Virginia Commonwealth University Health System Authority -N Deck

When staff are supervising children, they shall always ensure their care, protection, and guidance.

“On 03/30/2026, Child #1, age six months, sustained an injury to the arm when the child was not properly supported while being placed on a boppy pillow. The injury required outside medical attention.”

Rule 8VAC20-780-340-A.

The centers procedures for administering medication shall include methods to prevent use of outdated medication.

“The center did not have procedures that prevent use of outdated medication. The medication for child #16 had expired over one month ago.”

Rule 8VAC20-780-510-E.

Repeat Violation: Areas and equipment of the center, inside and outside, shall be maintained in a clean, safe and operable condition.

“In classroom #2, a section of the wall near the sink was peeling paint where children were observed.”

Rule 8VAC20-780-270-A.

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 classroom #11, cleaning materials were on the counter near the toilet, accessible to children. In classroom #12, a cabinet with bleach was unlocked.”

Rule 8VAC20-780-280-B.

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.”

Rule 22.1-289.035-B-2.

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.”

Rule 8VAC20-780-160-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.”

Rule 8VAC20-780-270-A.

The centers procedures for administering medication includes methods to prevent use of outdated medication.

“The medication for child #15 had expired one month ago.”

Rule 8VAC20-780-510-E.

8VAC20-780-130-E

Rule 8VAC20-780-130-E.

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.”

Rule 22.1-289.035-B-2.

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.”

Rule 22.1-289.035-B-4.

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.”

Rule 8VAC20-780-130-A.

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.”

Rule 8VAC20-780-130-E.

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.”

Rule 8VAC20-780-140-A.

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.”

Rule 8VAC20-780-150-B.

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.”

Rule 8VAC20-780-240-A.

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.”

Rule 8VAC20-780-260-A.

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.”

Rule 8VAC20-780-270-A.

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.?”

Rule 8VAC20-780-410-1.

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.”

Rule 8VAC20-780-550-P.

8VAC20-780-70

Rule 8VAC20-780-70.

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.”

Rule 8VAC20-780-90-A.

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.

Rule 8VAC20-780-270-A. From a complaint.

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.”

Rule 8VAC20-780-160-C.

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.”

Rule 8VAC20-780-240-A.

8VAC20-780-340-F

“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.”

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

8VAC20-780-40-E

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

8VAC20-780-240-A

Rule 8VAC20-780-240-A.

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.”

Rule 8VAC20-780-260-A.

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.”

Rule 8VAC20-780-270-A.

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.”

Rule 8VAC20-780-550-E.

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.”

Rule 8VAC20-780-60-C.

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.”

Rule 8VAC20-780-90-A.

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.”

Rule 22.1-289.035-B-2.

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.”

Rule 8VAC20-770-40-D-6.

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.”

Rule 8VAC20-780-280-B.

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.”

Rule 8VAC20-780-440-G.