22.1-289.035-B-3 · The center must request a search of the central registry prior to the employee's first day of employment. 1. Staff #1, employed for two months and 17 days, did not have documentation the central registry was requested prior to employment. The results of the central registry were received 9/16/2025. 2. Staff #3, employed for one month and 20 days, did not have documentation the central registry was requested prior to employment. The results of the central registry were received 10/29/2025. Staff #5, employed for seven months and 18 days, did not have documentation the central registry was requested prior to employment. The results of the central registry were received 03/31/2025.

Open Not marked corrected in the state record

Category: background checks. Open / not marked corrected.

22.1-289.035-A · Repeat

The center is required to have employees undergo a background check every five years. The central registry background check for staff #4 was overdue by six months.

Open Not marked corrected in the state record

Category: background checks. Open / not marked corrected.

8VAC20-780-60-A-8 · Each center shall maintain and keep at the center a separate record for each child enrolled which shall contain 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.

The record of child #7, diagnosed with a food allergy, did not contain a written allergy care plan.

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

8VAC20-770-60-B · Based on a review of five staff records and interviews, the center did not ensure one staff had a completed sworn statement or affirmation prior to employment.

Evidence: The sworn statement in the record of Staff #4, employed on 09/18/23, was completed on 10/06/23. During interview, a member of management reported Staff #4 completed the incorrect form at the time of employment and a new sworn statement was completed on 10/06/23. Documentation of the previous form could not be located.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

8VAC20-780-550-P · Based on record review, the child day center did not maintain a written record of children's injuries that contained all required information.

Evidence: 1.The record for Child #1 documented incident reports dated 8/21/23 and 8/23/23. 2.The 8/23/23 incident report did not contain the date and time that the parent was notified of the injury and documented the signature of one staff. A second staff signature or parent signature was required. 3. The 8/21/23 and 8/23/23 incident reports did not document future action to prevent recurrence of the injuries.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

22.1-289.035-A · Based on review of staff records and interview, the center did not ensure a repeat criminal history check was completed every five years.

Evidence: The record for Staff #11 (date of hire: 7/17/2013) documented a criminal history check dated 6/27/18 which is beyond 5 years. No additional information was provided.

Open Not marked corrected in the state record

Category: background checks. Open / not marked corrected.

8VAC20-790-600-D-1 · Based on a review of five staff records and interview, the vendor did not ensure one staff had current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care within 90 days of the date of employment.

Evidence: 1) The CPR certification in the record of Staff #5, employed on 09/12/22, was obtained on 03/08/23. 2) During interview, a member of management confirmed Staff #5 did not have current certification in CPR within 90 days of the date of employment.

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

8VAC20-770-60-C-2 · Based on a review of five staff records and interview, the center did not ensure one staff member had a central registry finding within 30 days of employment.

Evidence: 1) The central registry finding in the record of Staff #5, employed on 09/12/22, was dated 11/03/22. 2) During interview, a member of management confirmed the results of the central registry for Staff #5 were received more than 30 days after employment. The record did not contain documentation of any further contact with the Office of Background Investigations, and the staff member had been continuously employed.

Open Not marked corrected in the state record

Category: background checks. Open / not marked corrected.

8VAC20-770-60-C-2 · Based on a review of five staff records and interview, the center did not ensure one staff member had a central registry finding within 30 days of employment.

Evidence: 1) The record of Staff #2, employed on 05/23/22, did not contain the results of a central registry finding. 6) During interview, management confirmed the central registry findings were not received within 30 days of employment for Staff #2. The record did not contain documentation of any further contact with the Office of Background Investigations, and the staff member had been continuously employed.

Open Not marked corrected in the state record

Category: background checks. Open / not marked corrected.

8VAC20-790-600-D-1 · Based on a review of five staff records and interview, the vendor did not ensure one staff member who works directly with children had current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care.

Evidence: 1) The record for Staff #4, employed on 08/01/22, had a CPR certification that expired on 11/20/22. 2) During interview, management confirmed the CPR certification for Staff #4 was expired.

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.