Willow Tree Academy, LLC

8VAC20-780-130-E

“The center shall obtain documentation of additional immunizations once every six months for children under the age of two years. Child #1’s two year update is three months late.”

Rule 8VAC20-780-130-E.

22.1-289.035-A

“The center is required to have employees undergo a background check every five years. The most recent central registry check for staff #4 was overdue by a year and nine months.”

Rule 22.1-289.035-A.

8VAC20-820-120-E-3

“Notice of the superintendent’s intent to revoke or deny renewal of the license of a child day program will be provided by the department and shall be posted in a prominent place at each public entrance of the facility to advise consumers of serious or persistent violations. The notice was not posted at the time of the inspection.”

Rule 8VAC20-820-120-E-3.

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 center did not have a sworn statement for Staff #2, who is currently working.”

Rule 22.1-289.035-B-1.

22.1-289.035-B-4

“The center is required to obtain background checks from any state in which the individual has resided in the preceding five years. Staff #2, employed for one months, did not have documentation of a search of the sex offender registry search from a different state.”

Rule 22.1-289.035-B-4.

8VAC20-780-240-B

“Staff shall complete orientation training in subsection C of this section prior to the staff member working alone with children and no later than seven days of the date of assuming job responsibilities. The staff record did not contain documentation of staff 2 completing orientation training. The administrator verified staff 2 did not complete orientation. Staff 2 has been working with children at the facility for one month.”

Rule 8VAC20-780-240-B.

8VAC20-780-280-B

“REPEAT VIOLATION/SYSTEMIC DEFICIENCY Hazardous substances such as cleaning materials, insecticides, and pesticides shall be kept in a locked place using a safe locking method that prevents access by children. Gallons of paint, Zep glass cleaner, Pledge, Murphy Oil and other hazardous substances were on the floor and shelves in the hall closet. The closet was unlocked.”

Rule 8VAC20-780-280-B.

8VAC20-780-70

“Staff records shall be kept for each staff person and contain documentation that two or more references as to character and reputation as well as competency were checked before employment or volunteering. The record for staff 2, who has worked at the facility one month, did not have references.”

Rule 8VAC20-780-70.

8VAC20-780-210-A-4-a

“Within six months before being promoted or beginning work or one month after being promoted or beginning work, a minimum of 24 hours of training shall be received related to the care of children, including but not limited to: Preventing and reporting child abuse and neglect. Staff #2, promoted to program leader October 9, 2024 and observed as program leader of classroom #1 during the inspection, had not received this training.”

Rule 8VAC20-780-210-A-4-a.

8VAC20-780-510-F

“REPEAT VIOLATION/ SYSTEMIC DEFICIENCY The medication authorization shall be available to staff during the entire time it is effective. The center did not have parent or physician authorization for the medication for Child #1. The medication was at the center for four months.”

Rule 8VAC20-780-510-F.

8VAC20-780-80-A

“REPEAT VIOLATION For each group of children, the center shall maintain a written record of daily attendance that documents the arrival and departure of each child in care as it occurs. During the week of February 24, 2025, four classrooms did not maintain daily documentation of the departure of children and one classroom had documented arrival of a child who was not in attendance on that date.”

Rule 8VAC20-780-80-A.

8VAC20-780-510-F

“REPEAT VIOLATION SYSTEMIC VIOLATION The medication authorization shall be available to staff during the entire time it is effective. A medication prescribed to Child #3 was on site at the center; however, there was no medication authorization form for this medication.”

Rule 8VAC20-780-510-F.

8VAC20-780-550-P

“REPEAT VIOLATION The center shall maintain a written record of children’s serious and minor injuries in which entries are made the day of occurrence. The record shall include the following: Staff and parent signatures or two staff signatures. An injury report, found in the Preschool room, dated January 23, 2025 only contained one signature.”

Rule 8VAC20-780-550-P.

8VAC20-780-560-M

“No child shall be allowed to drink or eat while walking around. In staff #4’s classroom, three toddlers were observed walking around the classroom while drinking.”

Rule 8VAC20-780-560-M.

8VAC20-780-80-A

Rule 8VAC20-780-80-A.

8VAC20-790-530-C

“Records, reports, and information required may be kept as hard copy or electronically, except attendance records must be maintained as a written hard copy that records arrival and departure of each child in care as it occurs. The written attendance records for three rooms were not current and one classroom did not have a written attendance record.”

Rule 8VAC20-790-530-C.

8VAC20-780-270-A

“REPEAT VIOLATION Areas and equipment of the center, inside and outside, shall be maintained in a clean, safe and operable condition. Unsafe conditions shall include, but not be limited to, splintered, cracked or otherwise deteriorating wood; chipped or peeling paint; visible cracks, bending or warping, rusting or breakage of any equipment; head entrapment hazards; and protruding nails, bolts or other components that could entangle clothing or snag skin. In the infant room, the vinyl on the cushion climbing blocks/slide was peeling.”

Rule 8VAC20-780-270-A.

8VAC20-780-280-B

“REPEAT VIOLATION Hazardous substances such as cleaning materials, insecticides, and pesticides shall be kept in a locked place using a safe locking method that prevents access by children. In the 2’s room a cabinet was left unlocked with bottle of bleach solution in the cabinet.”

Rule 8VAC20-780-280-B.

8VAC20-780-50-A

“Staff and children’s records shall be treated confidentially. A child’s registration form, which contains confidential information, was posted on the transition classroom door in view of the public.”

Rule 8VAC20-780-50-A.

8VAC20-780-500-B

“REPEAT VIOLATION Disposable diapers shall be disposed in a leakproof or plastic-lined storage system that is either foot-operated or used in such a way that neither the staff member’s hand nor the soiled diaper touches an exterior surface of the storage system during disposal. The foot-operated trash can staff use to dispose of diapers was not working in the transition room. The trash can had diapers in it.”

Rule 8VAC20-780-500-B.

8VAC20-780-520-C

“Diaper ointment shall be inaccessible to children. In the transition room the diaper ointment was stored on an open shelf under the changing table accessible to children.”

Rule 8VAC20-780-520-C.

8VAC20-780-280-B

“REPEAT VIOLATION, SYSTEMIC VIOLATION Hazardous substances such as cleaning materials shall be kept in a locked place using a safe locking method that prevents access by children. A spray can of Febreze air freshener with warning label, ?Keep out of reach of children,? were unlocked on top of the paper towel holder in the hall bath used by children. Gallons of paint, Zep glass cleaner, Gorilla Contact Adhesive and other hazardous substances were on the floor and shelves in the hall closet. The closet was unlocked.”

Rule 8VAC20-780-280-B.

8VAC20-780-290-A-3

“In areas used by preschool age or younger children, electrical outlets shall have protective covers. An outlet in the Toddler room did not have a protective cover. The youngest child in care was 15 months.”

Rule 8VAC20-780-290-A-3.

8VAC20-780-40-M

“REPEAT VIOLATION, SYSTEMIC VIOLATION The center is required to keep a current list of all known allergies, sensitivities, and dietary restrictions in each room or area where children are present. The list must be dated and kept confidential. The posted list in the toddler room did not include one child’s dietary restriction.”

Rule 8VAC20-780-40-M.

8VAC20-780-430-I

“Combs, toothbrushes, or other personal articles shall be individually assigned. A child’s pacifier was not individually assigned.”

Rule 8VAC20-780-430-I.

8VAC20-780-440-B

“Cribs, cots, rest mats, and beds shall be identified for use by a specific child. In the infant room one crib was not labeled for a specific child and the crib was in use by an infant.”

Rule 8VAC20-780-440-B.

8VAC20-780-500-A

“Children’s hands shall be washed with soap and running water after toileting, or any contact with blood, feces or urine. Staff changed a child’s diaper in the toddler room and did not wash the child’s hands with soap and water afterwards.”

Rule 8VAC20-780-500-A.

8VAC20-780-560-J

“Tables shall be sanitized after each use for feeding. Children were observed playing at the tables after breakfast. The tables had spilled milk on them.”

Rule 8VAC20-780-560-J.

Based on record review and interview, the center failed to request a search of the central registry prior to employment of a new staff.

“Evidence: Staff 6, employed for a period of almost two months, was working alone in a classroom prior to the center requesting a search of the central registry.”

Rule 22.1-289.035-B-3.

Based on interview and document review, the center failed to obtain documentation of additional immunizations once every six months for children under the age of two years.

“Evidence: 1. A period of over nine months lapsed before the center obtained documentation of immunizations for child 6, less than two years of age.”

Rule 8VAC20-780-130-E.

Based on observation, the center failed to ensure areas and equipment of the center were maintained in a clean, safe and operable condition.

“Evidence: There were various areas of chipping paint and/or drywall thought the facility and the finish on multiple changing tables.”

Rule 8VAC20-780-270-A.

REPEAT VIOLATION, SYSTEMIC DEFICIENCY Based on observation, the center failed to ensure hazardous substances such as cleaning materials were kept in a locked place using a safe locking method that prevents access by children.

“Evidence: A storage closet, five classrooms, and four children’s restrooms contained multiple unlocked hazardous substances.”

Rule 8VAC20-780-280-B.

REPEAT VIOLATION Based on interviews, the center failed to ensure staff supervising children always provide care, protection, and guidance.

“Evidence: A three-year-old child was observed walking in the hall unsupervised near the kitchen. There were no staff present in the kitchen and the hallway door to the kitchen was open. A large pot containing boiling water with broccoli and a large pot containing a simmering substance were on the front burners of stove top.”

Rule 8VAC20-780-340-A.

Based on observation, interview, and record review, the center failed to ensure in each grouping of children at least one staff member who meets the qualifications of a program leader or program director is regularly present.

“Evidence: Staff in the transition room did not meet the qualifications of a program leader or program director.”

Rule 8VAC20-780-340-D.

Based on observation, the center failed to ensure children under the age of 10 are always within actual sight and sound supervision of staff.

“Evidence: 1. Staff 4 left four children unsupervised in the Junior PreK classroom, the youngest child was two-years-old and a three-year old child was observed walking unsupervised in the hallway. One child was observed standing on the edge of the top of a table. 2. Staff 8, PreK classroom youngest age three, left eight children alone in the classroom.”

Rule 8VAC20-780-340-F.

Based on observation, the center failed to ensure the staff-to-children ratio for 16 months to 24 months was one staff to five children whenever children are in care.

“Evidence: In the 2’s classroom, the youngest child (child 4) turns two in three months. The ratio was one staff to eight children.”

Rule 8VAC20-780-350-B-2.

Based on observation, the center failed to ensure the staff-to-children ratio for two-year-old’s is one staff to eight children whenever children are in care.

“Evidence: In the preschool classroom, the youngest child was two-years-old. There was one staff to 10 children.”

Rule 8VAC20-780-350-B-3.

SYSTEMIC DEFICIENCY Based on interview and document review, the center chose to assign a child to a different age group without a written assessment by the program director and program leader.

“Evidence: 1. The records for child 3, 4, 5, and 7 contained documentation requesting parental permission to move the child to the next developmental class based on completion of the Ages and Stages Questionnaire used to assess development; however, none of these records contained the written assessment, nor could the written assessments be provided by the center.”

Rule 8VAC20-780-350-Q.

Based on observation and interview, the center failed to maintain, in a way that is accessible to all staff who work with children, a current written, confidential list of all children’s allergies, sensitivities, and dietary restrictions documented in the allergy plan in each room or area where children are present.

“Evidence: The food allergies and sensitivities were posted in the transition room on the wall for anyone to see.”

Rule 8VAC20-780-40-M.

Based on observation, the center failed to dispose diapers in a leakproof or plastic-lined storage system that is either foot-operated or used in such a way that neither the staff member’s hand nor the soiled diaper touches an exterior surface of the storage system during disposal.

“Evidence: The foot-operated trash can staff use to dispose of diapers was not working in the Toddler 2’s room.”

Rule 8VAC20-780-500-B.

Based on observation, the center failed to ensure all nonprescription drugs and over-the-counter skin products shall be used in accordance with the manufacturer’s recommendations and shall not be kept or used beyond the expiration date of the product.

“Evidence: One diaper ointment was found to be expired.”

Rule 8VAC20-780-520-A.

Based on interview and record review, the center failed to ensure at least one CPR & first aid certified staff is present in each classroom at all times where children are present.

“Evidence: One classrooms did not have staff that has completed the hands on portion of CPR training.”

Rule 8VAC20-780-530-A.

Based on record review, the center failed to maintain a written record of children’s serious and minor injuries in which entries are made the day of occurrence and that have all the required information.

“Evidence: An injury report dated 8/28/24 did not contain the time parents were notified.”

Rule 8VAC20-780-550-P.

Based on interview and document review, the center failed to maintain a separate record for each child enrolled that contained the required information.

“Evidence: 1. The records for child 1, 2, 3, 4, 5, and 7 did not contain all required information.”

Rule 8VAC20-780-60-A.

Based on interview, a center staff failed to report suspected child abuse or neglect of a child in care immediately to the local Department of Social Services (DSS).

“Evidence: Staff 1 witnessed staff 2 shove a three year old child to the ground and failed to report the incident to the local DSS.”

Rule 63.2-1509-A. From a complaint.

Based on interviews, the center failed to ensure behavior guidance is constructive in nature, age and state appropriate, and is intended to redirect children to appropriate behavior and resolve conflicts.

“Evidence: The licensee confirmed that Staff 2 was observed getting in children’s faces and yelling at them since May. Staff 2 has been observed getting in children’s faces and yelling at them multiple times since May.”

Rule 8VAC20-780-400-B. From a complaint.

Based on observation and interview, the center failed to post a copy of the special order issued by the department in a prominent place at each public entrance of the licensed premises to advise consumers of serious or persistent violations.

“Evidence: The Special Order signed on 05/16/2024 was not posted in the center, as required.”

Rule 8VAC20-820-120-E-6. From a complaint.

Based on observation, the center failed to post the Notice of Intent issued by the department in a prominent place at each public entrance of the premises to advise consumers of serious or persistent violations.

“Evidence: An inspection of the facility was conducted. The Notice of Intent issued by the department on 03/28/2024 was not posted.”

Rule 22.1-289.023-A.

Based on record review and interview, the center failed to request out of state child abuse and neglect searches by the end of the 30th day of employment, failed to complete out of state sex offender registry searches by the first day of employment, and failed to obtain the results of an out of state criminal history name check.

“Evidence: The Sworn Statement completed by staff 8 (day of employment 2/5/24) indicated staff 8 lived in Colorado and Washington within the last five years. A sex offender registry search and child abuse and neglect searches were not completed for Colorado and Washington. A criminal history name check was not completed for Washington.”

Rule 22.1-289.035-B-4.

Based on record review, the center failed to obtain a physical examination and immunization record that is signed by a physician, his designee, or an official of a local health department.

“Evidence: Child 9’s immunization record and physical was not signed by a physician, his designee, or an official of a local health department.”

Rule 8VAC20-780-150-B.

(REPEAT VIOLATION) Based on observation, the center failed to ensure hazardous substances such as cleaning materials were kept in a locked place using a safe locking method that prevents access by children.

“Evidence: In the preschool classroom a spray bottle labeled bleach water was on an shelf.”

Rule 8VAC20-780-280-B.

Based on observation, the center failed to ensure time out was used sparingly and did not exceed one minute for each year of the child’s age.

“Evidence: When the licensing inspector arrived at 11:01 AM a child was seen sitting against the fence on the grass in time out on the playground. The child remained in time out until 11:09 AM. Per the teacher the child was four-years-old.”

Rule 8VAC20-780-400-C.

Based on documentation review, the center failed to ensure that the procedures for administering medication included all required components.

“Evidence: The center’s procedures for administering medication did not indicate that for nonprescription medication, the procedures shall be consistent with the manufacturer’s instructions for age, duration, and dosage, nor did it include methods to prevent use of outdated medications.”

Rule 8VAC20-780-510-E.

(REPEAT VIOLATION) Based on record review and interview, the center failed to have a medication authorization available to staff during the entire time it is effective.

“Evidence: The medication for child 10 did not have a parent authorization form.”

Rule 8VAC20-780-510-F.

(REPEAT VIOLATION) Based on observation, the center failed to ensure medication was kept in a locked place using a safe locking method that prevents access by children.

“Evidence: A child’s medication was observed in a zip lock bag on the top shelf of an open closet in the 2’s classroom.”

Rule 8VAC20-780-510-L.

(REPEAT VIOLATION)Based on interview and record review, the center failed to keep documentation to demonstrate that three lead teachers possess the education, certification, and experience required by the job position of lead teacher.

“Evidence: The records for staff 12 did not contain documentation to demonstrate that the staff possessed the education, certification, and experience to be lead teachers, as assigned by the job position.”

Rule 8VAC20-780-70.

Based on interview, the center failed to ensure care, protection, and guidance when supervising children.

Rule 8VAC20-780-340-A. From a complaint.

Based on interviews and record review, the center failed to ensure infants were fed on demand or in accordance with parental instructions.

“Evidence: 1. Staff 6 stated child 1 would normally take a bottle every 2 ? to 3 hours. Child 1 would drink two to three ounces out of each bottle. 2. Documentation and interviews indicate that child 1, age 7 months, was in care of the center from approximately 9:30 am ? 4:30 pm on 12/27/2023 and the only liquid the infant was provided during that time was two ounces of breastmilk. 3. Staff 2 stated she was not sure why they did not give child 1 more bottles.”

Rule 8VAC20-780-570-D. From a complaint.

Based on interview, the center failed to develop a written procedure for injury prevention.

“Evidence: The center was unable to provide a written procedure for injury prevention.”

Rule 8VAC20-780-40-I.

Based on observation and interview, the center failed to have a medication authorization available to staff during the entire time it is effective.

“Evidence: 1. Tylenol was found in the medication box in Toddler 3 classroom. There was no documentation with the Tylenol. 2. Staff 6 stated they could not find the form.”

Rule 8VAC20-780-510-F.

Based on observation, the center failed to keep medication in a locked place using a safe locking method that prevents access by children.

“Evidence: In two classrooms the medication box was located on the top shelf of a closet that has no door. Both medication boxes were unlocked. The box contained an albuterol inhaler in the Prek 2 classroom and the mediation box in the Toddler 3 classroom contained Tylenol.”

Rule 8VAC20-780-510-L.

Based on record review and interview, the center failed to obtain two or more references as to character and reputation as well as competency before employment.

“Evidence: 1. The record for staff 1 documents the employment date as 5/22/23. There was only one reference in the record. 2. The record for staff 5 documents the employment date as 5/30/23. There was no reference in the record. 3. Staff 6 verified the employment dates and the center did not have at least two references for staff 1 and staff 5.”

Rule 8VAC20-780-70.

Based on a review of the center’s policies and interview, the center failed to maintain compliance with their own policies and procedures required by these standards.

“Evidence: 1. The center’s written termination policy is “...a two-week written notice shall be given.” 2. Per interview with a parent and director, a child was terminated from care effective the end of the next day.”

Rule 8VAC20-780-40-E. From a complaint.

Based on interview, the center failed to ensure that the use of electronic smoking devices shall be prohibited in the interior of a center, in vehicles when children are being transported, and if permitted outside, shall be prohibited in the presence of children.

“Evidence: 1. Staff 1 stated that during breaks Staff 1 would smoke the electronic smoking device in the adult bathroom.”

Rule 8VAC20-790-640-E. From a complaint.

Based on observation, the center failed to ensure that hazardous substances were kept in a locked place using a safe locking method that prevents access by children.

“Evidence: 1. The two-year old classroom there was a bottle of Lysol Disinfectant Wipes sitting on a shelf above the sink. It was not in a locked location. 2. The Lysol Disinfectant Wipes stated to “keep out of reach of children”. 3. The three-year old classroom had an unlocked cabinet containing cleaning materials: sanitizing bleach water. The lock on the cabinet was observed to be broken and inoperable.”

Rule 8VAC20-780-280-B.

Based on record review and interview, the center failed to obtain an updated central registry background check five years since the previous central registry background check.

“Evidence: 1. The record for staff 5 contained a central registry background check dated 5/9/17. 2. The assistant director verified the 5/9/17 central registry background check is the most current one the center has.”

Rule 22.1-289.035-A.

Based on observation, the center failed to ensure a fan and cord was out of reach of children in a classroom.

“Evidence: In the 3’s and 4’s classroom (room 1), a pedestal fan was on the floor beside the children’s table with the cord in the children’s path. The fan was on and a child was seen touching the fan. The teacher quickly redirected the child.”

Rule 8VAC20-780-290-A-2.

Based on observation, the center failed to ensure the children’s allergy list is kept confidential in each room.

“Evidence: In the 2’s room (room 6), a child’s name and their allergy was posted on the mirror in the classroom above the sink.”

Rule 8VAC20-780-40-M.

Based on observation, the center failed to ensure diapers were disposed using a system that is either foot-operated or used in such a way that neither the staff member’s hand nor the soiled diaper touches an exterior surface of the storage system during disposal.

“Evidence: The foot pedal trashcan in the 2’s room (room 5) did not work. The trashcan had diapers in it. The director stated the trashcan broke the day before.”

Rule 8VAC20-780-500-B.

Based on observation and interview, the center failed to ensure the care and protection of children at all times.

Rule 8VAC20-780-340-A.

Based on observation, the findings of the most recent inspection of the facility was not posted.

“Evidence: 1. The most current inspection posted was 11/15/2021. 2. The last inspection conducted was on 04/28/2022.”

Rule 8VAC20-820-120-E-2.

Based on observation and discussion with staff, the center failed to ensure that children under 10 years of age shall always be within actual sight supervision of staff in one classroom.

“Evidence: 1. Staff #3 was seated in the doorway observing three children in the hallway and six children in front of Classroom A. 2. There were two children out of Staff #3’s sight and sound supervision in back of Classroom A due to classroom closet blocking her view. 3. Staff #3 stated was aware that she could not see the children in the back of Classroom A.”

Rule 8VAC20-780-340-F.

Based on observation and interviews, the center did not ensure that aides were at least 16 years of age.

Rule 8VAC20-780-220. From a complaint.

Based on interview and verification from staff the center did not ensure that aides were at least 16 years of age.

“Evidence: 1. Staff #1 stated that Staff #3 was currently employed by the center as an assistant. 2. Staff #2 verified that Staff #3 was employed and currently worked as an assistant in different classrooms the afternoons.”

Rule 22VAC40-185-220. From a complaint.