VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Chesterbrook Academy #819
12960 Troupe Street
Woodbridge, VA 22192
(703) 878-1220

Current Inspector: Donna Liberman (540) 359-5244

Inspection Date: Nov. 14, 2022

Complaint Related: No

Areas Reviewed:

8VAC20-780 Administration. 8VAC20-780 Staff Qualifications and Training. 8VAC20-780 Staffing and Supervision. 8VAC20-780 Special Care Provisions and Emergencies. 8VAC20-770 Background Checks. 22.1 Background Checks Code.

Comments:

An unannounced inspection was initiated on 11/14/22 with the Assistant Director from 12:45pm to 3:15pm. Additional documentation was requested to be scanned by the Director. The inspection was in response to a self-report by the center to the Licensing Inspector on 11/8/22 regarding an injury to a child in care on 11/7/22. Four staff records, one child record, the attendance records from 11/7/22, and accident/incident reports were reviewed. The playground and two classrooms were observed. Four staff were interviewed. Violations were cited as a result of the inspection. An exit interview was conducted with the Director on 11/29/22. If you have any questions, you may contact the Licensing Inspector, Laura Brindle, at laura.brindle@doe.virginia.gov or 540-905-2062.

Violations:

Standard #:	22.1-289.035-B-2
Description:	Based on review of four staff records, the center did not obtain documentation of the results of a national fingerprint-based background check prior to employment. Evidence: The fingerprints on record for Staff #3, with an employment date of 8/29/22, were dated 9/2/22. The fingerprints on record for Staff #4, with an employment date of 2/28/22, were dated 3/2/22.
Plan of Correction:	We will give fingerprint instructions to and send daily reminders to ensure Fingerprint Background Checks for all new hires will be collected before the given hire date.
Standard #:	22.1-289.035-B-4
Description:	Based on review of four staff records, the center did not obtain the results of a sex offender registry check from all states in which a staff member had resided within the past five years prior to employment, or the results of a central registry check from all states in which a staff member had resided within the past five years within 30 days of employment. Evidence: The sworn statement on record for Staff #4 indicated that the staff member had resided in Arizona within the past five years. The employment date for Staff #4 was 2/28/22. There was no documentation of the results of a sex offender registry check from Arizona prior to employment on record for Staff #4. There was no documentation of central registry check results on record for Staff #4.
Plan of Correction:	We will ensure that when the state and federal background checks conducted for each employee is not or partially covered by their previous state, that a further/additional CPS and sex offender check is done for our employees.
Standard #:	8VAC20-770-60-B
Description:	Based on review of four staff records, the center did not obtain documentation of a completed sworn disclosure statement for each staff prior to date of hire. Evidence: The sworn disclosure on record for Staff #3, with an employment date of 8/29/22, was dated 9/20/22. The sworn disclosure on record for Staff #4, with an employment date of 2/28/22, was dated 3/1/22.
Plan of Correction:	Sworn disclosure will be collected from all new staff before date of hire.
Standard #:	8VAC20-770-60-C-2
Description:	Based on review of four staff records, the center did not obtain documentation of the results of a central registry search within 30 days of employment for staff members. Evidence: The central registry results on record for Staff #2, with an employment date of 9/12/22, were dated 11/1/22. The central registry results on record for Staff #3, with an employment date of 8/29/22, were dated 11/1/22. The central registry results on record for Staff #4, with an employment date of 2/28/22, were dated 4/10/22.
Plan of Correction:	All CPS registry communications on delivery updates will be conducted every 30 days and all documentation will be placed in designated teachers files.
Standard #:	8VAC20-780-160-A
Description:	Based on review of four staff records, the center did not ensure that each staff member submitted documentation of a negative tuberculosis (TB) screening at the time of employment and prior to coming into contact with children. Evidence: The record for Staff #2, with an employment date of 9/12/22, did not contain documentation of a negative TB screening. The TB screening on record for Staff #3, with an employment date of 8/29/22, was dated 9/1/22. The TB screening on record for Staff #4, with an employment date of 2/28/22, was dated 3/15/22.
Plan of Correction:	We will ensure that all new staff has a TB screening completed before they begin employment.
Standard #:	8VAC20-780-60-A-8
Description:	Based on review of one child record and interview, the center did not 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: The record for Child A contained documentation on their physical from the physician that the child should ?avoid dairy? and that there was a risk for ?anaphylaxis?. Staff stated that the child?s reaction to the allergen was a rash. There was no allergy care plan on record for Child A.
Plan of Correction:	The parents had insisted and written that the only action to be taken was they would bring in the milk substitute for the child and that all of the meals given must be dairy free. We will ensure that the physical form is read thoroughly and insist that the parents have the physician sign a FARE plan/form.
Standard #:	8VAC20-780-340-A
Description:	Based on interviews and review of documentation, the center did not ensure that when staff were supervising children, they always ensured their care, protection, and guidance. Evidence: On the afternoon of 11/7/22, Staff #1, Staff #2, Staff #3, and Staff #4 took the Pre-Toddler and Toddler classes outside to the playground where they were combined. There were 7 Pre-Toddler children (aged 12-months to 16-months-old) and 10 Toddlers (aged 16-months to two-years-old) present. Staff #2 then went inside to speak with management and Staff #3 took one child inside to change their diaper, leaving Staff #1 and Staff #4 supervising 16 children. The ratio required, based on the children?s ages present, was 1 staff: 4 children. At approximately 4:30pm Staff #1 reported that they heard Child A begin to cry and observed the child on the ground near the slide. Staff #1 approached the child and asked what happened but the child continued to cry. Staff #4 approached and asked what happened and reported noticing that the child seemed to act as if their arm was hurt. Staff #2 reported hearing Child A crying when they returned to the playground. None of the staff removed the child?s jacket to check the arm. None of the staff called the child?s parents. Child A?s parent arrived at approximately 4:40pm and staff told them that they were unsure why the child was crying, and that they had been crying for approximately 10 minutes. None of the staff reported concerns about Child A?s arm possibly being hurt to the parent. After arriving home, Child A?s parent removed their jacket and noticed something wrong with Child A?s arm. They took the child to the Emergency Room where Child A was diagnosed with a fracture to their arm.
Plan of Correction:	One teacher is presently no longer in our employ and another is on leave. Special Professional Development training will be conducted for all our staff on Being a Responsive Teacher.
Standard #:	8VAC20-780-340-D
Description:	Based on review of staff records, the center did not ensure that in each grouping of children at least one staff member who met the qualifications of a program leader was regularly present. Evidence: Staff #4 was reported to be the ?Teacher in charge? of the Pre-Toddler class. The record for Staff #4 did not contain documentation to qualify the staff member as a program leader. Interviews also revealed that Staff #4 does not yet qualify as a program leader.
Plan of Correction:	We will ensure that within each grouping there is a staff that is lead qualified, present with the students at all times.
Standard #:	8VAC20-780-350-B-1
Description:	Based on review of documentation and interviews, the center did not ensure that the required staff:child ratios were followed. Evidence: 1. On the afternoon of 11/7/22 there were 7 children from the Pre-Toddler class (children 12-months to 16-months-old) and 10 children from the Toddler class (16-months to two-years-old) on the playground with four staff members. The Pre-Toddler class required a ratio of 1 staff: 4 children and the Toddler class required a ratio of 1 staff: 5 children. At approximately 4:30pm Staff #2 went inside to speak with Management and Staff #3 took a child inside to change their diaper, leaving Staff #1 and Staff #4 supervising 16 children. 2. All four staff from the Pre-Toddler and Toddler classrooms stated that the ratio for the Pre-Toddler class was 1 staff: 5 children. The Pre-Toddler classroom is for children aged 12-months to 16-months and requires a ratio of 1 staff: 4 children.
Plan of Correction:	Staff ratios will be posted in each classroom as a reminder and teachers will be given training on the process of next steps when classrooms are or potentially are out of ratio.