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Chesterbrook Academy #826
22695 Cotton Grass Way
Ashburn, VA 20148
(571) 223-3233

Current Inspector: Lisa Hudson (571) 389-2459

Inspection Date: Jan. 13, 2020

Complaint Related: No

Areas Reviewed:
22VAC40-191 Background Checks (22VAC40-191)
63.2 Child Abuse & Neglect
63.2(17) License & Registration Procedures

Technical Assistance:
Please ensure that the application for renewal is complete to include the licensing fee prior to your expiration date.

As discussed, although your daily schedule was posted, please ensure that staff follow protocol by updating the lesson plans posted to ensure that the daily activities are followed.

Discussed overall maintenance of the center to include programmatic equipment and playground equipment.

Per our discussion, the fenced area directly off the PreK 1 classroom is not in use.

An unannounced Renewal inspection was conducted this date to evaluate the Center's compliance during the past six months Provisional period. A total of 73 children with 12 staff were present during the inspection. A regional representative arrived during the inspection. Observations of all 8 classrooms were made. Observations of programming, diapering procedures and hand washing procedures were made. The Center's transition documentation was reviewed. All medications on site were reviewed, a total of 7 children's records and 6 staff records were completed to include documentation of lead qualifications. This inspection began at approximately 9am and ended at 2:05pm. Please contact me at: with any questions. Thank you.

Standard #: 22VAC40-185-130-B
Description: Based on child record review, additional immunizations were not obtained.
Evidence: Child #4 and #7 are under the age of two years. Child #4's most recent immunizations are dated 4/18/19. Child #7's most recent immunizations are dated 3/26/19. Updated immunizations are required every six months for children under the age of 2 years.

Plan of Correction: Moving forward management will track immunizations and health forms via Tadpoles in addition to monthly file audits conducted by the school leadership team with Regional Director oversight. This allows time for records to be loaded in Tadpoles by the management team.

Standard #: 22VAC40-185-160-A
Description: Based on staff record review, a TB risk assessment screening was not obtained for one staff.
Evidence: Staff #1 was hired on 10/28/19. A TB risk assessment was not obtained within the first 21 days of hire. No TB risk assessment was found for this staff.

Plan of Correction: Moving forward management will ensure that all TB test results are Correction Date 01/22/20
documented and placed in the staff members file.
Staff file audits will be done on a monthly basis to ensure TB test results
are received within the 21 days of employment.
If a staff member fails to provide the TB test on time the staff member will
not be permitted to work with children. Correction date includes three-day Test Result
reading time.

Standard #: 22VAC40-185-180-B
Description: Based on staff statements, staff failed to carry out their assigned responsibilities.
Evidence: Staff #3 was hired on 1/6/20 and Staff #2 was hired on 12/23/20. Despite documented training on emergency procedures, both staff had no knowledge of evacuation routes and locations for sheltering in place.

Plan of Correction: Retrain all staff on Emergency Procedures and evacuation routes. A second staff meeting will be held within 2 weeks that will focus on Emergency Procedures and Evacuation Routes. The training will take approximately 45 minutes. The emergency plan for the school will be distributed to all teachers with copies of the Fire Drill Primary and Secondary Routes of Exit. All teachers will sign off that they attended the training and the management team will document this training. The training will last approximately 45-minutes, the actual training time will be recorded on the certificate of completion. Fire Drills will be administered monthly and documented in the binder with participants noted.

Standard #: 22VAC40-185-210-A-4-a
Description: Based on staff statements and documented training, 2 staff who are designated lead teachers do not meet the qualifications for a lead teacher.
Evidence: Staff #7 was hired as a Lead Teacher on 10/16/19. Staff #7 has not completed 24 hours of Lead Teacher training. Staff #6 began employment as an Assistant Teacher. Staff #7 is currently in a Lead Teacher role. According to the Center's Director the date in which Staff #7 transitioned to a Lead Teacher role is unknown. Staff #7 has received only 18 of the required 24 hours of Lead Teacher training.

Plan of Correction: Moving forward to ensure that Lead Teachers meet the qualifications for the 01/15/2020
position the Principal will;
A staff member being promoted from within the school from Assistant Teacher
to Lead Teacher, the Principal will ensure that the teacher has 6 months of
supervised programmatic experience, 24 hours of training related to:
care of children including child development
playground safety
health and safety and preventing
reporting child abuse and neglect.
All trainings that encompass this requirement will be documented and logged
with the training summary attached to the certificate of completion and verified
by the Principal

A staff member being hired from outside of the Spring Education Group will be;
Hired as an Assistant Teacher
Required to work with a Lead Qualified Mentor Teacher

The Principal will ensure that the teacher has 6 months of supervised programmatic experience, and have 24 hours of training related to:

care of children including child development
playground safety
health and safety and preventing
reporting child abuse and neglect.
All trainings that encompass this requirement will be documented and logged
with the training summary attached to the certificate of completion and
verified by the Principal.

Once all trainings are documented are logged and verified and the 6 months of
supervised programmatic experience is met, the new staff member will
be promoted to Lead Teacher. At the time of the promotion the staff member will
receive a copy of the Job Description, the teacher will read, sign and date the document before
assuming the Lead Teaching position.

Standard #: 22VAC40-185-230-B
Description: Based on observation and staff statements, an independent contractor was not within sight and sound supervision of a staff member.
Evidence: An independent contractor was observed in the School Age Classroom alone with 7 children providing an ancillary service. No documentation of staff qualifications to include background checks were found for this contractor.

Plan of Correction: Moving forward all ancillary contractors will provide management will
background checks and TB tests before instructing the students. Upon contract,
the CBA Principal will request copies of the background check and TB Test before employees
of said service provide programming at the school. Contractors paperwork will be housed
in a separate binder for easy access. Providers will sign in for programming and school will
verify we have the proper background check and TB test on file before they begin work. Third contractor to bring in background check and TB Test by 1/22/20.

Standard #: 22VAC40-185-270-A
Description: Based on observation of the physical plant, areas of the building were not maintained in a clean and safe condition.
Evidence: The fencing located off the PreK 1 classroom's playground access has peeling paint on the top of the fence. The molding located on the edge of the counter top located in the Toddler A classroom near the diapering area was no longer attached. Staples located on a bulletin board within reach of children were found in the Toddler A classroom. The diapering area in the Beginner Classroom was dirty and had glitter on and around the surface.

Plan of Correction: Moving forward management will walk the interior and exterior of the building making notes of all items that need repair. If it is too dark out to observe the external of the building, the manager will walk the exterior when it is light enough to observe any areas of concern accurately. An ongoing log will be created for noting facility action items. The Principal and Regional Director will utilize a Facility Excellence Checklist to assure the building needs are properly evaluated and assessed.
The management team member that finds the violation will write it on the log and initial,
They will also verbally communicate with one another. The principal will communicate any issues that cannot be handled at the school level to the Regional Director and a copy of the email communication will be kept with the log until the repair has been made. The principal will follow up with the Regional Director if no response has been made to the request in 48 hours for non-emergencies. In the event of a facility emergency repair the
Request will be sent via email with high importance, followed by a phone call to the Regional Director.
Work Order submitted to Elam Services to repair by 1/17/20 peeling paint on
the outside fence and Pre-K room molding corrected. Management will retrain staff pertaining to staples being on a board within reach of students. Staples Removed 1/13/2020

Standard #: 22VAC40-185-500-A
Description: Based on observation of diapering procedures, proper hand washing was not conducted.
Evidence: Staff #3 failed to wash their hands between diapering two children. Staff #3 was observed wiping multiple children's noses and failed to wash hands in between each child.

Plan of Correction: A staff meeting is scheduled on 01/21/2020 at which time a full re-training of proper handwashing/
diapering procedures, diapering routines along with a proper sanitization of tables and chairs will
be covered with staff acknowledgement added to files for added documentation.
This training will be for a total of 45-minutes and will include a demonstration and a
skill assessment based on the information covered to ensure a firm understanding of
the sanitization and diapering process. The management team will also make impromptu visits to various rooms throughout the day to confirm that re-training was understood and being followed.

Standard #: 22VAC40-185-500-B
Description: Based on observation of the Intermediate classroom and staff statement, a diapering area was not accessible to this classroom.
Evidence: Staff stated that there are children in this class who are not potty trained and are in diapers. No accessible diapering area was found in this classroom.

Plan of Correction: Moving forward diaper changing mats will be provided for the Intermediate A classroom for diaper changes. The diaper station will remain clear of obstruction and sanitized properly. All Intermediate Room teachers will be retrained in procedure on 1/17/20 and sign off per acknowledgement for on-going performance.

Standard #: 22VAC40-185-550-E
Description: Based on staff statements, a record of practice drills was not maintained.
Evidence: Staff # 8 stated that the record for evacuation drills from July through December 2019 can not be located.

Plan of Correction: Moving forward Management will ensure that all fire drills, shelter in place
Tornado drills, etc. are done, documented and logged immediately.
Moving forward the Evacuation drill document will remain in the Emergency
Preparedness Binder where is will not be removed. When new drills are documented
the page will remain in the book.

Standard #: 22VAC40-185-560-G
Description: Based on observation of the Beginner and Toddler B classrooms, food brought from home was not properly labeled.
Evidence Food brought from home was found in children's cubicles that were not properly labeled with child's name and/or date that the food was brought into the center.

Plan of Correction: Staff will be retrained that all food items must be labeled correctly and school leadership team will send a reminder email to parents regarding correct labeling procedures. This will be a 15-minute training, the staff will sign off and the training will be documented in the meeting minutes and training binder.

Standard #: 22VAC40-185-560-K
Description: Based on observation of the Infant B, Toddler B and the School Age classrooms, properly sanitizing of tables and high chair trays was not conducted.
Evidence: The high chair tray in the Infant B classroom had food debris. The table surface located in the Toddler B classroom was dirty with dried food debris. Licensing Inspector informed Staff #3 about the table. The Licensing Inspector returned to the classroom approximately 30 minutes later and observed Staff #3 washing children's hands after returning from the playground and sitting them down at the table which remained unclean. The table surface located in the School Age classroom had dried food debris.

Plan of Correction: Retrain all staff on proper sanitization of surfaces such as high chairs 01/21/2020 (staff meeting) and tables. A staff meeting is scheduled on 01/21/2020 at which time a re-training of how
to properly sanitize high chairs and tables will take place for all teachers that work in the Infant
and Toddler Classrooms. Teachers will be provided with a Classroom Management Checklist that will be
reviewed for daily usage and submitted to the Lead Teachers for oversight and reporting to the school
leadership team. This training will last approximately 20-minutes. the training certificate will reflect actual training time and the teachers will be given a skills assessment to ensure knowledge of the training. Once the skills assessment is complete and the staff member has passed the management team will create a certificate documenting the training was completed and filed.
The management team will make impromptu visits to various rooms throughout the day to
confirm the training was understood and followed. Weekly and Monthly Classroom Observations by
management will be completed to assure proper procedure is being followed consistently.

Standard #: 22VAC40-80-120-E-2
Description: Based on observation of the Center, the findings for the most recent inspection was not found.
Evidence: The 1/13/19 Violation Notice was not found.

Plan of Correction: 1/13/19 Violation Notice has been posted. Moving forward management will ensure it is displayed in it ?s designated spot. This has been completed.

Standard #: 63.2(17)-1720.1-B-3
Description: Based on review of staff records, background search requests were not requested within 30 days of hire.
Evidence: Staff #1 was hired on 10/28/19. Staff #1's Sworn Statement indicated this staff has lived in 3 different States outside of Virginia in the past five years. An out of state Central Registry was not requested for 2 of the 3 States and 1 request was sent on 1/7/20.

Plan of Correction: Moving forward management will ensure that the CPS ? OBI document is reviewed
for full content and accuracy, the document has been notarized and a $10.00 money order
is made out to VDSS either before or on the first day of employment. Upon receiving the CPS-OBI document it
will be copied along with the money order and mailed the same day. A note will then be placed stating the date
and person prepared and mailed the CPS-OBI document. If management has not gotten a response within
weeks, management will email CPS operations inquiring about the background check. Any information
regarding the delay will be noted in the staff file. In the event the background check is not received on the 30th day from the first day of the
staff member?s employment then the staff member will not be scheduled until the background check
has been received. If a staff member is denied work due to a background check not being received an email
confirmation of this will be sent to the Regional Director to make them aware of the outstanding background
check. A copy of the sent email will be placed in the staff members file.


A compliance history is in no way a rating for a facility.

The online compliance history includes only information after July 1, 2003. In addition, the online compliance history includes information regarding adverse actions that may be the subject of a pending appeal. An adverse action is not final until a provider has exhausted or waived all due process rights. For compliance history prior to July 1, 2003, or information regarding the status of pending adverse actions, please contact the Licensing Inspector listed in the facility's information. The Virginia Department of Social Services (VDSS) is not responsible for any errors in or omissions from the compliance history information.

Virginia Quality is a voluntary quality rating and improvement system for early care and education facilities serving children ages birth through pre-K. To find programs participating in Virginia Quality, click here.

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