St. James's Children's Center

8VAC20-780-550-P

“The center shall maintain a written record of children's serious and minor injuries in which entries are made the day of the occurrence and include all of the required information. 1 out of 5 injury reports reviewed was missing the time that the parent was notified.”

8VAC20-780-70

“Staff records shall include documentation to demonstrate that the individual possesses the education, certification, and experience required by the job position. The record for staff #2, did not contain documentation that the individual possessed the education required by the job position.”

8VAC20-780-160-A

“Documentation of a negative tuberculosis (TB) screening must be submitted at the time of employment, before coming into contact with children, and shall have been completed within the last 30 days of the date of employment. The screening for Staff #1 was completed six days after hire.”

8VAC20-780-160-C

“(Repeat Violation) A tuberculosis (TB) screening is required every two years from the last screening. Staff #3 updated screening was due 2 months ago. The updated screenings have not yet been completed.”

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 record for C2 was not signed.”

8VAC20-790-600-F

“Repeat Violation Staff shall complete annually the department’s health and safety update course. The record for S2 did not contain documentation of this annual training since 01/21/2021. The record for S3 did not contain documentation of this annual training since 07/02/2024. The record for S4 did not contain documentation of this annual training since 06/04/2024. The record for S5 did not document completion of the health and safety course due by 10/8/2025. The record for S6 did not contain documentation of this annual training since 08/07/2019. The record for S7 did not document completion of the health and safety course due by 08/29/2025. The record for S8 did not contain documentation of this annual training since 01/05/2024. The record for S9 did not contain documentation of this annual training since 01/21/2021.”

8VAC20-790-600-F

“Repeat Violation Staff shall complete annually the department’s health and safety update course. The record for S2 did not document completion of the health and safety course due by 08/29/2025. The record for S4 did not contain documentation of this annual training since 01/05/2024. The record for S5 did not contain documentation of this annual training since 01/21/2021.”

22.1-289.035-A

“The center is required to have employees undergo a background check every five years. The most recent criminal record check for S4 and S5 were overdue by 8 months.”

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. The sworn statement for S3, who is currently working, was dated 23 days after their first day of employment.”

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 record for C3 was not signed.”

8VAC20-780-270-C

“Inside areas occupied by children shall be maintained no lower than 68 degrees F. The thermostat in the Cricket’s room registered the temperature in the classroom occupied by children at 66 degrees.”

8VAC20-780-320-B

“The center shall ensure the hot water at taps available to children were maintained within a range of 105 - 120 degrees Fahrenheit. The water temperature for the 2nd floor women’s rest room sink used by the children registered 122 degrees. It was tested with a digital thermometer.”

8VAC20-780-160-C

“A tuberculosis (TB) screening is required every two years from the last screening. S2?s updated screening was completed more than 20 months late.”

8VAC20-790-600-F

“Repeat Violation Staff shall complete annually the department’s health and safety update course. The record for S2 did not document completion of the health and safety course due by 08/29/2025. The record for S4 did not contain documentation of this annual training since 01/05/2024. The record for S5 did not contain documentation of this annual training since 01/21/2021.”

22.1-289.035-A

“The center is required to have employees undergo a background check every five years. The most recent criminal record check for S4 and S5 were overdue by 8 months.”

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. The sworn statement for S3, who is currently working, was dated 23 days after their first day of employment.”

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 record for C3 was not signed.”

8VAC20-780-270-C

“Inside areas occupied by children shall be maintained no lower than 68 degrees F. The thermostat in the Cricket’s room registered the temperature in the classroom occupied by children at 66 degrees.”

8VAC20-780-320-B

“The center shall ensure the hot water at taps available to children were maintained within a range of 105 - 120 degrees Fahrenheit. The water temperature for the 2nd floor women’s rest room sink used by the children registered 122 degrees. It was tested with a digital thermometer.”

8VAC20-780-160-C

“A tuberculosis (TB) screening is required every two years from the last screening. S2?s updated screening was completed more than 20 months late.”

8VAC20-790-600-F

“Repeat Violation Staff shall complete annually the department’s health and safety update course. The record for S2 did not document completion of the health and safety course due by 08/29/2025. The record for S4 did not contain documentation of this annual training since 01/05/2024. The record for S5 did not contain documentation of this annual training since 01/21/2021.”

22.1-289.035-A

“The center is required to have employees undergo a background check every five years. The most recent criminal record check for S4 and S5 were overdue by 8 months.”

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. The sworn statement for S3, who is currently working, was dated 23 days after their first day of employment.”

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 record for C3 was not signed.”

8VAC20-780-270-C

“Inside areas occupied by children shall be maintained no lower than 68 degrees F. The thermostat in the Cricket’s room registered the temperature in the classroom occupied by children at 66 degrees.”

8VAC20-780-320-B

“The center shall ensure the hot water at taps available to children were maintained within a range of 105 - 120 degrees Fahrenheit. The water temperature for the 2nd floor women’s rest room sink used by the children registered 122 degrees. It was tested with a digital thermometer.”

8VAC20-780-160-C

“A tuberculosis (TB) screening is required every two years from the last screening. S2?s updated screening was completed more than 20 months late.”

8VAC20-780-280-B

“Hazardous substances such as cleaning materials shall be kept in a locked place using a safe locking method that prevents access by children. In the 4-5 year old classroom, a disinfectant spray solution was observed on top of a paper towel dispenser unlocked.”

8VAC20-780-70

“Documentation of at least 2 references to character, reputation, and competency are to be checked prior to employment. Staff #2, who has been actively working at the center for two months, had two references with missing dates of contact.”

8VAC20-780-510-E

“The center shall ensure that procedures for administering medication shall include methods to prevent use of outdated medication The medication for child #6 expired six months ago. Medication was still on site.”

8VAC20-790-600-D-2

“All staff who work directly with children shall have within 90 days of employment current certification in first aid. S2 and S4, who are working with children, has not completed this course which is overdue by 4 months. S3, who is working with children, has not completed this course which is overdue by 5 months. S5, who is working with children, has not completed this course which is overdue by 6 months. S6, who is working with children, completed this course; however, it was overdue by 1 month.”

8VAC20-790-600-D-1

“All staff who work directly with children shall have within 90 days of employment current certification in cardiopulmonary resuscitation. S2 and S4, who are working with children, has not completed this course which is overdue by 4 months. S3, who is working with children, has not completed this course which is overdue by 5 months. S5, who is working with children, has not completed this course which is overdue by 6 months. S6, who is working with children, completed this course; however, it was overdue by 1 month.”

22.1-289.035-B-2

“Providers must obtain a completed national criminal background check prior to the employee's first day of employment. S5, who had been employed for 13 days, did not have a completed national criminal background check.”

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 record for C2 was not dated.”

8VAC20-780-160-A

“Repeat Violation Documentation of a negative tuberculosis (TB) screening must be submitted at the time of employment, before coming into contact with children, and shall have been completed within the last 30 days of the date of employment. S1 had been employed for 34 days.”

8VAC20-780-60-A

“Each center shall maintain and keep at the center a separate record for each child enrolled that contains all of the required information. The record for C3, enrolled for six months, was missing documentation of viewing proof of the child’s identity and age.”

8VAC20-780-240-C

“Staff orientation shall include all required facility specific topics. Orientation documentation for S2 and S5 did not include training regarding prevention of sudden infant death syndrome, use of safe sleep practice, prevention of shaken baby syndrome, and abusive head trauma.”

8VAC20-780-240-E

“Repeat Violation Staff are to complete within 30 days of the first date of employment orientation training in first aid and cardiopulmonary resuscitation (CPR). S2 employed for seven months has not completed this orientation.”

8VAC20-780-550-P

“The center shall maintain written records of children’s injuries that contains all of the required information. Injury reports dated 09/16/2024, 09/26/2024, 10/01/2024, 12/11/2024, and 03/04/2025 did not document the time of parental notification of the injury. Injury reports dated 09/13/2024, 10/01/2024, 11/14/2024, 12/11/2024, and 02/04/2025 did not document any future action to prevent recurrence of the injury.”

8VAC20-780-550-D

“8VAC20-780-550.D The center shall implement a monthly practice evacuation drill. Drills were not conducted in April 2024 and October 2024.”

8VAC20-790-600-D-2

“All staff who work directly with children shall have within 90 days of employment current certification in first aid. S2 and S4, who are working with children, has not completed this course which is overdue by 4 months. S3, who is working with children, has not completed this course which is overdue by 5 months. S5, who is working with children, has not completed this course which is overdue by 6 months. S6, who is working with children, completed this course; however, it was overdue by 1 month.”

8VAC20-790-600-D-1

“All staff who work directly with children shall have within 90 days of employment current certification in cardiopulmonary resuscitation. S2 and S4, who are working with children, has not completed this course which is overdue by 4 months. S3, who is working with children, has not completed this course which is overdue by 5 months. S5, who is working with children, has not completed this course which is overdue by 6 months. S6, who is working with children, completed this course; however, it was overdue by 1 month.”

22.1-289.035-B-2

“Providers must obtain a completed national criminal background check prior to the employee's first day of employment. S5, who had been employed for 13 days, did not have a completed national criminal background check.”

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 record for C2 was not dated.”

8VAC20-780-160-A

“Repeat Violation Documentation of a negative tuberculosis (TB) screening must be submitted at the time of employment, before coming into contact with children, and shall have been completed within the last 30 days of the date of employment. S1 had been employed for 34 days.”

8VAC20-780-60-A

“Each center shall maintain and keep at the center a separate record for each child enrolled that contains all of the required information. The record for C3, enrolled for six months, was missing documentation of viewing proof of the child’s identity and age.”

8VAC20-780-240-C

“Staff orientation shall include all required facility specific topics. Orientation documentation for S2 and S5 did not include training regarding prevention of sudden infant death syndrome, use of safe sleep practice, prevention of shaken baby syndrome, and abusive head trauma.”

8VAC20-780-240-E

“Repeat Violation Staff are to complete within 30 days of the first date of employment orientation training in first aid and cardiopulmonary resuscitation (CPR). S2 employed for seven months has not completed this orientation.”

8VAC20-780-550-P

“The center shall maintain written records of children’s injuries that contains all of the required information. Injury reports dated 09/16/2024, 09/26/2024, 10/01/2024, 12/11/2024, and 03/04/2025 did not document the time of parental notification of the injury. Injury reports dated 09/13/2024, 10/01/2024, 11/14/2024, 12/11/2024, and 02/04/2025 did not document any future action to prevent recurrence of the injury.”

8VAC20-780-550-D

“8VAC20-780-550.D The center shall implement a monthly practice evacuation drill. Drills were not conducted in April 2024 and October 2024.”

8VAC20-790-600-D-1

“Based on staff record review, the provider failed to ensure that staff received certification in first aid and CPR within 90 days of their employment. Evidence: The record for S1, employed 10/10/2023 did not contain documentation of first aid or CPR training. The record for S5, employed 03/14/2022 did not contain documentation of first aid or CPR training within 90 days of employment. The training was completed 08/28/2023.”

8VAC20-790-600-F

“Based on staff record review, the provider failed to ensure that staff received annual training to include the Department’s Health and Safety update course. Evidence: The record S5 documented that the most recent Department Health and Safety update course was completed 02/18/2022.”

8VAC20-770-60-C-2

“(Repeat violation) Based on staff record review, the provider failed to have central registry findings within 30 days of employment. Evidence: The record for S3, employed 01/18/2024 did not contain findings of a central registry search within 30 days of employment. The results were dated 02/20/2024.”

8VAC20-780-140-B

“Based on child record review, the provider failed to ensure that physical examinations shall be within the time period prescribed by the subsection of the standard based on the child’s age. Evidence: C1, age 3, enrolled 11/08/2023 had a physical examination dated 10/27/2022 which is outside the prescribed time period of 12 months prior to attendance.”

8VAC20-780-160-A

“(Repeat violation) Based on staff record review, the provider failed to ensure that three of five staff submit documentation of a negative tuberculosis screening at the time of employment or documentation completed within the last 30 calendar days of the date of employment. Evidence: The record for S1, employed 10/10/2023 did not document a tuberculosis (TB) screening within the required time frame. The screening was completed 01/08/2024. The record for S3, employed 01/18/2024 did not document a tuberculosis (TB) screening within the required time frame. The screening was completed 09/17/2023. The record for S4, employed 02/26/2024 did not document a tuberculosis (TB) screening within the required time frame. The screening was completed 09/26/2023.”

8VAC20-780-40-J

“(Repeat violation) Based on interview, the provider failed to 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: S6 reported the review of the injury prevention procedures has not been completed.”

8VAC20-780-240-B

“Based on staff record review, the provider failed to ensure that staff completed orientation training required by 8VAC20-780-(3)-240-C prior to the staff member working alone with children and no later than seven days of the date of assuming job responsibilities. Evidence: The staff record for S4 did not contain documentation of orientation.”

8VAC20-780-240-C

“Based on staff record review, the provider failed to ensure that staff received orientation training in facility specific topics. Evidence: Orientation form used by the center for S1, S2, and S5 failed to document training in sudden infant death syndrome, shaken baby syndrome and abusive head trauma.”

8VAC20-780-240-E

“(Repeat violation) Based on staff record review, the provider failed to ensure that staff within 30 days of the first day of employment complete orientation training in first aid and cardiopulmonary resuscitation (CPR). Evidence: Orientation form used by the center for S1, S2, S3, S4, and S5 did not document the orientation training in first aid and CPR.”

8VAC20-780-550-G

“Based on review of emergency evacuation drill documentation, the provider failed to ensure the documentation contained the required information. Evidence: The emergency drill documentation dated July 2023- February 2024 did not document the weather conditions during the drills.”

8VAC20-780-550-E

“Based on review of emergency drill documentation and interview, the provider failed to ensure that shelter in place procedures shall be practiced at least twice per year. Evidence: Emergency drill records were reviewed and did not document two shelter in place drills being conducted twice per year. S6 acknowledged that the shelter in place procedures were practiced once in 2023.”

8VAC20-790-600-D-1

“Based on staff record review, the provider failed to ensure that staff received certification in first aid and CPR within 90 days of their employment. Evidence: The record for S1, employed 10/10/2023 did not contain documentation of first aid or CPR training. The record for S5, employed 03/14/2022 did not contain documentation of first aid or CPR training within 90 days of employment. The training was completed 08/28/2023.”

8VAC20-790-600-F

“Based on staff record review, the provider failed to ensure that staff received annual training to include the Department’s Health and Safety update course. Evidence: The record S5 documented that the most recent Department Health and Safety update course was completed 02/18/2022.”

8VAC20-770-60-C-2

“(Repeat violation) Based on staff record review, the provider failed to have central registry findings within 30 days of employment. Evidence: The record for S3, employed 01/18/2024 did not contain findings of a central registry search within 30 days of employment. The results were dated 02/20/2024.”

8VAC20-780-140-B

“Based on child record review, the provider failed to ensure that physical examinations shall be within the time period prescribed by the subsection of the standard based on the child’s age. Evidence: C1, age 3, enrolled 11/08/2023 had a physical examination dated 10/27/2022 which is outside the prescribed time period of 12 months prior to attendance.”

8VAC20-780-160-A

“(Repeat violation) Based on staff record review, the provider failed to ensure that three of five staff submit documentation of a negative tuberculosis screening at the time of employment or documentation completed within the last 30 calendar days of the date of employment. Evidence: The record for S1, employed 10/10/2023 did not document a tuberculosis (TB) screening within the required time frame. The screening was completed 01/08/2024. The record for S3, employed 01/18/2024 did not document a tuberculosis (TB) screening within the required time frame. The screening was completed 09/17/2023. The record for S4, employed 02/26/2024 did not document a tuberculosis (TB) screening within the required time frame. The screening was completed 09/26/2023.”

8VAC20-780-40-J

“(Repeat violation) Based on interview, the provider failed to 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: S6 reported the review of the injury prevention procedures has not been completed.”

8VAC20-780-240-B

“Based on staff record review, the provider failed to ensure that staff completed orientation training required by 8VAC20-780-(3)-240-C prior to the staff member working alone with children and no later than seven days of the date of assuming job responsibilities. Evidence: The staff record for S4 did not contain documentation of orientation.”

8VAC20-780-240-C

“Based on staff record review, the provider failed to ensure that staff received orientation training in facility specific topics. Evidence: Orientation form used by the center for S1, S2, and S5 failed to document training in sudden infant death syndrome, shaken baby syndrome and abusive head trauma.”

8VAC20-780-240-E

“(Repeat violation) Based on staff record review, the provider failed to ensure that staff within 30 days of the first day of employment complete orientation training in first aid and cardiopulmonary resuscitation (CPR). Evidence: Orientation form used by the center for S1, S2, S3, S4, and S5 did not document the orientation training in first aid and CPR.”

8VAC20-780-550-G

“Based on review of emergency evacuation drill documentation, the provider failed to ensure the documentation contained the required information. Evidence: The emergency drill documentation dated July 2023- February 2024 did not document the weather conditions during the drills.”

8VAC20-780-550-E

“Based on review of emergency drill documentation and interview, the provider failed to ensure that shelter in place procedures shall be practiced at least twice per year. Evidence: Emergency drill records were reviewed and did not document two shelter in place drills being conducted twice per year. S6 acknowledged that the shelter in place procedures were practiced once in 2023.”