Carousel Children's Academy
9151 Centreville Road
Manassas, VA 20110
Current Inspector: Laura Brindle (540) 905-2062
Inspection Date: April 13, 2022
Complaint Related: No
- Areas Reviewed:
8VAC20-780 Staff Qualifications and Training.
8VAC20-780 Physical Plant.
8VAC20-780 Staffing and Supervision.
8VAC20-780 Special Care Provisions and Emergencies.
8VAC20-780 Special Services.
8VAC20-770 Background Checks (8VAC20-770)
22.1 Background Checks Code, Carbon Monoxide
- Technical Assistance:
Technical assistance was provided regarding:
-documentation for staff records
-agent background checks for Virginia and out-of-state
-medication authorization forms
An unannounced renewal inspection was conducted on 4/13/22 from 2:45pm to 6:05pm with the Director. There were 50 children in care, ranging in age from four-months to nine-years-old, supervised by seven staff. The children were observed having free play, playing "Simon says", playing at tabletops, and playing a group game. Four child records and four staff records were reviewed. The Center has multiple staff with current certification in CPR and First Aid as well as Daily Health Observation Training. Six medications and authorization forms were reviewed and the center has multiple staff current in Medication Administration Training (MAT). The attendance and emergency drill log were reviewed. The first aid kit was observed. The most recent Fire Inspection on file was dated 8/4/21 and the most recent Health Inspection on file was dated 7/1/21. If you have questions regarding this inspection, please contact the Licensing Inspector, Laura Brindle, at firstname.lastname@example.org or 540-905-2062.
Please complete the "Plan of Correction" and "Date to be Corrected" areas on the Violation Notice for each violation cited and return to me by close of business on 4/27/22. Plans of correction should include steps to correct the noncompliance with the standard, and measures to prevent the noncompliance from occurring again.
Standard #: 22.1-289-036-B-4 Description: Based on review of three agent records, the center did not obtain the results of a search of the child abuse and neglect registry from all states in which staff members have resided within the last five years within 30 days of becoming an agent. Evidence: The record for Agent C contains documentation that the agent lives in the state of Maryland. The record did not contain results of a search of the child abuse and neglect registry from Maryland. Agent C became an agent for the center in November 2019. Plan of Correction: The central registry search for state of MD was sent to MD agency for agent C on 4/20/2022 and results will be forwarded when received. A reminder has been created to ensure this will be renewed every five years.
Standard #: 8VAC20-770-40-D-1-a Description: Based on review of three agent records, the center did not obtain a sworn statement or documentation of the results of a central registry search within 30 days of service for all agents. Evidence: 1. The record for Agent A did not contain the results of a central registry search completed by the center. 2. The record for Agent B contained a sworn statement dated 4/15/22. Agent B began service in November 2019. 3. The record for Agent C did not contain the results of a central registry search by the center within 30 days of service. The sworn statement on record for Agent C was dated 4/15/22. Agent C began service in November 2019. Plan of Correction: 1. Central Registry search form for Agent A is already sent to VA DSS on 4/15/2022 and results will be forwarded when available.
2. Central Registry search form for Agent C is already sent to VA DSS on 4/20/2022 and results will be forwarded when available.
3. Sworn statements were updated for agent B and C on 4/15/2022.
4. A reminder has been created ensure these are renewed every 5 years for each of the agents.
Standard #: 8VAC20-780-130-A Description: Based on review of four child records, the center did not obtain documentation that each child had received the immunizations required before attending the center. Evidence: 1. The immunizations on record for Child D, with a start date of 2/2/22, were dated 3/23/22. 2. The record for Child E, with a start date of 3/28/22, did not contain documentation of immunizations. Plan of Correction: Parents of Child E has been notified to provide latest immunization records. Effective immediately all new enrollments will require latest immunization records prior to the day one unless allowed by a qualified written exemption. Additionally our child enrollment software (Procare) will be configured to enter requirements for children's immunization records at the required intervals based on the child's age. Reports will be run every month to identify children records requiring updates and parents will be notified to send updated records or face the disenrollment, unless allowed by written qualified exemption.
Standard #: 8VAC20-780-140-A Description: Based on review of four child records, the center did not obtain documentation of a physical examination by a physician within 30 days of attendance for a child. Evidence: The physical on record for Child D, with a start date of 2/2/22, was dated 3/23/22. Plan of Correction: All the new enrollments will be verified for current medical records. Additionally our child enrollment software (Procare) will be configured to enter requirements for children's medical records at the beginning in 30 days and updates at every 12 months. Reports will be run every month to identify children records requiring updates and parents will be notified to send updated records or face the disenrollment, unless allowed by written qualified exemption.
Standard #: 8VAC20-780-60-A Description: Based on review of four child records, the center did not obtain all of the required information for a child record. Evidence: The record for Child F, with a start date of 3/7/22 did not contain documentation of viewing proof of the child's identity and age. Plan of Correction: Child F's parents are notified to bring birth certificate for proof of identity and age. Effective immediately new enrollments will not be accepted without proper evidence of proof of child's identity and age.
Standard #: 8VAC20-780-270-A Description: Based on observation, the center did not ensure that equipment of the center, inside and outside, was maintained in a safe and operable condition. 1. In the "Frogs" (toddler) classroom and the "Ducks" (two-year-olds to four-year-olds) classroom, the window blinds were broken and hanging in some areas and tied up with string in other areas. 2. In the "Frogs" classroom the diaper changing pad was torn in multiple areas making it not non-absorbent. 3. In the "Cardinals" (four-year-olds to five-year-olds) classroom the red vinyl couch was torn on multiple corners. 4. In the School Age classroom there was a ceiling tile that was broken with a large piece of the corner missing. 5. On the larger playground there was: a wooden bench with wood deteriorating on the outside edges; wood on the fence that was splintering with long portions of wood strips hanging down and away from the fence; and the stairs on the play structure that were originally metal covered with rubber had deteriorated until the rubber was missing in many areas with the metal underneath exposed and rusted almost all the way through. 6. On the smaller playground there was a riding toy/play car that had a broken wheel and another riding toy/play car that had a missing roof support bar that had broken off. Plan of Correction: 1. The broken window blinds are removed from Frogs and Ducks classroom.
2. Replacement for diaper changing pad for Frogs classroom is ordered and will be delivered on 4/29/22.
3. The couch from Cardinals room is removed.
4. Ceiling tile from School age room will be replaced by 4/29/22.
5. The broke wooden bench is fixed as of 4/27/22. The fence is fixed as of 4/22/22. The steps for playground equipment cannot be fixed, hence the equipment will be removed. The contractor has assessed the equipment and the equipment will be removed when we receive proposal for the removal from the contractor. Anticipated date is 7/1/2022. In the meantime we will not let children use the steps on that equipment.
6. Broken play toys from smaller playground is removed.
Standard #: 8VAC20-780-280-B Description: Based on observation, the center did not ensure that hazardous substances, such as cleaning materials, were kept in a locked place using a safe locking method that prevents access by children. Evidence: 1. In the "Frogs" (toddler) bathroom a spray bottle labeled "Bleach and water" was observed on the counter. 2. In the "Frogs" classroom, a spray bottle labeled "Bleach and water" was observed on top of the cubby shelf. 3. In the "Ducks" (two-year-old to four-year-old) classroom a "Magic Eraser" sponge was observed in an unlocked drawer directly under the child sink. Plan of Correction: All the teachers and assistant teachers are strictly instructed to place hazardous substances in locked place after use. Signs reminding staff to do so will be displayed in all the bathrooms and appropriate areas of classrooms (changing tables, near shelves, etc.) until staff does it consistently. Center director will periodically check for proper locking of hazardous substances throughout the day.
Standard #: 8VAC20-780-340-D Description: Based on review of documentation, interview, and observation, the center did not ensure that in each grouping of children at least one staff member who meets the qualifications of a program leader was regularly present. Evidence: 1. On 4/13/22, in the afternoon, there was no qualified program leader with the children in the "Frogs" (toddler) classroom. The two teachers present were listed on the Staff Information Sheet for the renewal as assistant teachers and their records did not contain documentation to qualify as program leaders. The Staff Information Sheet for the renewal contains documentation that the program leader for the classroom leaves at 2:00pm each day, though the center is open until 6:30pm. 2. On 4/13/22, in the afternoon, there was no qualified program leader with the children in the School Age classroom. The teacher present was listed on the Staff Information Sheet as an assistant and their record did not contain documentation to qualify as a program leader. The Staff Information Sheet did not contain documentation of a program leader for the classroom. Plan of Correction: 1. We will review current staff experience and qualification to identify qualified program lead staff and will adjust the schedule of that staff to be program lead for Frogs classroom after 2pm. We will send updated staffing sheet with these changes.
2. Current staff in the school age room has more than 6 months of supervised child development experience and has some training hours training in playground safety, child abuse reporting and prevention and health and safety issues, CPR/First aid. We will continue to work with this staff to complete the required program leader training by 8/1/2022.
Standard #: 8VAC20-780-350-B-1 Description: Based on observation and interview, the center did not ensure that the staff-to-child ratio of 1:4 was followed for infants from birth up to 16-months-old. Evidence: At the start of the inspection at approximately 2:45pm, Administrator A was observed in the office with Agent A. At approximately 2:50pm Administrator A was observed in the Infant room with one staff and six infants. Interview revealed that the staff member had been alone with six babies for approximately 20 minutes before Administrator A went into the classroom. Plan of Correction: Administrator A was in the office as inspection began and went to Infants classroom to support existing staff with the ratio as Agent A manned the front office. One of the staff called in sick and created shortage. As we mentioned above we are actively interviewing candidates to hire a floater staff so they can fill in these times with support of Administrator A. We anticipate to hire new staff on or before 5/9/2022. We also anticipate one of the staff from infants room to be back by vacation in first week of June 2022.
Standard #: 8VAC20-780-350-B-4 Description: Based on observation, documentation review and interview, the center did not ensure that the ratio of 1:10 (staff: children) was maintained for children from four-years-old up to school age eligibility. Evidence: On 4/13/22 at approximately 3:28pm 10 children were observed in the "Cardinals" classroom with one staff member. When the attendance was reviewed and showed documentation of 11 children present, the staff reported that a child had just left at 3:25pm. The staff member acknowledged that they had been alone with 11 children "for a little while" until the 11th child went home. Plan of Correction: The afternoon assistant had to leave for a court appointment for which the school was not given adequate notification by the staff. We have given clear instructions to staff to inform school about scheduled appointment so we can adjust other staff schedule to fulfill the ratio. While it is extremely difficult to hire correct staff, we have tried really hard to hire required staff. Since previous ratio violation we have hired 3 more employees to support the required ratio. We are also in process of hiring another floater employee to support such incidents. We are also have put new enrollments on hold until we have addressed staffing needs. We anticipate to hire the new staff on or before 5/9/2022.
Standard #: 8VAC20-780-350-Q Description: Based on observation, record review, and interview, the center did not have documentation of a written assessment by the program director and program leader in order to assign children to a different age group and maintain the staff-to-child ratio and group size of the established age group. Evidence: On 4/13/22 18 children were observed with two staff in the "Ducks" classroom. Staff reported that four of the children were two-years-old and their records were reviewed for documentation in order to maintain the 1:10 ratio of the established age group with the two-year-olds present who typically require a 1:8 ratio. The four records did not contain documentation of a written assessment in order to maintain the ratio of 1:10, therefore a ratio of 1:8 was required. Plan of Correction: We believe the children that were promoted to Ducks were developmentally ready to move to Ducks. Two of the four children already have attend required age of 3 and two will be in two weeks. However we agree that we need to implement better written assessment for such early promotion to Ducks classroom and maintain a 1:10 ratio. We are developing comprehensive assessment document based on CDC guidelines and will re-do the assessment for the remaining two children and if the children don't qualify for Ducks class then the will be either sent back to Frogs classroom until they turn 3 or ratio in Ducks will be maintained at 1:8.
Standard #: 8VAC20-780-510-P Description: Based on review of six medications and authorization forms, the center did not ensure that when an authorization for medication expired, that the parent was notified that the medication needed to be picked up within 14 days or the parent must renew the authorization. Evidence: 1. A cold and mucus medication was onsite for Child A with written authorization from the parent that expired on 3/25/22. 2. An allergy medication was onsite for Child B with written authorization from the parent that expired on 7/27/21. 3. An asthma medication was onsite for Child C with written authorization from the parent that expired on 12/31/21. Plan of Correction: All the expired medications are properly discarded and parents are notified for new replacements. Medications will be checked on first working day every month for expiration date and expired medications will be properly discarded and parents will be informed to send new medications.
Standard #: 8VAC20-780-570-E Description: Based on observation, the center did not ensure that infant bottles were dated and labeled with the child's name. Evidence: During the inspection on 4/13/22, an infant bottle was observed in the refrigerator with no name or date. Two additional bottles were observed without a date. Plan of Correction: All the teachers and assistant teachers are strictly instructed to ensure that infant bottles and other children's food is properly dated and labeled and out of date items are removed and discarded. Signs to do so will be displayed in all areas where food is stored for infants and other classrooms. Center director will periodically check ensure compliance.
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.
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