VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Willowcreek Academy
6100 Redwood Square Center
Centreville, VA 20121
(703) 815-3000

Current Inspector: Sarah Marbert (703) 479-4678

Inspection Date: May 23, 2022

Complaint Related: No

Areas Reviewed:

8VAC20-780 Administration. 8VAC20-780 Staff Qualifications and Training. 8VAC20-780 Physical Plant. 8VAC20-780 Staffing and Supervision. 8VAC20-780 Programs. 8VAC20-780 Special Care and Emergencies 8VAC20-780 Special Services. 8VAC20-820 THE LICENSE. 8VAC20-820 THE LICENSING PROCESS. 8VAC20-820 HEARINGS PROCEDURES. 8VAC20-770 Background Checks (8VAC20-770) 20 Access to minor?s records 22.1 Background Checks Code, Carbon Monoxide 63.2 Child Abuse & Neglect

Technical Assistance:

Discussed with Director: best practice for Topical Ointment forms completion

Comments:

An in person renewal inspection was conducted today. All rooms are in ratio during the inspection. Children were observed resting, during a diapering, playing outside and washing hands. 4 staff records were reviewed. 5 child records were reviewed. Injury reports, first aid supplies, emergency supplies, playground, van, Safe sleep, Shaken baby Syndrome and Abusive Head trauma policies are all in compliance. See Violation Notice for non-compliances. A subsidy inspection was also conducted today. LI was present from 2:00 PM ? 5:10 PM. If you have any questions, please contact me at 703-479-4678 or at Sarah.Marbert@doe.virginia.gov. The inspection will be typed off site and emailed to the facility for signatures.

Violations:

Standard #:	22VAC40-185-130-A
Description:	Based on a review of records, one child record did not include documentation of immunizations before the child attended. Evidence: There is no record of immunizations available for review for Child #3. (Start date: 4/4/22)
Plan of Correction:	Notify parents this documentation is required.
Standard #:	8VAC20-780-140-A
Description:	Based on a review of records, one child record does not include documentation of a completed physical within 30 days of attendance. Evidence: There is no documentation of a physical available for review for Child #3. (Start date: 4/4/22)
Plan of Correction:	Notify parents this documentation is required.
Standard #:	8VAC20-780-160-A-1
Description:	Based on a review of records, one staff record did not include documentation of a completed Tuberculosis (TB) screening submitted prior to employment. Evidence: The TB screening documentation is dated 4/29/22. The date of hire is documented as 4/25/22. (Staff #3)
Plan of Correction:	Do not allow staff to start employment prior to TB test results.
Standard #:	8VAC20-780-60-A
Description:	Based on a review of records, one child record does not include all required information. Evidence: 5 records were reviewed. 1 of 5 did not include: *Mother?s work information (Child 1) *Allergy action plan for a food allergy (Child 1) *Start date (Child 4) *Proof of Birth documentation (Child 4)
Plan of Correction:	Missing information to be supplied by parents/center.
Standard #:	8VAC20-780-80-A
Description:	Based on a review of documentation, a written attendance sheet was not maintained in one classroom. Evidence: The Toddler/Preschool II attendance sheet did not accurately reflect the children in the room. There were 9 children present in the classroom. The attendance sheet showed 7 children present. 1 name had been whited out; however, the child was present. 1 child was not listed on the sheet.
Plan of Correction:	Ban white-out from the classrooms and discuss/retrain proper documentation of attendance w/ staff.
Standard #:	8VAC20-780-240-B
Description:	Based on a review of records, one staff person did not have documentation of completion of first aid and CPR training prior to working alone with children and later than 7 days from assuming job responsibilities. Evidence: 1 of 4 staff records reviewed had no documentation of First aid and CPR training. (Staff #3)
Plan of Correction:	Require staff to have CPR/FA cert. w/in 7 days of starting employment.
Standard #:	8VAC20-780-280-B
Description:	Based on direct observation, hazardous materials were not stored locked when not in use. Evidence: Spray bottles of cleaners were in the sink in the Infant 1 and Infant 2 rooms.
Plan of Correction:	Train/discuss w/ staff proper haz. mat storage.
Standard #:	8VAC20-780-560-G
Description:	Based on a review of bottes in the Infant 1 room, all bottles were not labeled and dated. Evidence: 1 of 4 infants with bottles did not have the bottles dated with today?s date.
Plan of Correction:	Supply labeling material in classroom to assist parents if needed, train staff to check bottles at drop off.