VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Peppertree Montessori at Lake Montclair
5167 Waterway Drive
Dumfries, VA 22025
(703) 763-0003

Current Inspector: Cathy Aylor (540) 222-6352

Inspection Date: Feb. 23, 2023

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 Provisions and Emergencies. 8VAC20-780 Special Services. 8VAC20-790 Subsidy Regulations. 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 32.1 Report by person other than physician 63.2 Child Abuse & Neglect

Technical Assistance:

1. Consultation provided on organization of files and recordkeeping. 2. You should audit all staff and children's files to get a handle on what is missing and make a plan to quickly obtain the missing components of the files. . 3. Reviewed standards pertaining to allergies, sensitivities, dietary restrictions. 4. Please read and review standards 40.M, 60.A.8, 240.C.10. 5. Staff needs ongoing training and clarification on what child has what allergy, sensitivity and dietary restrictions. 6. Sibling groups requires separate signed agreements.

Comments:

An unannounced monitoring inspection was conducted with the director and administrator from 8:20 am to 10:55 am. Sixteen children were present during the walk through, with 5 staff providing supervision. The ages of the children ranged from 5 months to 4 years. The Licensing Inspector was able to observe children arriving into the classrooms, painting activities in the 3 to 5 year old room, free play and morning snack. Six staff and six children's files were reviewed during this inspection. There was on emergency medication on site. There has been only 3 injuries/accident reports in 2022 and none to-date in 2023. Please provider your Licensing Inspector (LI) documentation when you send off for the missing background checks. This proof is needed within 10 days. Furthermore, make sure to send you LI documentation of all missing background checks upon completion. The areas of non compliance are outlined on the violation notice.

Violations:

Standard #:	22.1-289.035-B-2
Description:	Based on a review of six staff files and interviews with the administrative staff, it was determined that there was no fingerprint background check on file prior to the first day of employment. Evidence: There was no fingerprint background check on file for staff C, who was hired around 2/6/23.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-770-60-B
Description:	Based on a review of staff files and interviews, it was determined that sworn disclosure statements were not obtained for all staff prior to the first day of employment. Evidence: There were no sworn disclosure statements on file for staff B and C.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-770-60-C-2
Description:	Based on a review of six staff files and interviews with administration, it was determined that there were no Central Registry background checks on file for staff within 30 days of employment. Evidence: There were no Central Registry background checks on file for staff A, who was hired on 11/22/22, and staff B, who was hired 12/23/22.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-160-A
Description:	Based on a review of staff files and interviews, it was determined that each staff member did not have a tuberculosis test/screening/chest- x-ray on file at the time of employment. Evidence: There were no tuberculosis test /screenings on file for staff B and C. Staff B was hired on 12/23/22 and Staff C was hired 2/6/23.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-40-M
Description:	Based on observation and interview, it was determined that the written children's allergy list was not dated, and did not list all children's allergies, sensitivities, and dietary restrictions Evidence: 1. The allergy list in the 3 classrooms were not dated. 2. On child C's physical, the physician listed a nut allergy however this information was not listed on the current written list. 3.Child B has a dietary restriction to pork. Documentation from the parent(s) stated that the child is only allowed to eat chicken and vegetables. These restrictions were not on the allergy, sensitivity, dietary restriction list posted in the classrooms.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-60-A-8
Description:	Based on a review of recordkeeping and interviews, it was determined that there were no written care plans for each child with a diagnosed food allergy. Evidence: 1. There was no allergy care plan on file for child D who has a food allergy to eggs, nuts and milk. 2. Child C has a nut allergy as listed on the physical. There was no allergy care plan for this food allergy.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-70
Description:	Based on a review of six staff files and interviews, it was determined that there were no references on file for staff A, and C
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-80-A
Description:	Based on observation and interviews, it was determined that the center and its staff did not maintain a written record of daily attendance of each child in care. Evidence: There was no written attendance list maintained for the 3 to 5 year old classroom. There were 10 children present in this room.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-210-A
Description:	Based on a review of staff files and interviews, it was determined that staff B and C, both lead teachers however there was no documentation of a high school program completion or equivalent on file.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-210-A-4-b
Description:	Based on a review of files and interviews, it was determined that a lead teacher was not provided the 24 hours of lead teacher qualification training within a month of assuming lead teacher duties. Evidence: Staff B was hired as a lead teacher on 12/23/22 and the staff had not been given the 24 hours of lead teacher training.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-240-A
Description:	Based on a review of staff files and interviews, it was determined that the Virginia Dept of Education sponsored orientation course was not completed within 90 calendar day of employment. Evidence: Staff A,,D, E and F did not have the orientation course completed within 90 days of employment. Staff A was hired in 11/22/22, staff D and F were hired in 2021, staff E was hired on 10/26/22.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-240-B
Description:	Based on a review of recordkeeping and interviews, it was determined that orientation training was not provided prior to staff working alone with children and no later than seven days of the date of assuming job responsibilities. Evidence: There was no orientation training provided to staff A ( hired 11/22/22), staff B ( hired 12/23/22), staff C ( hired 2/6/23), staff E ( hired 10/26/22.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-245-J-1
Description:	Based on a review of recordkeeping and interview, it was determined that no staff has the Medications Administration Training (MAT) in the last three years, which is required to administer medication. Evidence: The center has the emergency medication, Epinephrine on site for child D. The center has no staff certified in MAT.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-270-A
Description:	Based on observation, it was determined that the center was not maintained in a safe manner. Evidence: The Licensing Inspector (LI) observed an whole in the wall in the toddler classroom. The whole measured approximately 4 by 2 inches and was accessible to the children.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-280-B
Description:	Based on observation, it was determined that hazardous substances were not kept locked to prevent access by children. Evidence: 1. The Licensing Inspector (LI) observed a container of Beta Fish Food with warnings/cautions on the container. The food was sitting on a shelf in an open closet that was accessible to the children in the 3 to 5 year old classroom. 2. The LI observed a large container of hand sanitizer sitting on a shelf which was accessible to the children in the 3 to 5 year old classroom. 3. The LI observed over 10 containers of spray chalk in the teachers closet in the toddler classroom. The lock to the door was not operational and the spray chalk stated to keep out of reach of children and had warnings listed.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-440-A
Description:	Based on observation and interview it was determined that there was no crib assigned to an infant during the designated rest period. Evidence: The LI observed child A ( 5 months of age) sleeping in a basinet. Interviews and observation revealed that the infant had not been assigned a crib and for the last two weeks the center provided a bassinet for the infant to sleep in.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-440-B
Description:	Based on observation and interview, it was determined that the one crib in the infant classroom was not assigned to be used by a specific child. Evidence: Observation revealed that child E's (10 months of age) crib did not have their name on the crib.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-440-G
Description:	Based on observation and interview, it was determined that children under 12 months of age were not using cribs. Evidence: There was no crib for child A, who is 5 months of age. The child had been sleeping in a basinet since enrollment, two weeks prior.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-510-L
Description:	Based on observation and interview, it was determined that medication ( Epinephrine) for child D was kept unlocked in the medication box on the office desk.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-530-A-1
Description:	Based on observation, a review of recordkeeping and interviews, it was determined that there was not at least one staff in each classroom/area where children were present within 90 days with CPR certification. Evidence: There was no documentation to show that the lead teachers in the Infant and the 3 to 5 year old classrooms had CPR certification within 90 days.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-530-A-2
Description:	Based on observation, a review of recordkeeping and interviews, it was determined that there was not at least one staff in each classroom/area where children were present within 90 days with First Aid certification. Evidence: There was no documentation to show that the lead teachers in the Infant and the 3 to 5 year old classrooms had First Aid certification within 90 days.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-550-D
Description:	Based on observation and interview, it was determined that the center has not implemented monthly practice evacuation drills Evidence: There were no escape drills conducted for 12/22 and 1/23.
Plan of Correction:	Not available online. Contact Inspector for more information.