Lilly Grace LLC

8VAC20-780-210-A-4 · Program leaders shall have fulfilled a high school program completion or the equivalent

and have met one of the following experience and education requirements. Staff #2, identified as a program leader, was observed alone and supervising a group of children. Staff #2 was promoted to program lead on June 1, 2026, however staff #2 only has four months of supervised programmatic experience when six months of programmatic experience is required.

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22.1-289.035-B-3 · Repeat

The center must request a search of the central registry prior to the employee's first day of employment. 1. Staff #1, employed for six months and 28 days, did not have documentation the central registry was requested prior to employment. The results of the central registry had not been obtained as of December 16, 2025. Staff #1 was observed working alongside two staff members.

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22.1-289.035-B-1 · The center shall obtain a completed sworn statement prior to the employee's first

day of employment. Staff #2, employed for one year, seven months, did not have a completed sworn statement.

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8VAC20-780-160-A · Each staff member shall submit documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with the children. Staff #1, employed for three years, did not have documentation of a tuberculosis screening. The record of staff #3, employed for four months, did not have documentation of a tuberculosis screening.

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8VAC20-780-160-C · Based on review of staff records and interview, the center did not obtain the results of a follow-up tuberculosis screening at least every two years from the date of the initial screening or testing.

Evidence: The most recent tuberculosis screening for staff #1 was dated 07/10/2022, exceeding two years. The director stated a follow-up tuberculosis screening had not been done.

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8VAC20-780-245-A · Repeat

Based on review of eight staff records, the center did not ensure two staff annually completed a minimum of 16 hours of training appropriate to the age of children in care. Evidence: 1. The record of staff #1, employed 01/05/2015, contained documentation of 11 annual training hours for the period 01/05/2023 through 01/04/2024. Staff #1 was missing five hours of annual training. T2. he record of staff #8, employed 07/07/2007, contained documentation of eight annual training hours for the period 07/07/2022 through 07/06/2023. Staff #8 was missing eight hours of annual training. The owner acknowledged the two staff did not have the required 16 hours of annual training.

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8VAC20-780-40-E · Based on observation and review of the license, the licensee did not ensure operational responsibilities, including compliance with the terms of the current license issued by the department.

Evidence: 1. Upon the arrival of the licensing inspector on 01/24/2024, Nine toddler age children and seven children under the age of 16 months were observed in classroom #4. The current license stipulates: ?When infants are in room 4, a maximum of seven children may be present?. 2. During the inspection on 01/24/2024, the licensing inspector observed 16 infants playing on the floor in classroom #8. The current license stipulates: ?Room 8- (formerly rooms 2 & 3) - A maximum of 13 infants may be in care at any one time?.

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22.1-289.035-A · Based on review of eight staff records and interview, the center did not ensure one staff obtained up-dated background checks every five years.

Evidence: 1. The record for staff #4 (employed 02/19/2013) contained the results of a fingerprint national criminal record check dated 05/31/2018, exceeding five years. 2. The director confirmed the fingerprint national criminal record check for staff #4 had not yet been obtained

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22.1-289.035-A · Based on review of staff records, the center did not obtain a repeat background check every five years.

Evidence: The record of staff #5, employed 05/18/2015, did not contain the results of a current central registry background report..

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