VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Montessori Academy of Virginia-Suffolk
5805 Harbourview Boulevard
Suffolk, VA 23435
(757) 484-4902

Current Inspector: Melinda Popkin (757) 802-5281

Inspection Date: Feb. 23, 2024

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. 8VAC20-820 THE LICENSE. 8VAC20-820 THE LICENSING PROCESS. 8VAC20-820 HEARINGS PROCEDURES. 8VAC20-770 Background Checks 20 Access to minor's records 22.1 Early Childhood Care and Education 63.2 Child Abuse & Neglect

Technical Assistance:

Please complete the "plan of correction" and date to be corrected" for each violation cited on the violation notice and return it to me within five (5) business days from today. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction should contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person or person(s) responsible for implementation. The Licensee must send evidence to the licensing inspector that the background checks have been requested no later than 10 days of this notification dated 3/11/2023. The applicant must also then forward the results to the licensing inspector upon receipt.

Comments:

An unannounced monitoring inspection was conducted on 2/23/2024 from 12:05 pm-4:05pm. At the time of entrance, 101 children, ages 18 months to 6 years old, were in care with 8 staff members present. The sample size consisted of 10 children?s records and 8 staff records. Children were observed eating lunch, which is brought from home, and resting quietly at nap time. Hand washing, restroom procedures, and transitions from the lunchroom to classrooms were observed. Medication administration was not observed. However, a sampling of 4 medications present on site were reviewed with regard to storage, expiration dates, written authorization and other required documentation. Information gathered during the inspection determined non-compliance with applicable standards or law and violations were documented on the violation notice issued to the program. Repeat violations were found and are identified within this report.

Violations:

Standard #:	22.1-289.011-F
Description:	Based on observation and interview, the licensee did not always post the documents required by the Superintendent shall be posted in a conspicuous place on the licensed premises. Evidence: The Results (violation notice) for the last licensing inspection were not posted in the facility at the time of the inspection. The program director present at the time of the inspection confirmed that the results were not posted in a the facility.
Plan of Correction:	The following responses were received by the licensee via email: The Office re-posted the documents in the lobby and will ensure that all program staff understand that these documents are required to be posted at all times and can not be taken down. (Photo of re-posted documents attached)
Standard #:	22.1-289.035-B-4
Description:	***REPEAT VIOLATION*** Based on a review of records and interview, the licensee did not always obtain a copy of the results of a criminal history record information check, a sex offender registry check, and 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. Eight staff records were reviewed: The record for staff #2 whose date of employment is 2/8/2023 documented her residence in Massachusetts (MA) within the past 5 years. The record for staff #2 did not contain the results of a Sex Offender Search or the results of a Criminal History Search for the state of MA. The record for staff #3 whose date of employment was 1/11/2024 documented her residence in Florida (FL) within the past 5 years. The record did not contain the results of a Search of the Abuse and Neglect Registry or the results of a Sex Offender Registry Search for the state of FL. The record for staff #4 whose date of employment was 1/3/2024 documented her residence in Florida (FL) and North Carolina (NC). The record did not contain the results of a Search of the Abuse and Neglect Registry or the results of a Sex Offender Registry Search for the state of FL and for the state of NC. The record for staff #6 whose date of employment was 12/4/2024 documented her residence in District of Columbia (DC), Delaware (DE), Maryland (MD), New Jersey (NJ) and Washington (WA). The record did not contain: the results of a Criminal History Search for DC; the results of a Criminal History Search for DE; the results of an Abuse and Neglect Registry Search for DE; the results of an Abuse and Neglect Registry Search for MD; the results of an Abuse and Neglect Registry Search for WA. The record for staff #7 whose date of employment was 9/26/2023 documented her residence in Florida (FL) within the past 5 years. The record did not contain the results of a Search of the Abuse and Neglect Registry or the results of a Sex Offender Registry Search for the state of FL. The Program Director in charge at the time of the inspection confirmed that this documentation was not present in the staff records at the time of the inspection.
Plan of Correction:	The following responses were received by the licensee via email: (staff #2) The Office processed a level 2 and level 3 sex offender record search and have attached results of those searches. The Office attempted to re-process a Criminal History Search and both links on the provided chart did not work. The Office called and was provided with a Self-Audit Request Form which requires a notary to process. Staff #2 has the form and is required to return it signed with a notary for processing in order to return to work on 3/11/2024. (staff #3) A follow up email for the submitted Abuse and Neglect request was sent on 3/1/2024 (email attached). Additionally, the results for the Sex Offender Registry Search are attached. (staff #4) The Sex Offender Registry Search Results from the NC and FL are attached. The website links on the Background Check chart for NC and FL would not load. The Office will try first thing again on 3/11/2024. Once background checks are processed, the Office will send follow-up documentation to Licensing. (staff #6) This staff member is no longer employed at MAV. (Staff #7) Sex Offender Registry Search Results are attached. A 2nd follow-up email has been sent regarding the originally submitted search (email attached).
Standard #:	8VAC20-780-60-A-8
Description:	Based on a review of records and interview, the licensee did obtain 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: Ten children's records were reviewed. The record for child #2 contained documentation that child #2 has a diagnosed allergy to avocado. Child #2's record did not contain a care plan from child #2's 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. The program director present during the inspection confirmed that this documentation was not in child #2's record at the time of inspection.
Plan of Correction:	The following responses were received by the licensee via email: The Office contacted the parent regarding this listed allergy. The parent stated she verbally informed the previous director that it was an FPIES allergy, indicating the child does not require an Epi-Pen for this allergen. The parent stated that the child no longer has this allergen. (See attached scan of parent email.) The Office can request an additional Doctor?s letter if needed.
Standard #:	8VAC20-780-70
Description:	***REPEAT VIOLATION*** Based on a review of records the licensee did not always ensure that each staff record contained the required documentation to include documentation of two or more references as to character and reputation as well as competency having been checked ore employment or volunteering. Evidence: Eight staff records were reviewed. The records for staff #1(employed 1/2/2024, staff #4 (employed 1/3/2024) and staff #7 (employed 9/26/2023) did not contain documentation to demonstrate that any reference checks as to the character, reputation and competency of the candidate had been checked prior to their employment or thereafter.
Plan of Correction:	The following responses were received by the licensee via email: The Office now has 2 reference letters for staff # 7 (Attached) The Office now has 2 reference letters for staff #4. (Attached) Staff # 1 is currently not at the facility as there was a death in their family and they are out of town. The Office communicated to them in person prior to their trip and reiterated the same in an email. (Attached)
Standard #:	8VAC20-780-240-B
Description:	***REPEAT VIOLATION***' Based on a review of records and interview, the licensee was unable to demonstrate that staff always complete orientation appropriate to the age of the children in care and including the required facility specific topics prior to the staff member working alone with children and no later than seven days of the date of assuming job responsibilities. Evidence: Eight staff records were reviewed. The records for staff #1(employed 1/2/2024), staff #3 (employed 1/11/2024), staff #4 (employed 1/3/2024) and staff # 6 (employed 12/4/2024) did not contain documentation to demonstrate that facility specific orientation training was completed. The program director present during the inspection confirmed that this documentation was not present in the staff records at the time of the inspection.
Plan of Correction:	The following responses were received by the licensee via email: The Office will re-review the required Orientation Training with the staff listed on 3/11/2024 and complete the required documentation.