8VAC20-780-40-E · Repeat Violations:

The operational responsibilities of the licensee shall include ensuring that the center's activities and services are maintained in compliance with the center's own policies and procedures that are required by the standards. The center's discipline policy for child guidance, behavior and classroom management states, "The staff models positive behavior and uses methods of discipline which encourage self control, self-direction, self-esteem and cooperation among children displaying a respect for themselves, their environment, and others with whom they come in contact." It was reported that a child questioned ?am I a little baby? when talking about potty training. Staff #1 confirmed that they have called children in the preschool classroom ?a baby? due to children having toileting accidents.

Open Not marked corrected in the state record

Category: ratio. Open / not marked corrected.

8VAC20-780-40-E · Repeat Violation:

The operational responsibilities of the licensee shall include ensuring that the center's activities and services are maintained in compliance with the center's own policies and procedures that are required by the standards. The center's discipline policy for child guidance, behavior and classroom management states, "The staff models positive behavior and uses methods of discipline which encourage self control, self-direction, self-esteem and cooperation among children displaying a respect for themselves, their environment, and others with whom they come in contact." The policy also states, "Children are not subject to discipline which is severe, humiliating, or frightening." A belt was provided by the parent to staff #2 to assist in redirection of behavior for child #1, age three years. Staff #2 accepted the belt and kept the belt in the classroom for approximately two months. Child #1 was aware the belt was located at the center.

Open Not marked corrected in the state record

Category: ratio. Open / not marked corrected.

8VAC20-780-60-A-7 · A written care plan is required 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.

Child #5, who has been enrolled for three years, has a diagnosed food allergy on their physical examination and did not have a written care plan in their file.

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

22.1-289.035-B-3 · Repeat Violation:

The center must request a search of the central registry prior to the employee's first day of employment. Staff #4, who had been employed for one month, had a central registry search requested five days after first day of employment.

Open Not marked corrected in the state record

Category: background checks. Open / not marked corrected.

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 Staff #2, who is currently working, could not be located at the time of inspection.

Open Not marked corrected in the state record

Open / not marked corrected.

8VAC20-790-600-D-1 · Repeat Violation:

All staff work directly with children shall have within 90 days of the date of employment current certification in cardiopulmonary resuscitation (CPR). Staff #3 had a CPR certification that expired three months ago.

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

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.

Staff #5, who had been employed for one month, did not have documentation of a central registry search requested at the time of inspection.

Open Not marked corrected in the state record

Category: background checks. Open / not marked corrected.

8VAC20-780-40-E · Complaint:

The operational responsibilities of the licensee shall include ensuring that the center's activities and services are maintained in compliance with the center's own policies and procedures that are required by the standards. The center?s discipline policy for child guidance, behavior and classroom management states, ?The staff models positive behavior and uses methods of discipline which encourage self control, self-direction, self-esteem and cooperation among children displaying a respect for themselves, their environment, and others with whom they come in contact.? Staff #1 spoke to children on multiple occasions with a negative and forceful tone that did not model positive behavior when children were not listening. Leadership acknowledged that staff #1 broke behavior management policy protocol.

Open Not marked corrected in the state record

Category: ratio. Open / not marked corrected.

8VAC20-770-60-C-2 · For staff hired before July 1, 2024, providers must obtain the results of a central registry search for an employee, within 30 days of service.

Staff #4 did not have central registry search results during the inspection and has been employed for over eight months.

Open Not marked corrected in the state record

Category: background checks. Open / not marked corrected.

8VAC20-780-70 · Based on record review, the center did not ensure staff records contained required documentation for each staff.

Evidence: 1. The record of Staff 1 (DOH 01/11/2023) and Staff #2 (DOH 01/15/2024) did not contain documentation of VDOE-sponsored orientation course. 2. Leadership acknowledged the VDOE-sponsored orientation trainings were missing. 3. Staff #5 (DOH 05/10/2021) did not have documentation of completed 16 hours of annual training between May 2023 and May 2024. 4. Staff #6 (DOH 02/13/2017) did not have documentation of completed 16 hours of annual training between February 2023 and February 2024. 5. Leadership acknowledged the documentation of annual trainings were missing.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

8VAC20-790-600-D-1 · Based on record review and staff interview, the vendor did not ensure CPR is completed within 90 days of employment.

Evidence: 1. Staff #3 (DOH 03/07/2024) did not have CPR documentation. 2. Leadership acknowledged there was no certification in the staff file.

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

8VAC20-780-350-B-4 · Based on interview, the center did not ensure to follow the required staff to child ratios for children age three through school age eligible as required.

Evidence: 1. In interview, administration and staff stated that the preschool classroom had run out of ratio by several children for up to 10 minutes in the mornings due to short staffing. The staff to child ratio for the classroom is one staff to ten children. (1:10)

Open Not marked corrected in the state record

Category: ratio. Open / not marked corrected.

8VAC20-780-60-A · Repeat

Based on record review and interview, the center failed to ensure that the separate record for each child enrolled contains all of the elements as required by the standards. Evidence: 1.The record for Child #4, did not document the address of the two designated people to call in an emergency if a parent cannot be reached. 2.The record for Child #5 did not document the address for one person designated to call in an emergency if a parent cannot be reached.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

8VAC20-790-600-F · Based on review of staff records, the vendor did not ensure that each staff

complete annually the Virginia Annual Health and Safety Update Course sponsored by the Department. Evidence: 1. The record for Staff #3 (date of employment: 6/6/2022) contained documentation of the Virginia Annual Health and Safety Update Course dated 3/8/2022. 2. The record for Staff #4 (date of employment:7/6/2020) contained documentation of the Virginia Annual Health and Safety Update Course dated 4/21/21). 3. The record for Staff #7 (date of employment: 4/25/2018) did not contain documentation of the Virginia Annual Health and Safety Update Course being completed since the date of employment. 4. The record for Staff #8 (date of employment: 8/30/21) contained documentation of the Virginia Annual Health and Safety Update Course dated 7/23/2020.

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

8VAC20-780-40-E · Based on interviews with four staff and documentation review, the licensee failed to ensure operational responsibilities that the center?s activities and services are maintained in compliance with the standards and the center?s own policies and procedures required by the standards.

Evidence: 1. On 08/11/2023, Staff #2 self-reported an incident that occurred on 08/10/2023 where Staff #1 admitted to forcing Child #1(age 3) to rest in the bathroom during the designated rest period. 2. During an interview with Staff #4, it was stated, that Staff #1 admitted during a meeting with Staff #2 and Staff #4 on 8/11/2023 that she forced Child #1 to rest in the bathroom on 8/10/2023 because Child #1 was not listening. 3. During an interview with Staff #3, it was stated, that Staff #1 told her on 08/11/2023 that she forced Child #1 to rest on his cot in the bathroom on 08/10/2023 and stated, it was dark in there. 4. During an interview with Staff #5, it was stated that she was in the classroom with Child #1 on 08/10/2023 from approximately 12:30 pm-1:40 pm and Child #1?s cot had to be moved several times due to Child #1 being hard to put to nap. Staff #5, stated she left the classroom at approximately 1:40 pm when Staff #1 returned to the classroom. Staff #5 stated, she was surprised that Child #1 was asleep when she returned to the classroom and stated, Staff #1 told her, she slid Child #1?s cot into the bathroom. 5. The center?s policy for Child Guidance, Discipline and Classroom Management states, ?The purpose of discipline for young children is to teach coping skills and discourage inappropriate behavior. At The Learning Experience, the staff models positive behavior and uses methods of discipline which encourage self control, self direction, self esteem and cooperation among children displaying a respect for themselves, their environment and others whom they come in contact. Under no circumstances is any kind of abuse, physical punishment, deprivation or ridicule to be used as a form of discipline.?

Open Not marked corrected in the state record

Category: ratio. Open / not marked corrected.

8VAC20-780-140-A · Repeat

Based on record review, the center did not ensure one of six children?s records contained documentation of 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 (enrollment date: 7/6/21) did not document a physical examination.

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

8VAC20-790-600-D-1 · Based on record review, the vendor did not ensure all staff who work directly with children have within 90 days of the date of employment current certification in cardiopulmonary resuscitation (CPR) as appropriate to the age of the children.

Evidence: 1. The record of staff # 6 (employment date: 12/13/2022) did not have documentation showing that the staff has a current certification in cardiopulmonary resuscitation (CPR) as appropriate to the age of the children. 2. The record of staff #2 (employment date: 3/18/2022) and staff #4 (employment date: 11/17/2022) did not have documentation showing that the staff members have a current certification in cardiopulmonary resuscitation (CPR) as appropriate to the age of the children. 3. The record of staff # 7 (employment date: 11/24/2021) did not have documentation showing that the staff has a current certification in cardiopulmonary resuscitation (CPR) as appropriate to the age of the children. 4. The record of staff #8 (employment date: 10/24/2022) and staff #9 (employment date: 7/8/2022) did not have documentation showing that the staff members have a current certification in cardiopulmonary resuscitation (CPR) as appropriate to the age of the children.

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

8VAC20-770-60-B · Based on record review, the center did not ensure three of nine staff records contained documentation of a completed sworn statement or affirmation prior to employment.

Evidence: 1. The record of staff #1 (employment date: 4/13/2023) did not have documentation of a completed sworn statement or affirmation. 2. The record of staff #3 (employment date: 5/02/2023) did not have documentation of a completed sworn statement or affirmation. 3. The record of staff #7 (employment date: 11/24/2021) had documentation of a completed sworn statement or affirmation dated 11/29/2021.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

22.1-289.035-B-2 · Based on record review, the vendor did not ensure one of seven staff records contained documentation of fingerprint based national criminal history search results prior to employment.

Evidence: 1. The record of Household Member #2 (employment date: 12/12/2022) did not have documentation of fingerprint based national criminal history search results.

Open Not marked corrected in the state record

Category: background checks. Open / not marked corrected.

8VAC20-780-130-A · Based on a review of one child?s record and interview, the center did not ensure one child had received the immunizations required by the State Board of Health before the child attended the center.

Evidence: 1) The record for Child #1, date of attendance 07/28/22, did not contain documentation of the child?s immunizations. 2) During interview, Staff #1 confirmed the immunizations for Child #1 were not obtained before the child attended the center.

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

8VAC20-780-400-A · Based on interviews, the center did not ensure that in order to promote a child's physical, intellectual, emotional, and social well-being and growth, staff interacted with one another to provide needed help, comfort, support and promote ways of getting along.

Evidence: 1) Staff interviewed reported that on 06/29/22, Staff #4 was observed ?yelling? and ?raising her voice? in front of the children at other staff members when inquiring about a child?s injury (Child #2). 2) Staff interviewed reported that Staff #2 was observed saying ?profanities? and ?yelling? in front of the children after Staff #4 confronted the staff. 3) While in front of the children, Staff #2 was observed saying to Staff #4: ?You?re not going to talk to me like that. I can go the [expletive] home? and proceeded to leave the facility.

Open Not marked corrected in the state record

Open / not marked corrected.

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

Evidence: 1) The record of Staff #2, employed 05/23/22, did not contain the results of the central registry finding. 2) The record of Staff #6, employed 05/28/21, did not contain the results of the central registry finding. 3) During interview, management acknowledged the central registry finding for Staff #2 and Staff #6 were not on file. The records did not contain documentation of any further contact with the Office of Background Investigations, and the staff members had been continuously employed.

Open Not marked corrected in the state record

Category: background checks. Open / not marked corrected.

8VAC20-790-600-F · Based on a review of eight staff records, the vendor did not ensure five staff members completed the department's health and safety update course within the required timeframe.

Evidence: The following staff members did not complete the Virginia Annual Health and Safety Update Training for Child Care Staff within one year of vendor approval: Staff #3 (employed 05/28/21); Staff #4 (employed 05/28/21); Staff #6 (employed 05/28/21); Staff #7 (employed 05/28/21); and Staff #8 (employed 05/28/21). The staff should have completed the training no later than 06/04/2022.

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

8VAC20-770-60-B · Based on a review of one staff record, the center did not obtain a completed sworn statement or affirmation within the required timeframe.

Evidence: The sworn statement in the record for Staff #1, employed 05/28/21, was dated 06/01/21. A sworn statement is required to be obtained prior to employment.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

8VAC20-780-550-P · Based on documentation reviewed, the center did not maintain a written record of children?s serious and minor injuries with the required information.

Evidence: A sample of 11 incident reports written for Child #1 were reviewed. The following was not documented: 1) One written incident report reviewed did not include the date the injury occurred; the date and time when parents were notified; any future action to prevent recurrence of the injury; staff and parent signatures or two staff signatures; and documentation on how parent was notified. 2) Two written incident reports reviewed did not include the date and time when parents were notified; any future action to prevent recurrence of the injury; staff and parent signatures or two staff signatures; and documentation on how parent was notified. 3) Eight written incident reports reviewed did not include any future action to prevent recurrence of the injury; the date and time when parents were notified; and documentation on how parent was notified.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

22VAC40-665-530-7 · Based on a review of five staff records and interview, the vendor did not ensure two staff records contained all the required information.

Evidence: 1) The tuberculosis (TB) screening results in the record for Staff #4, hired on 09/08/2021, were dated 10/05/2021. 2) The tuberculosis (TB) screening results in the record for Staff #5, hired on 09/13/21, were dated 10/27/21. 3) During interview, a member of management acknowledged the TB results for Staff #4 and Staff #5 were not obtained at the time of employment and prior to staff coming into contact with children. Staff hired prior to 10/13/2021 were required to be evaluated by a health professional and be issued a statement that the individual is determined to be free of communicable tuberculosis (TB). Documentation of the screening shall be submitted at the time of employment and prior to coming into contact with children and such documentation was to be retained in the staff record.

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

22.1-289.035-B-2 · Based on a review of five staff records and interview, the center did not ensure that two out of five staff obtained fingerprint results prior to hire.

Evidence: 1) The record for Staff #1, hired on 11/07/21, had fingerprint results that were dated 11/09/21. 2) The record for Staff #2, hired on 11/13/21, had fingerprint results that were dated 11/18/21. 3) During interview, a member of management confirmed the fingerprint results for Staff #1 and Staff #2 were received after their hire date.

Open Not marked corrected in the state record

Category: background checks. Open / not marked corrected.