licensee did not ensure to a obtain criminal records check prior to the end of the 30th day of employment /service for new agents/board officers. Evidence: Area Manager confirmed, the criminal record results available for Agent #1 was dated 2-14-2022 and the start date for Agent #1 was 1-1-2022.”

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

“Based on record review and licensee interviews, the licensee did not ensure to a obtain a copy of the results of a search of the central registry ( CPS ) by the end of the 30th day of employment /service for new agents/board officers. Evidence: Area Manager confirmed, the CPS check for Agent #1 was submitted on 2-12-2022 and Agent #1 start date was 1-1-2022. CPS results were not available for review for Agent #1.”

8VAC20-780-60-A-8

“Based on observation and record review, the licensee did not ensure there was a written care plan 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. Evidence: The physical signed by a physician for Child #2 confirms they have a food allergy/intolerance to strawberries and shellfish. There was not a written allergy care plan available for review.”

22.1-289-036-B-4

“Based on record review and licensee interviews, the licensee did not ensure to a obtain a sex offender check prior to the end of the 30th day of employment /service for new agents/board officers. The out of state background checks are required for any person who has lived out side of Virginia within the last five years. Evidence: Area Manager confirmed, there was not criminal record result available for review for Agent #1 who lived in New Jersey within the last five years. Agent #1, start date 1-1-2022.”

22.1-289.036-B-2

“Based on record review and licensee interviews, the licensee did not ensure to a obtain criminal records check prior to the end of the 30th day of employment /service for new agents/board officers. Evidence: Area Manager confirmed, the criminal record results available for Agent #1 was dated 2-14-2022 and the start date for Agent #1 was 1-1-2022.”

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

“Based on record review and licensee interviews, the licensee did not ensure to a obtain a copy of the results of a search of the central registry ( CPS ) by the end of the 30th day of employment /service for new agents/board officers. Evidence: Area Manager confirmed, the CPS check for Agent #1 was submitted on 2-12-2022 and Agent #1 start date was 1-1-2022. CPS results were not available for review for Agent #1.”

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 and a sex offender check prior to employment The licensee also did not ensure to obtain the out of state search of the central registry check ( CPS ) as required. The out of state background checks are required for any person who has lived outside of Virginia within the last five years. Evidence: Area Manager confirmed, there were not criminal record check results or child protective service check results available for review for Staff #2 who lived in South Carolina within the last five years according to center documentation. Staff #2 (date of hire 10-18-21).”

8VAC20-770-60-C-2

“Based on record review and licensee interviews, the licensee did not ensure to obtain a search of the central registry ( CPS ) for employees within 30 days of employment. Evidence: Area Manager confirmed, there were not findings of the Virginia ( CPS ) available for review during the inspection for Staff #2 (date of hire 9-30-2021) and Staff #3 (date of hire 10-18-2021).”