The Cottage School

***Repeat Violation*** Staff shall complete the departments health and safety update course annually.

“Staff #3 did not have documentation of completing the annual health and safety update course which was overdue by 35 days.”

Rule 8VAC20-790-600-F.

The center shall obtain documentation of additional immunizations once every six months for children under the age of two years.

“The record for child #3 did not have additional immunizations, which were due on 4/30/24, 10/30/24, and 4/30/25. 2. The record for child #4 did not have additional immunizations, which was overdue by 58 days.”

Rule 8VAC20-780-130-E.

A tuberculosis (TB) screening is required every two years from the last screening.

“The updated screening for Staff #2 was due seven days ago.”

Rule 8VAC20-780-160-C.

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

“1. A crack in the wall with peeling paint was within reach of children in the toddler room. 2. On the playground, the mud kitchen had a missing knob leaving the head of the nail sticking out. The wooden playhouse had several screws sticking out toward the inside of the playhouse. The wooden clubhouse had rough jagged wood edges and warped boards. 3. In bathroom #1, a chair with a blue vinyl covering was torn.”

Rule 8VAC20-780-270-A.

***Systemic Deficiency*** Hazardous substances must be in a locked place that prevents access by children.

Rule 8VAC20-780-280-B.

Where playground equipment is provided, resilient surfacing shall comply with minimum safety standards.

“The playground rock climbing wall for children had less than 6 inches of required resilient surfacing under and around the climbing equipment and fall zones.”

Rule 8VAC20-780-330-B.

The operational responsibilities of the licensee shall include ensuring that the center’s activities, services, and facilities are maintained in compliance with these standards, the center’s own policies and procedures that are required by these standards, and the terms of the current license issued by the department.

“The stipulations shown on the face of the license states the following: 1. In accordance with the Certificate of Occupancy: Children 2 ? years and less may only be in the two first floor classrooms with direct access to the exterior of the building and public way. 2. On the first floor, two additional classrooms were observed with children under 2 ? years of age. Room #5 had 11 children ages 2 years to 2 ? years. Room #7 had four children ages 12 months to 16 months.”

Rule 8VAC20-780-40-E.

***Repeat Violation Systemic Deficiency*** Medication shall be labeled with child’s name, the name of the medication and dosage amount, and times to be given.

“Child B had emergency medication at the center. The medication was not labeled with the child’s name, the name of the medication and dosage amount, and times to be given.”

Rule 8VAC20-780-510-G.

***Repeat Violation Systemic Deficiency*** 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 B had over the counter medication which expired 11/2025 and the medication had not been returned to the parents.”

Rule 8VAC20-780-510-P.

At least one staff in each classroom or area where children are present shall have current certification in both CPR and first aid.

“Staff #5 was alone with a group of six children (ages 4 yrs to 5 yrs) and was not certified in CPR or first aid.”

Rule 8VAC20-780-530-A.

A first aid kit must contain all required items.

“The first aid kit did not include one of the two triangular bandages.”

Rule 8VAC20-780-540-C.

The center shall implement a monthly practice evacuation drill.

“The center did not implement a monthly practice evacuation drill for December 2025.”

Rule 8VAC20-780-550-D.

Staff records shall be kept for each staff person and contain all required information.

“The record for Staff #1, identified as program leader, did not include documentation of educational requirements. Staff #1 was working alone with children.”

Rule 8VAC20-780-70.

***Systemic Deficiency*** All staff who work directly with children shall have within 90 days of the date of employment, current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care.

“1. Staff #2, employed for over two years, did not have current CPR certification. 2. Staff #4, employed for over one year, did not have current CPR certification. 3. Staff #5, employed for over one year, did not have current CPR certification.”

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

***Systemic Deficiency*** All staff who work directly with children shall have within 90 days of the date of employment, current certification in first aid appropriate to the ages of children in care.

“1. Staff #2, employed for over two years, did not have current first aid certification. 2. Staff #4, employed for over one year, did not have current first aid certification. 3. Staff #5, employed for over one year, did not have current first aid certification.”

Rule 8VAC20-790-600-D-2.

***Repeat Violation*** Staff who work directly with children shall annually attend at least 16 hours of training and staff development activities, to include the department’s health and safety update course.

“1. Staff #1 did not have a completed annual health and safety update course for 2026 and was overdue by 17 days. 2. Staff #4 did not have a completed annual health and safety update course for 2025. 3. Staff #5 did not have a completed annual health and safety update course for 2025.”

Rule 8VAC20-790-600-F.

The center shall maintain a written record of children’s serious and minor injuries in which entries are made the day of occurrence to include all of the required elements.

“1. Five of 12 written injury reports did not include the date and time a parent was notified. 2. Three of 12 written injury reports did not include documentation of staff and parent signatures or two staff signatures. 3. One of 12 written injury reports did not include documentation of any future action to prevent recurrence of the injury.”

Rule 8VAC20-780-550-P. From a complaint.

Whenever the center has agreed to administer prescribed medications, the administration shall be performed by a staff member who has completed a training and are required to be retrained at three- year intervals.

“There were no staff members on site that were certified to administer emergency medications.”

Rule 8VAC20-780-245-J.

The center shall ensure that areas and equipment of the center, inside and outside, are maintained in a clean, safe and operable condition.

“In room #3, a crack in the wall exposed rough edges.”

Rule 8VAC20-780-270-A.

The operational responsibilities of the licensee shall include ensuring that the center’s activities, services, and facilities are maintained in compliance with these standards, the center’s own policies and procedures that are required by these standards, and the terms of the current license issued by the department.

“1. The center’s medication policy states that “The center will not be responsible for administering medications except those that are necessary to address emergency needs and these will be monitored monthly by the Director to ensure they are in date.? 2. Child C had emergency medication that expired October 2025 and the medication had not been returned to the parents.”

Rule 8VAC20-780-40-E.

Children’s hands shall be washed with soap and running water after toileting and any contact with blood, feces, or urine. Staff shall wash their hands with soap and running water before and after helping a child use the toilet.

“In room #2, a staff member changed a child’s diaper and did not wash the child’s hands and the staff member did not wash their hands once diapering was completed.”

Rule 8VAC20-780-500-A.

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.

“In bathroom #1, there was not a trashcan or disposal system that had a lid as required for soiled disposable diapers. Diapers and/or pull ups were observed in the trash can.”

Rule 8VAC20-780-500-B.

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 B had over the counter medication authorization which expired 10/27/25 and the medication had not been returned to the parents.”

Rule 8VAC20-780-510-P.

Each center shall maintain and keep at the center a separate record for each child enrolled which shall contain the required information.

“The records for child #1 and child #6 did not have documentation of child updates and confirmation of up-to-date information.”

Rule 8VAC20-780-60-A.

The center shall obtain documentation of additional immunizations once every six months for children under the age of two years.

“The record for child #4 did not have additional immunizations, which were overdue by 125 days.”

Rule 8VAC20-780-130-E.

Staff are to complete the VDOE sponsored online orientation course within 90 days of hire.

“The record for staff #2, who is working with children, did not have documentation of the course which is overdue by 30 days.”

Rule 8VAC20-780-240-A.

***Repeat Violation*** Medication shall be labeled with child’s name, the name of the medication and dosage amount, and times to be given.

“Child A had emergency medication at the center. The medication was not labeled with the child’s name, the name of the medication and dosage amount, and times to be given.”

Rule 8VAC20-780-510-G.

***Repeat Violation*** Each center shall maintain and keep at the center a separate record for each child enrolled that contains all of the required information.

“Child A and Child C did not have a written care plan for a diagnosed food allergy.”

Rule 8VAC20-780-60-A.

Staff who work directly with children shall, in addition to preservice and orientation training, annually attend at least 16 hours of training and staff development activities, to include the department’s health and safety update course.

“Staff #5 had documentation of the department’s health and safety update course that was dated 58 days after it was due.”

Rule 8VAC20-790-600-F.

The center must request a search of the central registry prior to the employee’s first day of employment.

“Staff #1 who has been employed for 41 days, did not have central registry results. Staff #1 was working alone with children.”

Rule 22.1-289.036-B-3.

The center shall ensure that areas and equipment of the center, inside and outside, are maintained in a clean, safe and operable condition.

“On the playground one wooden playhouse had a screw sticking out toward the inside of the playhouse. A second wooden playhouse had rough wood edges within reach of children.”

Rule 8VAC20-780-270-A.

Medication shall be labeled with child’s name, the name of the medication and dosage amount, and times to be given.

“Child A, child B, and child C had emergency medication at the center. The medication was not labeled with the child’s name, the name of the medication and dosage amount, and times to be given.”

Rule 8VAC20-780-510-G.

Each center shall maintain and keep at the center a separate record for each child enrolled that contains all of the required information.

“Child A, child B, and child C did not have a written care plan for a diagnosed food allergy.”

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

Repeat Violation Based on a review of staff records, the center did not ensure staff had the satisfactory results of the fingerprint-based national criminal background check prior to employment.

“Evidence: 1. The record for staff #1 (employed: 3/18/24) had results of the fingerprint-based national criminal background check dated 3/19/24. 2. The record staff #6 (employed 8/14/23) had results of the fingerprint-based national criminal background check dated 10/03/23.”

Rule 22.1-289.035-B-2.

Repeat Violation Based on review of records, the center did not ensure that each staff member shall submit documentation of a negative tuberculosis screening (TB) at the time of employment and prior to coming in contact with children.

“Evidence: 1. The record for staff #5 (employed: 2/19/24) had documentation of a TB screening on 2/22/24. 2. The record for staff #6 (employed: 8/14/23) had documentation of a TB screening on 8/25/23. 3. The record for staff #9 (employed: 4/01/24) had documentation of a TB screening on 4/05/24.”

Rule 8VAC20-780-160-A.

Based on a review of records and interview, the licensee failed to provide licensing an annual fire inspection report from the appropriate fire official having jurisdiction.

“Evidence: 1. The last documented fire inspection was dated 11/21/22. 2. The administrator reported the annual fire inspection had not been completed annually.”

Rule 8VAC20-780-260-A.

Based on observation and interview, the center did not ensure that medication shall be labeled with the child’s name, the name of the medication, the dosage amount, and the time or times to be given.

“Evidence: 1. The medication for child A (birth date: 06/03/23) had emergency medication that was not labeled with name and dosage amount. 2. The administrator acknowledged that the medication for child A was not labeled with name and dosage amount.”

Rule 8VAC20-780-510-G.

Based on observation and staff interview, the licensee did not ensure the prepared infant formula shall be refrigerated, dated, and labeled with the child’s name.

“Evidence: 1. Child A had one prepared bottle without a date. Child B had three prepared bottles without a date. Child C had three prepared bottles without a date. Child D had one prepared bottle without a date. 2. One Dr. Brown’s bottle with white substance did not have a name or date.”

Rule 8VAC20-780-570-E.

Based on a review of staff records and interview, the center did not ensure staff had the satisfactory results of the fingerprint-based national criminal background check prior to employment.

“Evidence: 1. The record for staff #2 (employed: 8/14/23) had fingerprint results dated 8/25/23. record for 2. The record for staff #4 (employed: 01/02/24) did not contain the results of the fingerprint-based national criminal background check.”

Rule 22.1-289.035-B-2.

Based on record review and interview, the center did not ensure one of two staff records had documentation of a completed sworn statement or affirmation prior to the first day of employment.

“Evidence: 1. The record of staff #1 (employed: 8/14/23) had documentation of a completed sworn statement or affirmation dated 1/11/24. 2. A member of management stated that staff # 1did not complete a sworn statement prior to hire.”

Rule 8VAC20-770-60-B.

Based on review of records and interview, the center did not ensure that each staff member shall submit documentation of a negative tuberculosis screening (TB) at the time of employment and prior to coming in contact with children.

“Evidence: 1. The record for staff #1 (employed: 8/14/23) had documentation of a TB screening on 11/08/22. The record for staff #3 (employed: 9/12/23) had documentation of a TB screening on 1/27/23.”

Rule 8VAC20-780-160-A.

Based on record review, the center failed to ensure that program leaders shall meet all the required qualifications.

“Evidence: 1. The record for staff #1 (employed: 8/14/23) did not have documentation on file to demonstrate program leader qualifications.”

Rule 8VAC20-780-210-A.

Based on observation, the center failed to ensure that the variety of daily activities for all age groups shall be age and stage appropriate and provide opportunities for teacher-directed, self-directed, and self-chosen tasks and activities; a balance of active and quiet activities; individual and group activities; and curiosity and exploration.

“Evidence: There were jingle bells tied to piece of fabric in the infant classroom. One infant had one of the jingle bells in their mouth. The jingle bells were one inch in diameter posing a choking hazard.”

Rule 8VAC20-780-360-A.

Based on a review of children’s records, the center did not ensure that each record contains all required information.

“Evidence: The records for child #1 (enrolled: 9/08/23), child #2 (enrolled: 10/20/23), child #3 (enrolled: 10/13/23), child #4 (enrolled: 8/07/23), and child #5 (enrolled: 8/14/23) did not contain documentation of viewing proof of the child’s identity and age.”

Rule 8VAC20-780-60-A.

Based on record review, the center did not ensure that each staff record contains all required information.

“Evidence: The records for staff #3 (employed: 9/12/23) and staff #4 (employed: 1/02/24) did not contain documentation of two or more references before employment.”

Rule 8VAC20-780-70.

Based on observation, the center did not ensure the diapering area contained 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: 1. In room #1 there was a diaper changing area. The touchless storage system for dirty diapers was not working at the time of inspection.”

Rule 8VAC20-780-500-B.