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AVSP Youth Program
20585 Ashburn Village Blvd.
Ashburn, VA 20147
(703) 729-0581 (209)

Current Inspector: Whitney Mcgrath (571) 835-4717

Inspection Date: Aug. 22, 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 Provisions and Emergencies
8VAC20-780 Special Services.
8VAC20-820 THE LICENSE.
8VAC20-820 THE LICENSING PROCESS.
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:
Missing background checks were confirmed on 9/8/2022 for a board officer. The renewal application will not be processed until all missing background checks have been reviewed.

Comments:
Today an unannounced Renewal Inspection took place between the hours of 9:10am and 10:05am. There were 2 rooms observed with a total of 43 children with 2 staff, which is not within the supervision guidelines. The children were observed playing freely in the gym, coloring and going outside to eat a morning snack. A complete inspection of the physical plant, children and staff records, fire drill log and emergency procedures were observed during this inspection. Violations were found during todays inspection and can be viewed on the Violation Notice. The violation notice was revised on 9/8/2022 to include additional violations for missing background checks for a Board Officer.

If you have any questions, please e-mail me at whitney.mcgrath@doe.virginia.gov. Thank you for your cooperation during the inspection.

Violations:
Standard #: 22.1-289-036-B-4
Description: Based on record review and interview, an out-of-state child abuse and neglect background check has not been completed within the first 30 days of employment for each agent that has resided outside of the state of Virginia.
Evidence: Board Officer #1 documented on their sworn disclosure statement that they reside outside of the state of Virginia. When asked for the out-of-state central registry background check for Board Officer #1, the licensee's corporate office stated in an email on 9/8/2022, that the out-of-state central registry background search would be initiated and mailed that day.

Plan of Correction: Sent in mail last Thursday.

Standard #: 22.1-289.036-B-2
Description: Based on interview, each applicant has not submitted fingerprint results prior to the first date of employment.
Evidence: When asked to view the fingerprint results of Board Officer #1 (date of hire: 9/20/2021) the program director contacted their corporate office. The licensees corporate office confirmed in an email on 9/7/2022 that Board Officer #1 has not yet initiated their fingerprint background check.

Plan of Correction: Fingerprint has been completed.

Standard #: 8VAC20-770-40-D-1-a
Description: Based on interview, each applicant has not completed a sworn disclosure statement prior to the first date of employment and/or a central registry background check within the first 30 days of employment.
Evidence: When asked to view the sworn disclosure statement and central registry background check results of Board Officer #1 (date of hire: 9/20/2021) the program director contacted their corporate office. On 9/7/2022, the licensee's corporate office provided a sworn disclosure statement that was signed on 8/29/2022 and a central registry background check that was notarized on 9/3/2022. The corporate office stated that the central registry background search would me mailed 9/8/2022.

Plan of Correction: Sworn disclosure has been completed. Central registry was sent out by mail last Thursday.

Standard #: 8VAC20-780-130-A
Description: Based on record review, the program did not obtain documentation of immunizations for each child before the child can attend the center.
Evidence: Child #5's record did not contain documentation of immunizations.

Plan of Correction: Email the parent to have them send them over.

Standard #: 8VAC20-780-40-N
Description: Based on a review of documentation, the center does not have written playground safety procedures.
Evidence: When requested, the Director could not produce the playground safety procedures. This was previously cited on 12/13/2021 and 3/28/2022.

Plan of Correction: Place a playground safety procedure up on board for staff to see/follow.

Standard #: 8VAC20-780-60-A
Description: Based on record review, children's records did not contain all required information.
Evidence: Child #1's record did not contain a street address for the emergency contact and did not have a second emergency contact.

Plan of Correction: Email parent to collect info.

Standard #: 8VAC20-780-245-L
Description: Based on interview, there was not at least one staff member on duty who has obtained within the last three years instruction in performing the daily health observation of children.
Evidence: The program director confirmed that none of the staff have completed daily health observation training. This was previously cited on 12/13/2021, 3/28/2022 and 6/22/2022.

Plan of Correction: Use the link [licensing inspector] provided and complete the daily observation.

Standard #: 8VAC20-780-340-F
Description: Based on observation, children under 10 years of age were not always within actual sight and sound supervision of staff.
Evidence:
1. At the start of the inspection, the Director was observed in the hallway having a conversation with a family that was dropping their child off. After approximately 2 minutes, the Director joined a group of 19 children in the gym. There was no additional staff supervising the children in the gym while the Director was working with the family down the hall.
2. A child was observed leaving the classroom to place artwork in their locker. The child then lingered in the hallway unsupervised for approximately one minute to watch the children playing in the gym before the Director instructed the child to return to the classroom.
This was previously cited on 3/28/2022 and 6/22/2022.

Plan of Correction: Close after school classroom door to limit the children access to change locations without asking. Have staff member watch children at all times. Same applies for gym.

Standard #: 8VAC20-780-350-C
Description: Based on observation, the center did not follow the staff-to-child ratio applicable to the youngest child in the group in a regularly mixed age group.
Evidence: In the classroom there 20 children of a mixed age group of children 5 years through 12 years with one staff. In the gym there were 19 children of a mixed age group of children 5 years through 12 years with one staff. The ratio for children age 5 is one staff per 18 children.

Plan of Correction: Hire more staff to make sure we meet the proper ratios.

Standard #: 8VAC20-780-550-A
Description: Based on a review of documentation, the center does not have a written emergency preparedness plan that addresses staff responsibility and facility readiness with respect to emergency evacuation and relocation, shelter-in-place, and lockdown.
Evidence: When requested, the Director could not produce an emergency preparedness plan.

Plan of Correction: Type up a clear written emergency action plan and place in classroom board and go over with staff.

Standard #: 8VAC20-820-120-E-2
Description: Based on observation, the findings of the most recent inspection was not posted.
Evidence: The inspection posted at the facility is dated 3/28/2022. The most recent inspection of the center was on 6/22/2022.

Plan of Correction: Posted on the classroom board.

Disclaimer:

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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