Right at School, LLC- Bethel Manor

8VAC20-780-130-A

“The center shall obtain documentation that each child has received the immunizations required by the State Board of Health before the child can attend the center. The record for Child #4 and Child #5 who had been attending for 3 weeks did not have documentation of immunizations.”

Rule 8VAC20-780-130-A.

8VAC20-780-40-J

“Repeat Violation Injury prevention procedures shall be updated at least annually based on documentation of injuries and a review of the activities and services. There was not annual update available to review.”

Rule 8VAC20-780-40-J.

8VAC20-780-550-P

“The center shall maintain a written record of children’s serious and minor injuries in which entries are made on the day of occurrence. Injury reports were reviewed and 4 out of 6 were missing information to include the date and time the parent was notified of the injury, and the second required signature.”

Rule 8VAC20-780-550-P.

8VAC20-780-140-A

“Physical examinations completed by a physician shall be obtained prior to the first day of attendance or within 30 days after the first day of attendance. There was no physical examination in the record of Child #1, who had been enrolled for 11 months and Child #7 who had been enrolled for 14 months.”

Rule 8VAC20-780-140-A.

8VAC20-780-150-B

“Repeat Violation Immunization records are required to be signed and dated by a physician, his designee, or an official of the local health department. The immunization records for Child #2, Child #4 and Child #7 were not signed. Child #2 has been enrolled for 11 months, Child #4 has been enrolled for 3 weeks, and Child #7 has been enrolled for 14 months.”

Rule 8VAC20-780-150-B.

8VAC20-780-420-E-3

“Staff shall request at least annually parent confirmation that the required information in the child’s record is up to date. Up-to-date information is required to be requested from the parent for each child’s record at least annually. The information in the record of Child #6 had not been updated in over 18 months which is overdue by 6 months and information for Child #7 had not been updated in over 14 months which is overdue by 2 months.”

Rule 8VAC20-780-420-E-3.

8VAC20-780-510-I

“Prescription medication may be administered if the parent has completed a written authorization. Three medications were administered to Child #8 without parent authorization. Medication A and medication B were administered 3 separate days in July and medication C was administered 2 separate days in July, the parent authorization on file had expired June 30, 2025.”

Rule 8VAC20-780-510-I.

8VAC20-780-510-P

“When an authorization for medication expires, the parent shall be notified that the medication needs to be picked up within 14 days or the parent must renew the authorization. Medications that are not picked up by the parent within 14 days will be disposed of by the center by either dissolving the medication down the sink or flushing it down the toilet. Child #6 had 2 medications (medication D and E) with an expired authorization by12 months, and the medication had not been sent home or disposed as required.”

Rule 8VAC20-780-510-P.

8VAC20-780-550-D

“The center shall implement a monthly practice evacuation drill. There was not documentation of drills conducted in April, May and June 2025.”

Rule 8VAC20-780-550-D.

8VAC20-780-60-A

“Repeat Violation The record for Child #1, enrolled for 11 months, was missing the second emergency contact name, their address and phone number.”

Rule 8VAC20-780-60-A.

8VAC20-780-70

“Documentation shall be kept at the center for each staff member regarding a name, address, and telephone number of a person to be notified in an emergency and any health problems that may interfere with fulfilling the job responsibilities. Staff #1, Staff #3, Staff #4, Staff #5, Staff #6 and Staff #7 did not have emergency contact information or health related information at the center.”

Rule 8VAC20-780-70.

8VAC20-790-600-F

“Staff who work directly with children shall annually complete the health and safety update course. Staff #4’s record did not contain documentation for the 2024 health and safety update course.”

Rule 8VAC20-790-600-F.

22.1-289.035-B-2

“Providers must obtain a completed national criminal background check prior to the employee’s first day of employment. Staff #4, was dated 11 days after their employment.”

Rule 22.1-289.035-B-2.

8VAC20-780-150-B

“Each immunization report shall include dates immunizations were received and shall be signed by a physician, his designee, or an official of a local health department. The record’s for child #1, 2, and 5 were not signed.”

Rule 8VAC20-780-150-B.

8VAC20-780-160-C

“A tuberculosis (TB) screening is required every two years from the last screening. Staff #2 updated screening was due 5 months ago.”

Rule 8VAC20-780-160-C.

8VAC20-780-40-M

“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 list was not dated and was not current because it was missing the name of a child with a known allergy.”

Rule 8VAC20-780-40-M.

8VAC20-780-550-E

“Shelter in place procedures shall be practiced a minimum of twice per year. There was no documentation of shelter in place drills being conducted in 2024.”

Rule 8VAC20-780-550-E.

8VAC20-780-60-A

“Centers must keep a separate record for each child enrolled that contains all of the required information. Child 2’s record was missing one custodial parent’s work phone number and the phone number of the child’s physician. Child 3’s record was missing both custodial parent’s work phone numbers.”

Rule 8VAC20-780-60-A.

Based on a review of 8 staff records and staff interviews, the vendor did not ensure staff completed who work directly with children shall have completed the departments health and safety update course.

“Evidence: Staff #3, Staff #5 and Staff #8 do not have the annual updated health and safety course.”

Rule 8VAC20-790-600-F.

Based on record review and staff interviews, the licensee did not ensure each staff member had completed orientation training in all required facility specific topics.

“Evidence: Staff #5 did not have documentation they had not obtained orientation training related to prevention of abusive head trauma.”

Rule 8VAC20-780-240-C.

(Repeat Violation) Based on a review of 8 staff records and staff interviews, the licensee did not ensure staff completed 16 hours of annual training.

“Evidence: Staff #5?s and Staff #8?s record did not include documentation of 16 hours of training.”

Rule 8VAC20-780-245-A.

Based on center documentation review and staff interview the licensee did not ensure the injury prevention procedures shall be updated at least annually based on documentation of injuries and a review of the activities and services.

“Evidence: Senior Program Manager confirmed they did not have an updated injury prevention plan.”

Rule 8VAC20-780-40-J.

Based on observation and staff interviews, the licensee did not ensure the center shall maintain, in a way that is accessible to all staff who work with children, a current written list of all children’s allergies, sensitivities, and dietary restrictions. This list shall be dated and kept confidential in each room or area where children are present.

“Evidence: The current written list of all children’s allergies, sensitivities, and dietary restrictions did not include the information for Child #2 who has a restriction of pork.”

Rule 8VAC20-780-40-M.

Based on review of documentation and staff interviews, the licensee did not ensure when an authorization for medication expires, the parent shall be notified the medication needs to be picked up within 14 days or the parent must renew the authorization. Medications that are not picked up by the parent within 14 days will be disposed of by the center by either dissolving the medication down the sink or flushing it down the toilet.

“Evidence: 1.Child #4 had a medication (Epi-pen) and the medication authorization designated expiration at the end of the 2023- 2024 school year . 2.Child #1 had a medication (Albuterol) and the medication authorization expired July 1, 2024. 3.These medications had not been sent home to the parents or disposed of as required.”

Rule 8VAC20-780-510-P.

Based on center documentation review and staff interviews, the licensee did not ensure the center shall maintain a written record of children’s serious and minor injuries in which entries are made the day of occurrence that includes all required information.

“Evidence: Injury reports were reviewed and 6 out of 7 were missing some information related to the date, time and how the parent was notified of the injury.”

Rule 8VAC20-780-550-P.

(Repeat Violation) Based on record review and staff interviews, the licensee did not ensure each center shall maintain and keep at the center a separate record for each child enrolled which shall contain all required information.

“Evidence: 1. Records for Child #7 and Child #6 did not include complete emergency contact information to include the city, state and zip code for the emergency contacts listed. 2. Records Child #1, #2, #3,#4,#5,#7 and #8 did not include proof of identity.”

Rule 8VAC20-780-60-A.

Based on record review and licensee interviews, the licensee did not ensure to a obtain the out of state criminal records check prior to employment. The out of state background checks are required for any person who has lived outside of Virginia within the last five years.

“Evidence: Staff #4?s criminal record results ( CRC ) for Texas was dated 11-27-23 after employment began. Staff #2 began employment on 11-8-23.”

Rule 22.1-289.035-B-4.

Based on a record review and staff interviews, the licensee did not ensure staff obtained a minimum of 16 hours of annual training related to the care of children.

“Evidence: The records for Staff #1 and Staff #4 did not include documentation of 16 hours of training.”

Rule 8VAC20-780-245-A.

Based on staff interviews and review of documentation, the licensee did not ensure to maintain documentation of monthly emergency evacuation drills.

“Evidence: Staff #4 confirmed they did not have documentation of evacuation drills conducted in December 2023.”

Rule 8VAC20-780-550-G.

Repeat Violation Based on record review and staff interviews, license did not ensure that children’s records contained all required information.

“Evidence: The record for Child #3 was missing the employment phone numbers for both parents listed, the name, phone number and address for second emergency contact and the previous programs attended.”

Rule 8VAC20-780-60-A.

Repeat Violation Based on record review and staff interviews, the licensee did not ensure each staff record contained all required documentation.

“Evidence: The record for Staff #4, (designated Program Director) did not include documentation to demonstrate they possess the education, and certification required by the job position.”

Rule 8VAC20-780-70.

8VAC20-790-600-F

“Based on staff record review and staff interviews, the vendor did not ensure that staff who work directly with children shall have completed the departments health and safety update course. Evidence: The record for Staff #3 did not include the required annual 3-hour health and safety update course. The most recent was dated 2-19-2017.”

Rule 8VAC20-790-600-F.

8VAC20-780-150-B

“Based on record review and provider interview, the licensee did not ensure the physical examination and dates of immunizations shall include the signature of a physician, his designee, or an official of a local health department Evidence: The immunization documents in the record for Child #4 did not include a physician or designated individual’s signature.”

Rule 8VAC20-780-150-B.

8VAC20-780-60-A

“Based on record review and staff interviews, license did not ensure that children’s records contained all required information. Evidence: The following records were missing information as listed below; 1.Child #2 was missing the city, state, and zip code for both emergency contacts listed. 2.Child #3 was missing the physicians phone number and the phone number for one emergency contact listed.”

Rule 8VAC20-780-60-A.

8VAC20-780-70

“Based on record review and staff interviews, the licensee did not ensure each staff record contained all required documentation. Evidence: The record for Staff #3, (designated as a program leader/educator ) did not include documentation to demonstrate they possess the education, certification, and experience required by the job position.”

Rule 8VAC20-780-70.

Based on record review, the licensee did not ensure each staff member submit documentation of a negative tuberculosis screening have been completed within the last 30 calendar days of the date of employment and be signed by a physician, physician’s designee, or an official of the local health department.

“Evidence: Staff#1 hire date was 06/3/2022 and tuberculosis screening was completed 06/06/2022. Staff #2 hire date was 03/24/2023 and tuberculosis screening was completed 03/29/2023.”

Rule 8VAC20-780-160-A.

Based on record review and staff interviews, the licensee did not ensure child ratio was maintained for the children, school age elgible up to 9 years - ratio 1:18.

“Evidence: The head count sheets and observation maintained by the center for the morning program revealed that the center did not meet the required staff-to-children ratio on the following date: On April 25, 2023, from 7:30am- 8:30am, two staff were present upon arrival with 38 children and by the time children were dismissed to school their was 53 children with 2 staff . Confirmed with Staff.”

Rule 8VAC20-780-350-B-5.

Based on observation and record review, the licensee did not ensure allergy list was updated.

“Evidence: Child #1 had an allergy and was not listed on the allergy list.”

Rule 8VAC20-780-40-M.

Based on record review , the licensedi did not ensure 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.

“Evidence: Child #1 had a doctor diagnosed allergy and did not have written care plan from physician.”

Rule 8VAC20-780-60-A-8.

Based on record review, the licensee did not ensure all staff with in 90days have a current cpr and first aid.

“Evidence: Staff #1 hire date was 06/03/2022 documents provided did not documentaiton of CPR and First Aid. Staff #1 has been employed for more than 30 days.”

Rule 8VAC20-790-600-D-1.

8VAC20-770-60-C-2

“Based on staff interview and record review, the licensee did not ensure central registry findings with in 30days of employment. Evidence: During the time records were requested Staff#2 hire date 08/15/2022 did not have central registry results.”

Rule 8VAC20-770-60-C-2.

Based on record review and staff interview, the licensee did ensure staff obtained a tuberculosis screening reults prior to working with children and within 30 day prior from employment date.

“Evidence: Staff #1 hire date 06/03/2022, results of tuberculosis test was completed 06/06/2022. Staff #2 hire date 08/15/2022 results , results of tuberculosis test was completed 09/30/2022.”

Rule 8VAC20-780-160-A.

Based on observation and staff interview, the licensee did not ensure any child for whom emergency medication have been prescribed shall always be in the care of a staff member or independent contractor who is MAT certified.

“Evidence: On September 29, 2022, the three staff present were not certified in Medication Administration (MAT) training and would not be able to administer the emergency medication. Child #1 and Child #2 were both present and had emergency meducation on site during the inspeciton.”

Rule 8VAC20-780-245-J-3.

Based on record review and staff interview, the licensee did not enusre there were at least one staff member on duty who has obtained with the last three years instruction in performing the daily health observation.

“Evidence: Upon arrival staff #2 and staff #3 were present and there was no staff that was on duty with the daily health observation training. Staff #1 arrived at 6:50 am did not have Daily Health Observation. The staff records provided did not have documentaiton of daily health observation for the three staff present during the inspection.”

Rule 8VAC20-780-245-L.

8VAC20-780-40-K

“Based on interview, the licensee did not ensure there was written procedures for prevention of abusive head trauma. Evidence: Confirmed by administrative staff that the facility did not have written procedures for abusive head trauma.”

Rule 8VAC20-780-40-K.

Based on staff interview and record review, the licensee did not ensure there was a dated allergy list.

“Evidence: The allergy list provided during the inperson inspection was not dated.”

Rule 8VAC20-780-40-M.

Based on record review, the licensee did not ensure there was at least one staff in each classroom with current certification in cardiopulmonary resuscitation (CPR).

“Evidence: During the inspection conducted and remote record review, staff #1, staff #2 and staff #3 did not have current certification in cardiopulmonary resuscitation (CPR). Staff #1, staff #2 and staff #3 were the only staff at the facility.”

Rule 8VAC20-780-530-A-1.

Based on record review, the licensee did not ensure there was at least one staff in each classroom with current certification in first aid from an organization such as the American Red Cross, American Heart Association, American Safety and Health Institute, or National Safety Council.

“Evidence: During the inspection conducted and remote record review, staff #1, staff #2 and staff #3 did not have current certification in in first aid. Staff #1, staff #2 and staff #3 were the only staff at the facility.”

Rule 8VAC20-780-530-A-2.

Based on record review and staff interview, the licensee did not have record of dates of the practice emergency drills.

“Evidence: There was not emergency drill documentation available at the center during the inperson insepection for the months of March , April , May and June 2022.”

Rule 8VAC20-780-550-H.

Based on record review, the licensee did not ensure injury report obtained all required informaiton.

“Evidence: Child #3 injury report did not obtain time parent was contacted , date parent was contacted and how parent was contacted. Staff #1 confirmed the information was not on the injury report.”

Rule 8VAC20-780-550-P.

Based on record review and staff interview, the licensee did not ensure staff records obtained on site the following name, address, and telephone number of a person to be notified in an emergency.

“Evidence : Staff #4 confirmed staff #2 and staff #3 did not have emergency contact information at the center.”

Rule 8VAC20-780-70.

Based on record review and licensee interviews, the licensee did not ensure to a obtain a sex offender check prior to the end of the 30th day of employment /service for new agents/board officers. The out of state background checks are required for any person who has lived out side of Virginia within the last five years.

“Evidence: Area Manager confirmed, there was not criminal record result available for review for Agent #1 who lived in New Jersey within the last five years. Agent #1, start date 1-1-2022.”

Rule 22.1-289-036-B-4.

Based on record review and licensee interviews, the licensee did not ensure to a obtain a criminial record check prior to employment. The out of state background checks are required for any person who has lived out side of Virginia within the last five years.

“Evidence: Staff #1 hire date 10/26/2021. Staff #1 lived out of state (Alaska) in the past 5 years. The center was unable to provide criminal record results . Out state criminial record results should be completed prior to employment.”

Rule 22.1-289.035-B-4.

Based on record review and licensee interviews, the licensee did not ensure to a obtain criminal records check prior to the end of the 30th day of employment /service for new agents/board officers.

“Evidence: Area Manager confirmed, the criminal record results available for Agent #1 was dated 2-14-2022 and the start date for Agent #1 was 1-1-2022.”

Rule 22.1-289.036-B-2.

Based on record review and licensee interviews, the licensee did not ensure to a obtain a copy of the results of a search of the central registry ( CPS ) by the end of the 30th day of employment /service for new agents/board officers.

“Evidence: Area Manager confirmed, the CPS check for Agent #1 was submitted on 2-12-2022 and Agent #1 start date was 1-1-2022. CPS results were not available for review for Agent #1.”

Rule 8VAC20-770-40-C-1-b.

Based on record review, the licensee did not ensure there was 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.

“Evidence: Child #1 had a doctor diagnosed allergy, but did not have a written care plan for a diagnosed food allergy from a physician.”

Rule 8VAC20-780-60-A-8.

Based on record review, the licensee did not ensure that each staff record obtained all required documents.

“Evidence: Staff #1 record did not obtain documentation of 2 or more references, verification of age , job title and education.”

Rule 8VAC20-780-70.

Based on record review, the licensee did not ensure a copy of the results of a search of the child abuse and neglect registry or equivalent registry from any state in which the individual has resided in the preceding five years.

“Evidence: Staff #1 hire date 08/30/2021 ,there was no results or documentation that a out of state search of the child abuse and neglect registry for the state of California was completed.”

Rule 22.1-289.035-B-4.

Based on record review, the licensee did not ensure a annual fire inspection is completed.

“Evidence: The fire inspection provided during the inspection was dated 11/06/2020. The fire inspection is more than a year old.”

Rule 8VAC20-780-260-A.