VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Learning at the Lake, LLC
16050 Mountain Road
Montpelier, VA 23192
(804) 363-9124

Current Inspector: Heather Dapper (804) 625-2304

Inspection Date: April 5, 2023

Complaint Related: Yes

Areas Reviewed:

X 8VAC20-780 Administration. X 8VAC20-780 Staff Qualifications and Training. X 8VAC20-780 Physical Plant. X 8VAC20-780 Staffing and Supervision. X 8VAC20-780 Programs. X 8VAC20-780 Special Care Provisions and Emergencies X 8VAC20-780 Special Services. X 8VAC20-820 THE LICENSE. X 8VAC20-820 THE LICENSING PROCESS. X 8VAC20-820 HEARINGS PROCEDURES. X 8VAC20-770 Background Checks X 22.1 Early Childhood Care and Education X 63.2 Child Abuse & Neglect

Comments:

The licensing inspector conducted an unannounced complaint investigation in response to a complaint that was received by the Office of Child Care Health and Safety on March 29, 2023, regarding allegations in the area of supervision. The investigation was initiated on April 5, 2023 and concluded on April 5, 2023. On April 5, 2023, the inspector was on site at the center from approximately 12:55pm to 3:45pm. Interviews with the center staff were completed, observations were made in the center, and documentation was reviewed. The inspector completed an additional interview on April 5, 2023. The preponderance of the evidence gathered during the investigation supports the allegation; therefore, the complaint is determined to be valid. Though not a part of the original complaint, there were violations found during the inspection regarding children?s records, staff records and ratio. See the violation notice for more details. 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 5 business days from today. Please 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 noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measures. Please do not use staff names, list staff by positions only. If you have any questions about this inspection, please contact the licensing inspector at (804) 929-3771. Revised 5/2/2023

Violations:

Standard #:	8VAC20-780-140-A
Complaint related:	No
Description:	Based on record review the center did not ensure each child have a physical examination by or under the direction of a physician, before the child?s attendance or within 30 days after the first day of attendance. Evidence: The record of child #1 (enrollment date: 9/12/2022) did not have documentation of a physical examination.
Plan of Correction:	The Director will do better to maintain the children's records. I have put in place a monthly review for all records to check for missing or outdated documents.
Standard #:	8VAC20-780-160-A
Complaint related:	No
Description:	Based on record review, the center did not ensure each staff member and individual from an independent contractor submit documentation of a negative tuberculosis screening at the time of employment and prior to coming in contact with children. Evidence: The record of staff #2 (employment date: 1/16/2023) did not have documentation of a negative tuberculosis screening.
Plan of Correction:	The Director will make every effort to collect all information at the beginning of employment or within the 60 days of hire. The employee no longer works for Learning at the Lake.
Standard #:	8VAC20-780-160-C
Complaint related:	No
Description:	Based on record review, the center did not ensure at least every two years from the date of the initial screening or testing, staff members obtain and submit the results of a follow-up tuberculosis screening. Evidence: The record of staff #1 (employment date: 10/25/2021) did not have documentation of a follow up tuberculosis screening at least two years from the date of the initial screening. The staff member?s tuberculosis screening was dated 1/11/2019.
Plan of Correction:	The Director will do better to maintain staff records and keep all of their records up to date. I have put in place a staff checklist that will be reviewed every two months to keep all the staff on track with all of their appropriate paperwork.
Standard #:	8VAC20-780-40-E
Complaint related:	Yes
Description:	Based on documentation review and an interview, the licensee failed to ensure that the center?s activities, services, and facilities are maintained in compliance with Child Day Center Licensing Standards, the center?s own policies and procedures that are required by the standards, and the terms of the current license issued by the department. Evidence: The center?s procedures for identifying where attending children are at all times as required by standard 8VAC20-780 240.D.3 stated the following: ?THE TEACHERS AND ASSISTAN[T]S WILL KNOW WHERE THE CHILDREN ARE AT ALL TIMES. UNDER NO CIRCUMSTANCES WILL THE CHILDREN EVER BE LEFT UNATTENDED. SOMEONE MUST BE WITH THEM WHEN THEY MOVE FROM ONE PLACE TO ANOTHER.? An incident occurred on March 28, 2023, when staff #1 and staff #2 were not able to identify where child #1 (Age 2 years) was located. Staff #2 stated that child #1 was left unattended for approximately less than 2 minutes.
Plan of Correction:	The Staff has been re-trained on outside activities and playground safety. All classes will be going outside at different times with at least 3 adults. The daycare is also having a fence installed in the playground are beginning the week of May 1, 2023
Standard #:	8VAC20-780-70
Complaint related:	No
Description:	Based on record review, the center did not ensure one of two staff records contained all required documentation. Evidence: The record of staff #2 (employment date:1/16/2023) did not have the following: staff person?s name, address; two references; documentation to demonstrate that the individual possesses the education, certification, and experience required by the job position, and orientation training; and emergency contact address.
Plan of Correction:	The Director will make every effort to collect all information at the beginning of employment or within the 60 days of hire. Updated name, address, references, their addresses & phone #s and emergency contacts. Employee is no longer working for Learning at the Lake.
Standard #:	8VAC20-780-340-A
Complaint related:	Yes
Description:	Based on interviews, the center staff did not ensure the care and protection of a child they were supervising on March 28, 2023. Evidence: On April 5, 2023 the licensing inspector conducted interviews with staff #1, staff #2 and an additional witness. The following was determined: 1. Staff #1 and staff #2 were in charge of supervising a group of 20 children including child #1 (age 2 years) on March 28, 2023. While on the playground both staff members noticed that child #1 was not with the group of children. 2. Both staff #1 and staff #2 confirmed that child #1 was playing with a toy on an island in the center?s parking lot, in front of the center, while both staff and the group of children were located on the playground behind the center. 3. On March 28, 2023, between the hours of 10:30am and 12:00pm, while driving on the street adjacent to the center, a witness noticed a child who fit the description of child #1 playing with a toy on an island alone in the center?s parking lot.
Plan of Correction:	The Staff has been re-trained on outside activities and playground safety. All classes will be going outside at different times with at least 3 adults. The daycare is also having a fence installed in the playground are beginning the week of May 1, 2023
Standard #:	8VAC20-780-340-F
Complaint related:	Yes
Description:	Based on interviews, the center failed to ensure that children under 10 years of age are always within actual sight and sound supervision of staff. Evidence: On April 5, 2023, the licensing inspector conducted interviews with staff #1 and staff #2 at the center. On March 29, 2023 the inspector received written information from a witness and interviewed the same witness on April 5, 2023. The following was determined: 1. On March 28, 2023, child #1 (Age 2 years) exited the center?s playground area alone, and entered the front parking lot of the center. Staff #1 and staff #2 was supervising a group of 20 children, between the ages of 16 months to 4 years, on the playground. 2. Child #1 was found and picked up by staff #2 approximately less than two minutes after staff #2 noticed that child #2 was missing from the playground. 3. While driving on the street adjacent to the center, a witness noticed a child playing on an island in the center?s parking lot alone with no staff in sight. The witness then turned their vehicle around and drove past the center again. The witness then noticed a male staff member pick up child #1 and walk towards the center.
Plan of Correction:	The Staff has been re-trained on outside activities and playground safety. All classes will be going outside at different times with at least 3 adults. The daycare is also having a fence installed in the playground are beginning the week of May 1, 2023
Standard #:	8VAC20-780-350-C
Complaint related:	Yes
Description:	Based on interviews and record review, the center did not ensure when children are in ongoing mixed age groups, the staff-to-children ratio and group size applicable to the youngest child in the group shall apply to the entire group. Evidence: 1. Staff #1 stated that the Preschool teacher was not present on March 28, 2023 and as a result, all of the children from the Toddler 1 (Ages 16-24 months), Toddler 2 (Age 2 years) and Preschool (3-4 years) classrooms were combined for the entire day. 2. Both staff #1 and staff #2 confirmed that they were the only two teachers on the playground with the Toddler 1 (Ages 16-24 months), Toddler 2 (Age 2 years) and Preschool (3-4 years) classrooms on March 28, 2023. 3. The attendance record for the Toddler 1 (Ages 16-24 months) classroom showed that there were 7 children present on March 28, 2023. The attendance record for the Toddler 2 (Age 2 years) showed that there were 6 children present on March 28, 2023. The attendance record for the Preschool (3-4 years) classroom showed that there were 7 children present on March 28, 2023. Staff #1 confirmed the group of Toddler 1, Toddler 2 and the Preschool group combined, totaled 20 children. 4. Staff #1 stated that there were two teachers with the group of 20 children for the entire day. 5. Staff #2 stated that there were two teachers with the group of 20 children for some of the day and the center representative came into the classroom to help periodically. 6. The required staff-to-child ratio for the group of 20 children (approximate ages 16 months to 4 years) was 1:5. The center maintained a 1:10 ratio during some of the day and while on the playground on March 28, 2023.
Plan of Correction:	The Staff has been re-trained on outside activities and playground safety. All classes will be going outside at different times with at least 3 adults. The daycare is also having a fence installed in the playground are beginning the week of May 1, 2023
Standard #:	8VAC20-780-530-A
Complaint related:	No
Description:	Based on interviews and record review, the center did not ensure that at least one staff in each classroom or area where children are present have current certification in first aid and CPR. Evidence: 1. The record of staff #2 (employment date:01/16/2023) did not have documentation of a current certification in first aid and CPR. 2. Staff #2 is the assigned Toddler 2 classroom teacher. The center representative confirmed that staff #2 is the assigned teacher for the Toddler 2 classroom and is often alone with the children assigned to the Toddler 2 classroom.
Plan of Correction:	The director will make every effort to collect all information at the beginning of employment or within the 60 days of hire. The employee is no longer working at Learning at the Lake.