Virginia Commonwealth University Health System Authority -N Deck

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 #2, who had been employed for four days, did not have a completed national criminal background check. Staff #8 had a completed national criminal background check dated 15 days after their date of employment. Staff #10 had a completed national criminal background check dated 17 days after their date of employment.”

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. Staff #7 TB was dated 48 days prior to their date of employment.”

8VAC20-780-510-E

“The centers procedures for administering medication includes methods to prevent use of outdated medication. The medication for child #15 had expired one month ago.”

8VAC20-780-270-A

“The center shall ensure that areas and equipment of the center, inside and outside, are maintained in a clean, safe and operable condition. In classroom #6, a large area rug was laying on top of finished floor that was unraveling at the corner ends and was a tripping hazard. In classroom #8, a metal step trashcan was rusty and in reach of children. On the playground, a hole in the ground did not have a covering, creating a tripping hazard.”

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 #2, who had been employed for four days, did not have a completed national criminal background check. Staff #8 had a completed national criminal background check dated 15 days after their date of employment. Staff #10 had a completed national criminal background check dated 17 days after their date of employment.”

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. Staff #7 TB was dated 48 days prior to their date of employment.”

8VAC20-780-510-E

“The centers procedures for administering medication includes methods to prevent use of outdated medication. The medication for child #15 had expired one month ago.”

8VAC20-780-270-A

“The center shall ensure that areas and equipment of the center, inside and outside, are maintained in a clean, safe and operable condition. In classroom #6, a large area rug was laying on top of finished floor that was unraveling at the corner ends and was a tripping hazard. In classroom #8, a metal step trashcan was rusty and in reach of children. On the playground, a hole in the ground did not have a covering, creating a tripping hazard.”

8VAC20-780-130-E

“Based on a review of children’s records, the center did not ensure that each child’s record contained documentation of additional immunizations once every six months for children under the age of two years. Evidence: 1. Child #2, 2 years of age, had immunization records dated 09/19/2022 and 10/27/2023. Child’s first day of attendance was 09/19/2022. An updated immunization was required in March of 2023. 2. Child #9, 16 months of age, had one immunization record dated 08/08/2023 and 01/08/2024. Child’s first day of attendance was 08/21/2023. An updated immunization was required in July of 2024.”

8VAC20-780-130-E

“Based on a review of children’s records, the center did not ensure that each child’s record contained documentation of additional immunizations once every six months for children under the age of two years. Evidence: 1. Child #2, 2 years of age, had immunization records dated 09/19/2022 and 10/27/2023. Child’s first day of attendance was 09/19/2022. An updated immunization was required in March of 2023. 2. Child #9, 16 months of age, had one immunization record dated 08/08/2023 and 01/08/2024. Child’s first day of attendance was 08/21/2023. An updated immunization was required in July of 2024.”

8VAC20-780-130-E

“Based on a review of children’s records, the center did not ensure that each child’s record contained documentation of additional immunizations once every six months for children under the age of two years. Evidence: 1. Child #2, 2 years of age, had immunization records dated 09/19/2022 and 10/27/2023. Child’s first day of attendance was 09/19/2022. An updated immunization was required in March of 2023. 2. Child #9, 16 months of age, had one immunization record dated 08/08/2023 and 01/08/2024. Child’s first day of attendance was 08/21/2023. An updated immunization was required in July of 2024.”

8VAC20-780-410-1

“Based on review of documentation provided by the center and interview with center director, it was determined that staff roughly handled a child. Evidence: On November 9, 2023, S1 roughly handled a child by ?speaking in a negative tone to the child, and was standing on the child’s hair, restricting their movement.?”

8VAC20-780-260-A

“(Repeat violation) Based on interview, the center failed to provide an annual inspection report from the appropriate fire official having jurisdiction. Evidence: The center failed to have an annual fire inspection report inspection available for viewing during the inspection.”

8VAC20-780-270-A

“(Repeat violation) Based on observation, the provider did not ensure that all areas of the center be maintained in a clean, safe, and operable condition. Evidence: The black metal fence surrounding the playground had several loose panels and the garden fabric near the play structure tunnel was loose creating a tripping hazard.”

8VAC20-780-130-A

“Based on record review, the provider failed to ensure 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 C2, enrolled 09/18/2023 documented immunizations being received 12/22/2023.”

22.1-289.035-B-4

“Based on staff record review, the provider failed to obtain the results of a sex offender registry search, out of state criminal history name check, and out-of-state child abuse and neglect search from any state in which the individual has lived in the preceding five years. Evidence: The staff record for S5, employed 09/03/2023 documented S5 having lived out-of-state in two different states in the last five years. The record did not contain: a sex offender searches for one of the two states in which the individual lived in the preceding five years; the results of the two out-of-state child abuse and neglect searches; and the criminal history name check for two of the two states the individual lived in the preceding five years. Staff record for S6, employed 09/03/2023 documented S6 having lived out-of-state in the last five years. The record did not contain the results of a child abuse and neglect search.”

8VAC20-780-130-E

“Based on child record review, the provider failed to obtain documentation of additional immunizations once every six months for children under the age of two years. Evidence: The record for C4, under the age of 2, enrolled 06/06/2022 did not contain additional immunizations due within six months of immunizations in the record dated 12/06/2022. The record for C10, under the age of 2, enrolled 11/28/2022 did not contain additional immunizations due within six months of immunizations dated 01/24/2023.”

8VAC20-780-140-A

“Based on record review, the provider failed to ensure that each child shall have 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 C2, enrolled 09/18/2023 documented the physical examination being received 12/22/2023.”

8VAC20-780-550-P

“Based on review of the center’s written record of children serious or minor injuries the center failed to document the date and time when parents were notified of the injuries. Evidence: The written records for serious or minor injuries for C11 (12/06/2023), C12 (10/09/2023), C13 (10/03/2023), C14 (11/28/2023), C15 (11/29/2023), and C16 (11/22/2023 and 12/05/2023) did not document the date and time when parents were notified of the injuries.”

8VAC20-780-150-B

“Based on child record review, the provider failed to assure that each report of immunizations shall be signed by a licensed physician, the physician’s designee, or an official of a local health department. Evidence: The immunizations for C10 dated 01/24/2023 were not signed by the licensed physician, the physician’s designee, or an official of a local health department.”

8VAC20-780-70

“Based on staff record review, the provider failed to ensure that 10 of 11 records contained required information. Evidence: 1. Record for S1, employed 12/10/2023 did not contain information about any health problems that may interfere with fulfilling the job responsibilities. 2. Record for S2, employed 12/10/2023 did not contain employment references and information about any health problems that may interfere with fulfilling the job responsibilities. 3. Record for S3, employed 07/23/2023 did not contain employment references and information about any health problems that may interfere with fulfilling the job responsibilities. 4. Record for S4, employed 02/05/2023 did not contain: employment references; information about any health problems that may interfere with fulfilling the job responsibilities; and telephone number of a person to be notified in an emergency which shall be kept at the center. 5. Record for S5, employed 09/03/2023 did not contain employment references and information about any health problems that may interfere with fulfilling the job responsibilities. 6. Record for S7, employed 06/25/2023 did not contain: employment references; information about any health problems that may interfere with fulfilling the job responsibilities; and a telephone number of a person to be notified in an emergency which shall be kept at the center. 7. Record for S8, employed 08/06/2023 did not contain information about any health problems that may interfere with fulfilling the job responsibilities. 8. Record for S9, employed 08/20/2023 did not contain employment references and information about any health problems that may interfere with fulfilling the job responsibilities. 9. Record for S10, employed 02/19/2023 did not contain information about any health problems that may interfere with fulfilling the job responsibilities and a telephone number of a person to be notified in an emergency which shall be kept at the center. 10. Record for S11, employed 03/05/2023 did not contain information about any health problems that may interfere with fulfilling the job responsibilities”

8VAC20-780-90-A

“(Repeat violation) Based on review of ten children records, the provider did not ensure that four of ten children’s records contained a written agreement between the parents and the center shall be in each child’s record by the first day of the child’s attendance. Evidence: The records for C2, enrolled 09/18/2023, C6, enrolled 10/16/2023, C7, enrolled 08/14/2023, and C10 enrolled 11/28/2023 did not contain signed written agreements between the parents and the center.”

8VAC20-780-240-A

“(Repeat violation) Based on record review, the provider failed to ensure that staff shall complete the Virginia Department of Education-sponsored orientation course within 90 days of employment. Evidence: The record for S6, employed 09/03/2023 contained a certificate of completion of the Virginia Preservice Training dated 12/12/2023.”

22.1-289.035-B-2

“Based on record review, the provider failed to ensure that all applicants for employment shall submit to fingerprinting and undergo a national criminal background check prior to employment. Evidence: The record for staff S3, employed 07/23/2023 did not have results of a national criminal background check prior to the first day of employment. The results of the national criminal background check are dated 09/01/2023.”

8VAC20-780-410-1

“Based on review of documentation provided by the center and interview with center director, it was determined that staff roughly handled a child. Evidence: On November 9, 2023, S1 roughly handled a child by ?speaking in a negative tone to the child, and was standing on the child’s hair, restricting their movement.?”

8VAC20-780-260-A

“(Repeat violation) Based on interview, the center failed to provide an annual inspection report from the appropriate fire official having jurisdiction. Evidence: The center failed to have an annual fire inspection report inspection available for viewing during the inspection.”

8VAC20-780-270-A

“(Repeat violation) Based on observation, the provider did not ensure that all areas of the center be maintained in a clean, safe, and operable condition. Evidence: The black metal fence surrounding the playground had several loose panels and the garden fabric near the play structure tunnel was loose creating a tripping hazard.”

8VAC20-780-130-A

“Based on record review, the provider failed to ensure 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 C2, enrolled 09/18/2023 documented immunizations being received 12/22/2023.”

22.1-289.035-B-4

“Based on staff record review, the provider failed to obtain the results of a sex offender registry search, out of state criminal history name check, and out-of-state child abuse and neglect search from any state in which the individual has lived in the preceding five years. Evidence: The staff record for S5, employed 09/03/2023 documented S5 having lived out-of-state in two different states in the last five years. The record did not contain: a sex offender searches for one of the two states in which the individual lived in the preceding five years; the results of the two out-of-state child abuse and neglect searches; and the criminal history name check for two of the two states the individual lived in the preceding five years. Staff record for S6, employed 09/03/2023 documented S6 having lived out-of-state in the last five years. The record did not contain the results of a child abuse and neglect search.”

8VAC20-780-130-E

“Based on child record review, the provider failed to obtain documentation of additional immunizations once every six months for children under the age of two years. Evidence: The record for C4, under the age of 2, enrolled 06/06/2022 did not contain additional immunizations due within six months of immunizations in the record dated 12/06/2022. The record for C10, under the age of 2, enrolled 11/28/2022 did not contain additional immunizations due within six months of immunizations dated 01/24/2023.”

8VAC20-780-140-A

“Based on record review, the provider failed to ensure that each child shall have 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 C2, enrolled 09/18/2023 documented the physical examination being received 12/22/2023.”

8VAC20-780-550-P

“Based on review of the center’s written record of children serious or minor injuries the center failed to document the date and time when parents were notified of the injuries. Evidence: The written records for serious or minor injuries for C11 (12/06/2023), C12 (10/09/2023), C13 (10/03/2023), C14 (11/28/2023), C15 (11/29/2023), and C16 (11/22/2023 and 12/05/2023) did not document the date and time when parents were notified of the injuries.”

8VAC20-780-150-B

“Based on child record review, the provider failed to assure that each report of immunizations shall be signed by a licensed physician, the physician’s designee, or an official of a local health department. Evidence: The immunizations for C10 dated 01/24/2023 were not signed by the licensed physician, the physician’s designee, or an official of a local health department.”

8VAC20-780-70

“Based on staff record review, the provider failed to ensure that 10 of 11 records contained required information. Evidence: 1. Record for S1, employed 12/10/2023 did not contain information about any health problems that may interfere with fulfilling the job responsibilities. 2. Record for S2, employed 12/10/2023 did not contain employment references and information about any health problems that may interfere with fulfilling the job responsibilities. 3. Record for S3, employed 07/23/2023 did not contain employment references and information about any health problems that may interfere with fulfilling the job responsibilities. 4. Record for S4, employed 02/05/2023 did not contain: employment references; information about any health problems that may interfere with fulfilling the job responsibilities; and telephone number of a person to be notified in an emergency which shall be kept at the center. 5. Record for S5, employed 09/03/2023 did not contain employment references and information about any health problems that may interfere with fulfilling the job responsibilities. 6. Record for S7, employed 06/25/2023 did not contain: employment references; information about any health problems that may interfere with fulfilling the job responsibilities; and a telephone number of a person to be notified in an emergency which shall be kept at the center. 7. Record for S8, employed 08/06/2023 did not contain information about any health problems that may interfere with fulfilling the job responsibilities. 8. Record for S9, employed 08/20/2023 did not contain employment references and information about any health problems that may interfere with fulfilling the job responsibilities. 9. Record for S10, employed 02/19/2023 did not contain information about any health problems that may interfere with fulfilling the job responsibilities and a telephone number of a person to be notified in an emergency which shall be kept at the center. 10. Record for S11, employed 03/05/2023 did not contain information about any health problems that may interfere with fulfilling the job responsibilities”

8VAC20-780-90-A

“(Repeat violation) Based on review of ten children records, the provider did not ensure that four of ten children’s records contained a written agreement between the parents and the center shall be in each child’s record by the first day of the child’s attendance. Evidence: The records for C2, enrolled 09/18/2023, C6, enrolled 10/16/2023, C7, enrolled 08/14/2023, and C10 enrolled 11/28/2023 did not contain signed written agreements between the parents and the center.”

8VAC20-780-240-A

“(Repeat violation) Based on record review, the provider failed to ensure that staff shall complete the Virginia Department of Education-sponsored orientation course within 90 days of employment. Evidence: The record for S6, employed 09/03/2023 contained a certificate of completion of the Virginia Preservice Training dated 12/12/2023.”

22.1-289.035-B-2

“Based on record review, the provider failed to ensure that all applicants for employment shall submit to fingerprinting and undergo a national criminal background check prior to employment. Evidence: The record for staff S3, employed 07/23/2023 did not have results of a national criminal background check prior to the first day of employment. The results of the national criminal background check are dated 09/01/2023.”

8VAC20-780-410-1

“Based on review of documentation provided by the center and interview with center director, it was determined that staff roughly handled a child. Evidence: On November 9, 2023, S1 roughly handled a child by ?speaking in a negative tone to the child, and was standing on the child’s hair, restricting their movement.?”

8VAC20-780-260-A

“(Repeat violation) Based on interview, the center failed to provide an annual inspection report from the appropriate fire official having jurisdiction. Evidence: The center failed to have an annual fire inspection report inspection available for viewing during the inspection.”

8VAC20-780-270-A

“(Repeat violation) Based on observation, the provider did not ensure that all areas of the center be maintained in a clean, safe, and operable condition. Evidence: The black metal fence surrounding the playground had several loose panels and the garden fabric near the play structure tunnel was loose creating a tripping hazard.”

8VAC20-780-130-A

“Based on record review, the provider failed to ensure 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 C2, enrolled 09/18/2023 documented immunizations being received 12/22/2023.”

22.1-289.035-B-4

“Based on staff record review, the provider failed to obtain the results of a sex offender registry search, out of state criminal history name check, and out-of-state child abuse and neglect search from any state in which the individual has lived in the preceding five years. Evidence: The staff record for S5, employed 09/03/2023 documented S5 having lived out-of-state in two different states in the last five years. The record did not contain: a sex offender searches for one of the two states in which the individual lived in the preceding five years; the results of the two out-of-state child abuse and neglect searches; and the criminal history name check for two of the two states the individual lived in the preceding five years. Staff record for S6, employed 09/03/2023 documented S6 having lived out-of-state in the last five years. The record did not contain the results of a child abuse and neglect search.”

8VAC20-780-130-E

“Based on child record review, the provider failed to obtain documentation of additional immunizations once every six months for children under the age of two years. Evidence: The record for C4, under the age of 2, enrolled 06/06/2022 did not contain additional immunizations due within six months of immunizations in the record dated 12/06/2022. The record for C10, under the age of 2, enrolled 11/28/2022 did not contain additional immunizations due within six months of immunizations dated 01/24/2023.”

8VAC20-780-140-A

“Based on record review, the provider failed to ensure that each child shall have 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 C2, enrolled 09/18/2023 documented the physical examination being received 12/22/2023.”

8VAC20-780-550-P

“Based on review of the center’s written record of children serious or minor injuries the center failed to document the date and time when parents were notified of the injuries. Evidence: The written records for serious or minor injuries for C11 (12/06/2023), C12 (10/09/2023), C13 (10/03/2023), C14 (11/28/2023), C15 (11/29/2023), and C16 (11/22/2023 and 12/05/2023) did not document the date and time when parents were notified of the injuries.”

8VAC20-780-150-B

“Based on child record review, the provider failed to assure that each report of immunizations shall be signed by a licensed physician, the physician’s designee, or an official of a local health department. Evidence: The immunizations for C10 dated 01/24/2023 were not signed by the licensed physician, the physician’s designee, or an official of a local health department.”

8VAC20-780-70

“Based on staff record review, the provider failed to ensure that 10 of 11 records contained required information. Evidence: 1. Record for S1, employed 12/10/2023 did not contain information about any health problems that may interfere with fulfilling the job responsibilities. 2. Record for S2, employed 12/10/2023 did not contain employment references and information about any health problems that may interfere with fulfilling the job responsibilities. 3. Record for S3, employed 07/23/2023 did not contain employment references and information about any health problems that may interfere with fulfilling the job responsibilities. 4. Record for S4, employed 02/05/2023 did not contain: employment references; information about any health problems that may interfere with fulfilling the job responsibilities; and telephone number of a person to be notified in an emergency which shall be kept at the center. 5. Record for S5, employed 09/03/2023 did not contain employment references and information about any health problems that may interfere with fulfilling the job responsibilities. 6. Record for S7, employed 06/25/2023 did not contain: employment references; information about any health problems that may interfere with fulfilling the job responsibilities; and a telephone number of a person to be notified in an emergency which shall be kept at the center. 7. Record for S8, employed 08/06/2023 did not contain information about any health problems that may interfere with fulfilling the job responsibilities. 8. Record for S9, employed 08/20/2023 did not contain employment references and information about any health problems that may interfere with fulfilling the job responsibilities. 9. Record for S10, employed 02/19/2023 did not contain information about any health problems that may interfere with fulfilling the job responsibilities and a telephone number of a person to be notified in an emergency which shall be kept at the center. 10. Record for S11, employed 03/05/2023 did not contain information about any health problems that may interfere with fulfilling the job responsibilities”

8VAC20-780-90-A

“(Repeat violation) Based on review of ten children records, the provider did not ensure that four of ten children’s records contained a written agreement between the parents and the center shall be in each child’s record by the first day of the child’s attendance. Evidence: The records for C2, enrolled 09/18/2023, C6, enrolled 10/16/2023, C7, enrolled 08/14/2023, and C10 enrolled 11/28/2023 did not contain signed written agreements between the parents and the center.”

8VAC20-780-240-A

“(Repeat violation) Based on record review, the provider failed to ensure that staff shall complete the Virginia Department of Education-sponsored orientation course within 90 days of employment. Evidence: The record for S6, employed 09/03/2023 contained a certificate of completion of the Virginia Preservice Training dated 12/12/2023.”

22.1-289.035-B-2

“Based on record review, the provider failed to ensure that all applicants for employment shall submit to fingerprinting and undergo a national criminal background check prior to employment. Evidence: The record for staff S3, employed 07/23/2023 did not have results of a national criminal background check prior to the first day of employment. The results of the national criminal background check are dated 09/01/2023.”

8VAC20-780-270-A Complaint related: Yes

“Based on observation and interviews, the center did not ensure that areas and equipment of the center, inside and outside, were maintained in a clean, safe and operable condition. Evidence: 1.The fences located on the toddler/preschool playground had cracked and loose boards with gaps of 1-1 ? inches posing a risk for splitters. 2.The toddler/preschool playground had exposed tree roots throughout and an exposed pipe posing a trip hazard. 3.The toddler/preschool playground had a loose hand rail on the slide deck with chipped and missing wood. 4.The toddler/preschool playground had a lattice under the slide deck with loose wood and two exposed nails within the reach of children. 5.The pergola located on the toddler/preschool playground had a post with chipped and missing wood. 6.The storage shed on the toddler/preschool playground had rotted and missing wood. 7.The infant/toddler playground had a fence with a missing slate and an exposed nail. 8.Tree roots were exposed near the bridge for children on the infant/toddler playground posing a trip hazard.”

8VAC20-780-160-C

“Based on records review, and interview, the center failed to ensure that all staff submit documentation of a repeat tuberculosis screening at least every two years from the date of the initial screening or testing. Evidence: 1) The record for staff #5, date of employment 5/6/18, contained a tuberculosis screening dated 10/19/18. 2) The record for staff #10, date of employment 06/3/18, contained a tuberculosis screening dated 06/07/18. 3) When interviewed, administrators stated that the most recent tuberculosis screenings could not be located.”

8VAC20-780-240-A

“Based on records review, and interview, the center failed to ensure that the Virginia Department of Education (VDOE) sponsored orientation course is completed within 90 calendar days of employment. Evidence: The record for staff #3, date of employment 05/29/22, did not contain evidence of the VDOE orientation course being completed. When interviewed, Administration acknowledged that staff #3 had not completed the VDOE orientation course within 90 calendar days.”

8VAC20-780-40-E Complaint related: Yes

“Based on documentation review, and interview, the center failed to ensure that the center’s own policies and procedures are followed. Evidence: Documentation review and interview revealed that an evacuation drill occurred on 12/16/22 at 10:00 am. Interviews revealed that a 6-month-old infant was left alone in the building for approximately 1 minute. The center did not follow its own fire drill policy that states that the ?last teacher out should make sure that no children are left in the room.? Interview on 3/10/23 with staff #1, date of employment 1/4/18, and the Assistant Director confirmed that the center’s policy was not followed.”

8VAC20-780-340-F Complaint related: Yes

“Based on interview, and documentation review, the center failed to ensure that children under 10 years of age shall always be within actual sight and sound supervision of staff. Evidence: Documentation review and interviews revealed that an evacuation drill occurred on 12/16/22 at 10:00 am and classroom #1 had 7 children and 2 staff at that time. Interviews revealed that a 6-month-old infant was left alone in the building for approximately 1 minute and was found by the Assistant Director while doing a classroom sweep.”

8VAC20-780-160-C

“Based on records review, and interview, the center failed to ensure that all staff submit documentation of a repeat tuberculosis screening at least every two years from the date of the initial screening or testing. Evidence: 1) The record for staff #5, date of employment 5/6/18, contained a tuberculosis screening dated 10/19/18. 2) The record for staff #10, date of employment 06/3/18, contained a tuberculosis screening dated 06/07/18. 3) When interviewed, administrators stated that the most recent tuberculosis screenings could not be located.”

8VAC20-780-240-A

“Based on records review, and interview, the center failed to ensure that the Virginia Department of Education (VDOE) sponsored orientation course is completed within 90 calendar days of employment. Evidence: The record for staff #3, date of employment 05/29/22, did not contain evidence of the VDOE orientation course being completed. When interviewed, Administration acknowledged that staff #3 had not completed the VDOE orientation course within 90 calendar days.”

8VAC20-780-40-E Complaint related: Yes

“Based on documentation review, and interview, the center failed to ensure that the center’s own policies and procedures are followed. Evidence: Documentation review and interview revealed that an evacuation drill occurred on 12/16/22 at 10:00 am. Interviews revealed that a 6-month-old infant was left alone in the building for approximately 1 minute. The center did not follow its own fire drill policy that states that the ?last teacher out should make sure that no children are left in the room.? Interview on 3/10/23 with staff #1, date of employment 1/4/18, and the Assistant Director confirmed that the center’s policy was not followed.”

8VAC20-780-340-F Complaint related: Yes

“Based on interview, and documentation review, the center failed to ensure that children under 10 years of age shall always be within actual sight and sound supervision of staff. Evidence: Documentation review and interviews revealed that an evacuation drill occurred on 12/16/22 at 10:00 am and classroom #1 had 7 children and 2 staff at that time. Interviews revealed that a 6-month-old infant was left alone in the building for approximately 1 minute and was found by the Assistant Director while doing a classroom sweep.”

8VAC20-780-160-C

“Based on records review, and interview, the center failed to ensure that all staff submit documentation of a repeat tuberculosis screening at least every two years from the date of the initial screening or testing. Evidence: 1) The record for staff #5, date of employment 5/6/18, contained a tuberculosis screening dated 10/19/18. 2) The record for staff #10, date of employment 06/3/18, contained a tuberculosis screening dated 06/07/18. 3) When interviewed, administrators stated that the most recent tuberculosis screenings could not be located.”

8VAC20-780-240-A

“Based on records review, and interview, the center failed to ensure that the Virginia Department of Education (VDOE) sponsored orientation course is completed within 90 calendar days of employment. Evidence: The record for staff #3, date of employment 05/29/22, did not contain evidence of the VDOE orientation course being completed. When interviewed, Administration acknowledged that staff #3 had not completed the VDOE orientation course within 90 calendar days.”

8VAC20-780-40-E Complaint related: Yes

“Based on documentation review, and interview, the center failed to ensure that the center’s own policies and procedures are followed. Evidence: Documentation review and interview revealed that an evacuation drill occurred on 12/16/22 at 10:00 am. Interviews revealed that a 6-month-old infant was left alone in the building for approximately 1 minute. The center did not follow its own fire drill policy that states that the ?last teacher out should make sure that no children are left in the room.? Interview on 3/10/23 with staff #1, date of employment 1/4/18, and the Assistant Director confirmed that the center’s policy was not followed.”

8VAC20-780-340-F Complaint related: Yes

“Based on interview, and documentation review, the center failed to ensure that children under 10 years of age shall always be within actual sight and sound supervision of staff. Evidence: Documentation review and interviews revealed that an evacuation drill occurred on 12/16/22 at 10:00 am and classroom #1 had 7 children and 2 staff at that time. Interviews revealed that a 6-month-old infant was left alone in the building for approximately 1 minute and was found by the Assistant Director while doing a classroom sweep.”

8VAC20-780-270-A

“Based on observation, the center did not maintain equipment of the center in a clean, safe, and operable condition. Evidence: 13 out of 18 classrooms had cabinets that were broken and/or locks that were inoperable.”

8VAC20-780-550-E

“Based on a review of documentation, the center did not ensure to conduct two Shelter In Place drills per year. Evidence: The drill log listed fire and lock-down drills but it did not contain any shelter in place drills.”

8VAC20-780-90-A

“Based on a review of records, the center did not obtain a written agreement between the parent and the center. Evidence: 1 of 10 enrolled children’s records did not contain the written parent agreement.”

8VAC20-780-60-C

“Based on a review of records, the center did not document viewing proof of the child’s identity and age. Evidence: Two of ten enrolled children’s records viewed were missing documentation of reviewed proof of the child’s identity.”

8VAC20-780-260-A

“Based on a review of documentation, and interview, the center did not provide to the Licensing Inspector an annual fire inspection report. Evidence: The requested fire inspection report was not sent to the Licensing Inspector within the requested time frame.”

8VAC20-780-240-A

“Based on a review of records, the center did not ensure that the Virginia Department of Education (VDOE) sponsored orientation course was completed within 90 calendar days of employment. Evidence: 2 out of 10 staff records reviewed, staff #7 and staff #8 did not contain documentation of completion of the VDOE Orientation training course. The date of employment for Staff#7 was documented as 3/7/22. The date of employment for Staff #8 was documented as 2/21/22. All staff hired after 10/13/21 must complete the VDOE orientation course within 90 calendar days of employment.”

8VAC20-780-270-A

“Based on observation, the center did not maintain equipment of the center in a clean, safe, and operable condition. Evidence: 13 out of 18 classrooms had cabinets that were broken and/or locks that were inoperable.”

8VAC20-780-550-E

“Based on a review of documentation, the center did not ensure to conduct two Shelter In Place drills per year. Evidence: The drill log listed fire and lock-down drills but it did not contain any shelter in place drills.”

8VAC20-780-90-A

“Based on a review of records, the center did not obtain a written agreement between the parent and the center. Evidence: 1 of 10 enrolled children’s records did not contain the written parent agreement.”

8VAC20-780-60-C

“Based on a review of records, the center did not document viewing proof of the child’s identity and age. Evidence: Two of ten enrolled children’s records viewed were missing documentation of reviewed proof of the child’s identity.”

8VAC20-780-260-A

“Based on a review of documentation, and interview, the center did not provide to the Licensing Inspector an annual fire inspection report. Evidence: The requested fire inspection report was not sent to the Licensing Inspector within the requested time frame.”

8VAC20-780-240-A

“Based on a review of records, the center did not ensure that the Virginia Department of Education (VDOE) sponsored orientation course was completed within 90 calendar days of employment. Evidence: 2 out of 10 staff records reviewed, staff #7 and staff #8 did not contain documentation of completion of the VDOE Orientation training course. The date of employment for Staff#7 was documented as 3/7/22. The date of employment for Staff #8 was documented as 2/21/22. All staff hired after 10/13/21 must complete the VDOE orientation course within 90 calendar days of employment.”

8VAC20-770-40-D-6

“Based on review of five staff records and interview, the center did not ensure a required sworn statement and central registry finding check from an applicant, licensee, registrant, or other person required to obtain background checks was not dated more than 90 days prior to the date of employment, volunteering, or residing in the home. Evidence: 1. The record for staff #2, hired 08/22/2021, had documentation of a sworn statement dated 04/20/2021 and a central registry check dated 05/07/2021, both exceeding 90 days prior to hire. 2. Human resource staff #2 was delayed in starting employment while waiting to receive out of state background checks.”

22.1-289.035-B-2

“Based on a review of five staff records and interview, the center did not ensure one staff member completed a national fingerprint check prior to the first day of employment and within the required time frame. Evidence: 1. The national fingerprint check for Staff #2, hired 08/22/2021, was dated 04/26/2021 exceeding 90 days prior to employment. 2. Human Resource reported Staff #2 employment date was delayed based on waiting for out of state checks to be received and a new updated fingerprint was not conducted. 3. Fingerprint background check are required prior to hire and can not be any older than 90 days.”

8VAC20-780-440-G

“Based on observation and interview, the center did not ensure children under 12 months of age used a crib for sleeping. Evidence: 1. Child #5, age five months, was observed sleeping on a cot in the green room. 2. Staff stated he was tired and she placed him on a cot in the play area so she could see him while he slept.”

8VAC20-780-280-B

“Based on observation and interview, the center did not ensure hazardous materials such as cleaning products were kept in a locked place using a safe locking method that prevents access by children. Evidence: 1. Cleaning products were observed in the unlocked wall cabinet in two of the toddler classrooms. 2. Staff #1 stated the one cabinet had a broken latch and could not be locked.”