VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Learning Experience
4683 Pouncey Tract Road
Glen allen, VA 23059
(804) 360-4226

Current Inspector: Florence Martus (804) 389-0157

Inspection Date: June 15, 2023

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 8VAC20-770 Background Checks 20 Access to minor's records 22.1 Early Childhood Care and Education 32.1 Report by person other than physician 63.2 Child Abuse & Neglect

Technical Assistance:

n/a

Comments:

An unannounced monitoring inspection was conducted on Thursday, June 15, 2023 to determine the center's compliance with licensing standards. The inspector was on site from 9:00am to approximately 2:05pm. There were a total of 130 children present in the direct care of 15 staff members. The director and assistant director assisted the inspector throughout the inspection. Upon the inspector's arrival, the children and staff were observed in their respective classrooms. The children were observed during transitions, during free-play, and teacher-led activities. The center is equipped with age-appropriate materials and equipment for the children's use. Staff were engaged with the children and offered guidance when needed. The areas where children receive care were inspected and found to be in compliance. The required postings were observed. Transportation is provided and vehicles used for transportation were inspected. Medication is administered and medications and authorizations were reviewed. During the inspection, ten children's records and ten staff records were reviewed. Information gathered during the inspections determined non-compliance with applicable standards or law and violations were documented on the violation notice issued to the program. 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 the date of receipt. You should 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 stand(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).

Violations:

Standard #:	22.1-289.035-B-4
Description:	Based on a review of ten staff records and interview, the center did not obtain a copy of the results of a criminal history record information check, a sex offender registry check, and a search of the child abuse and neglect registry or equivalent registry from any state in which one individual had resided in the preceding five years within the required timeframe. Evidence: 1) The record of Staff #4, employed on 06/06/22, indicated the staff had resided in a state outside of Virginia within the last five years. The record did not contain the results of a criminal history record information check, a sex offender registry check, or a search of the child abuse and neglect registry or equivalent registry from the state. 2) During interview, a member of management confirmed the required out-of-state background checks were not obtained for Staff #4. The out-of-state criminal history record information check and the sex offender registry check are required to be obtained prior to employment. The out-of-state search for founded complaints of child abuse or neglect is required to be requested within the first 30 days of employment.
Plan of Correction:	Per the Center: "CD will review staff paperwork on paperwork day. Paperwork day will be day 1 upon fingerprint receipt of background. Owner will follow up on new hire packet on same day and approve all submitted documents to ensure all are accounted for."
Standard #:	8VAC20-770-60-B
Description:	Based on a review of ten staff records and interview, the center did not ensure one staff had a completed sworn statement or affirmation prior to employment. Evidence: 1) The record of Staff #10, employed on 02/13/23, did not contain a completed sworn statement or affirmation. 2) During interview, a member of management confirmed the center did not have a completed sworn statement or affirmation on file for Staff #10.
Plan of Correction:	Per the Center: "CD will review staff paperwork on paperwork day. Paperwork day will be day 1 upon fingerprint receipt of background. Owner will follow up on new hire packet on same day and approve all submitted documents to ensure all are accounted for."
Standard #:	8VAC20-770-60-C-2
Description:	Based on a review of ten staff records and interview, the center did not ensure seven staff members had a central registry finding within 30 days of employment. Evidence: 1) The central registry finding in the record of Staff #1, employed on 06/01/21, was completed on 01/19/22. The record did not contain documentation that the center followed up with the Office of Background Investigation within 30 days of employment. 2) The records of Staff #4 (DOE: 06/06/22); Staff #5 (DOE: 05/04/23); Staff #7 (DOE: 08/22/22); Staff #8 (DOE: 11/01/22); Staff #9 (DOE: 11/21/22); and Staff #10 (DOE: 02/13/23) did not contain a central registry finding within 30 days of employment. 3) During interview, a member of management confirmed the results of the central registry finding for the staff were not received. The center did not have documentation of following up with the Office of Background Investigation within 30 days of employment for Staff #5, Staff #8, Staff #9, or Staff #10.
Plan of Correction:	Per the Center: "CD will review staff paperwork on paperwork day. Paperwork day will be day 1 upon fingerprint receipt of background. Owner will follow up on new hire packet on same day and approve all submitted documents to ensure all are accounted for."
Standard #:	8VAC20-780-160-A
Description:	Based on a review of ten staff records and interview, the center did not ensure seven staff members submitted documentation of a negative tuberculosis (TB) screening within the required timeframe. Evidence: 1) The record of Staff #2, employed on 04/25/22, did not contain documentation of a negative TB screening. 2) The record of Staff #3, employed on 06/12/23, did not contain documentation of a negative TB screening. 3) The record of Staff #6, employed on 06/12/23, did not contain documentation of a negative TB screening. 4) The record of Staff #7, employed on 08/22/22, did not contain documentation of a negative TB screening. 5) The record of Staff #8, employed on 11/01/22, contained a TB screening that was completed on 11/21/22. 6) The record of Staff #9, employed on 11/21/22, did not contain documentation of a negative TB screening. 7) The record of Staff #10, employed on 02/13/23, did not contain documentation of a negative TB screening. 8) During interview, a member of management confirmed the TB screenings were not obtained within the required timeframe. Documentation of the screening shall be submitted at the time of employment and prior to coming into contact with children. The documentation shall have been completed within the last 30 calendar days of the date of employment and be signed by a physician, physician's designee, or an official of the local health department.
Plan of Correction:	Per the Center: "1. All outstanding TB tests will be turned into CD by 7/17/23 to correct noncompliance. 2. CD will review staff paperwork on day 1 upon receipt of fingerprint background check, then submit paperwork to owner for review to ensure all documents are received and employee is able to work."
Standard #:	8VAC20-780-160-C
Description:	Based on a review of ten staff records and interview, the center did not ensure one staff obtained the results of a follow-up tuberculosis (TB) screening at least every two years from the date of the first initial screening or testing. Evidence: 1) The most recent TB screening in the record of Staff #1, employed on 06/01/21, was completed on 05/19/21 and expired on 05/19/23. 2) During interview, a member of management confirmed the center does not have documentation of a current negative TB screening on file for Staff #1.
Plan of Correction:	Per the Center: "CD will use center calendar reminder system to record TB expiration dates and put in reminders for 2 weeks before expiration to ensure TB stays current. CD, AD and owner will have access to the calendar tool. CD will submit to owner renewed TB test to ensure compliance. All expired TBs are due to the owner by 7/17/23."
Standard #:	8VAC20-780-70
Description:	Based on a review of ten staff records and interview, the center did not ensure two staff records contained the required information. Evidence: 1) During interview, Staff #2 was identified as a program leader, but the staff record did not contain documentation that the staff possesses the education, certification, and experience required by the job position. 2) During interview, Staff #8 was identified as a program leader, but the staff record did not contain documentation that the staff possesses the education, certification, and experience required by the job position.
Plan of Correction:	Per the Center: "Lead teacher training and record now in place. Going forward, lead teacher training will be completed within employee's first 30 days if support staff and within first week for all new lead staff."
Standard #:	8VAC20-780-240-A
Description:	Based on a review of ten staff records and interview, the center did not ensure five staff completed the Virginia Department of Education-sponsored (VDOE) orientation course within 90 calendar days of employment. Evidence: 1) The following staff records did not contain documentation that the staff completed the VDOE-sponsored orientation course - Staff #2 (DOE: 04/25/22); Staff #7 (DOE: 08/22/22); Staff #8 (DOE: 11/01/22); Staff #9 (DOE: 11/21/22); and Staff #10 (DOE: 02/13/23). 2) During interview, a member of management reported the center did not have documentation that the staff completed the VDOE-sponsored orientation course.
Plan of Correction:	Per the Center: "All outstanding DOE orientations will be submitted to the CD by 7/24/23. Going forward, CD will use the center calendar system to track the employees 90 days. Once the DOE orientation is obtained, CD will submit to the owner to ensure compliance."
Standard #:	8VAC20-780-240-B
Description:	Based on a review of ten staff records, the center did not ensure four staff completed orientation training prior to the staff members working alone with children and no later than seven days of the date of assuming job responsibilities. Evidence: 1) The orientation training in the record of Staff #2, employed on 04/25/22, was completed on 12/29/22. 2) The orientation training in the record of Staff #8, employed on 11/01/22, was completed on 11/11/22. 3) The orientation training in the record of Staff #9, employed on 11/21/22, was completed on 06/15/23. 4) The orientation training in the record of Staff #10, employed on 02/13/23, was completed on 02/28/23.
Plan of Correction:	Per the Center: "Orientation will be completed on day 1 with paperwork orientation and submitted with day 1 paperwork to ensure compliance. All staff orientation in place as of 6/`6/23."
Standard #:	8VAC20-780-240-E
Description:	Based on a review of ten staff records, the center did not ensure one staff completed orientation training in first aid and cardiopulmonary resuscitation (CPR), as appropriate to the age of the children in care within 30 days of the first day of employment. Evidence: Staff #2, employed on 04/25/22, completed the first and CPR orientation training on 12/29/22.
Plan of Correction:	Per the Center: "CPR within 30 days and CD will submit to owner to ensure compliance. Class scheduled for 7/26/23."
Standard #:	8VAC20-780-245-A
Description:	Based on a review of ten staff records, the center did not ensure two staff completed annually a minimum of 16 hours of training appropriate to the age of children in care. Evidence: 1) The documentation of training in the record of Staff #1, employed on 06/01/21, did not contain sufficient documentation to show the staff completed 16 hours of annual training from 06/2022-06/2023. 2) The documentation of training in the record of Staff #2, employed on 04/25/22, did not contain sufficient documentation to show the staff completed 16 hours of annual training from 04/2022-04/2023.
Plan of Correction:	Per the Center: "All training will be kept in training binder and reviewed on a monthly basis. Going forward, admin on site will note anniversary dates within the system and put reminders on calendar to ensure all training areas are covered and ensure compliance."
Standard #:	8VAC20-780-280-B
Description:	Based on observations, the center did not ensure hazardous substances such as cleaning materials, insecticides, and pesticides shall be kept in a locked place using a safe locking method that prevents access by children. Evidence: 1) In the Preppers classroom, a bottle of bleach/water solution was observed in an unlocked cabinet. 2) In the PreK-1 classroom, two bottles of cleaning materials were observed in an unlocked cabinet.
Plan of Correction:	Per the Center: "Cabinet locked upon finding. Going forward, retrain staff on locking spray. Review health and safety orientation on 7/15/23."
Standard #:	8VAC20-780-280-H
Description:	Based on observation and interview, the center did not ensure purses were not accessible to children. Evidence: 1) In the Preschool 2 classroom, two staff purses were observed on a countertop within the reach of children. 2) In the School Age classroom, a staff purse was observed in an area that was accessible to children. 3) A member of management acknowledged the purses belonged to staff members and they should have been locked to ensure cosmetics, medications, or other harmful agents were not accessible to children.
Plan of Correction:	Per the Center: "All belongings put away during visit. Going forward, all staff retrained on personal belongings being put away under lock. CD, AD, and any office personnel will spot check the classrooms during period walk through to ensure all belongings are put away."
Standard #:	8VAC20-780-290-A-3
Description:	Based on observation, the center did not ensure electrical outlets shall have protective covers that are of a size that cannot be swallowed by children. Evidence: During the inspection of the classrooms, the inspector observed the following - 1) In the Preppers classroom, one electrical outlet did not have a protective cover. 2) In the Infant B classroom, one electrical outlet did not have a protective cover. 3) In the Toddler A classroom, two electrical outlets did not have protective covers. 4) In the Toddler B classroom, three electrical outlets did not have protective covers. 5) In the Twaddlers classroom, two electrical outlets did not have protective covers. 6) In the Preschool 1 classroom, one electrical outlet did not have a protective cover. 7) In the Preschool 2 classroom, one electrical outlet did not have a protective cover.
Plan of Correction:	Per the Center: "Outlet covers placed during visit. Going forward, admin will check all outlet covers during period building walkthrough."
Standard #:	8VAC20-780-500-B
Description:	Based on observation, and interview, the center did not ensure the diapering area in one classroom had a nonabsorbent surface for diapering or changing. Evidence: 1) The top portion of the diaper changing pad in the Twaddler classroom had a tear on it, therefore it is no longer non-absorbent. 2) During interview, a member of management confirmed the diaper changing pad in the Twaddler classroom is torn.
Plan of Correction:	Per the Center: "Diaper changing pad replaced. Going forward, admin will spot check changing pads provided during classroom walkthroughs."
Standard #:	8VAC20-780-510-P
Description:	Based on a review of documentation, medication review, observation, and interview, the center did not ensure when an authorization for medication expired, the parent shall be notified that the medication needs to be picked up within 14 days or the parent must renew the authorization. Evidence: 1) A medication authorization for a long-term prescription medication was observed on 06/15/23 for Child #14. The authorization was signed on 10/11/21 and expired within six months. The medication was observed on site at the time of the inspection. 2) During interview, a member of management acknowledged the authorization has not been renewed and that the medication has not been properly disposed of. When an authorization for medication expires, the parent shall be notified that the medication needs to be picked up within 14 days or the parent must renew the authorization. Medications that are not picked up by the parent within 14 days will be disposed of by the center by either dissolving the medication down the sink or flushing it down the toilet.
Plan of Correction:	Per the Center: "AD will log all long term medications into the center calendar system and follow up with parent. All expired medications and/or plans will be sent with parent upon expiration date. CD and owner will have access to the calendar and spot check information monthly."
Standard #:	8VAC20-780-520-C
Description:	Based on observation and interview, the center did not ensure all requirements were met when diaper ointment or cream is used. Evidence: 1) In the Preppers classroom, a diaper ointment was observed for Child #11. 2) During interview, a member of management reported the center did not have written parent authorization noting any adverse reactions. 3) Diaper ointment and creams were observed next to the changing table in the Preppers classroom. They were accessible to children and seven of them were not labeled with the child's name. If diaper ointment or cream is used, the following requirements shall be met: 1. Written parent authorization noting any known adverse reactions shall be obtained; 2. These products shall be in the original container and labeled with the child's name; 3. These products do not need to be kept locked but shall be inaccessible to children; 4. A record shall be kept that includes the child's name, date of use, frequency of application and any adverse reactions; and 5. Staff members without medication administration training may apply diaper ointment, unless it is prescription diaper ointment, in which case the storing and application of diaper ointment must meet medication-related requirements.
Plan of Correction:	Per the Center: "Diaper creams removed from room. Proper diaper cream form obtained for any student needing cream. Going forward, teachers retrained on health and safety as it relates to diaper cream and permissions."
Standard #:	8VAC20-780-530-A
Description:	Based on observation, a review of records, and interview, the center did not ensure at least one staff in each classroom or area where children are present shall have current certification in cardiopulmonary resuscitation (CPR) and first aid as appropriate to the age of the children in care. Evidence: 1) Staff #10, employed on 02/13/23, was the only staff member present in the Preppers classroom. 2) The record did not contain documentation that the staff has current certification in CPR and first aid. 3) During interview, a member of management confirmed Staff #10 does not have current certification in CPR and first aid. 4) Staff #3, employed on 06/12/23, and Staff #8, employed on 11/01/22, were the only staff members present in the Preschool 2 classroom. 5) Their records did not contain documentation that the staff have current certification in CPR and first aid. 6) During interview, a member of management confirmed the staff do not have current certification in CPR and first aid.
Plan of Correction:	Per the Center: "CPR class is scheduled for 7/26/23 for all staff. Going forward, CPR/first aid class will be held in the new staff members first 90 days. Proof of completion will be put into file and submitted to owner to ensure compliance."
Standard #:	8VAC20-780-550-E
Description:	Based on a review of documentation and interview, the center did not ensure shelter-in-place procedures shall be practiced a minimum of twice per year. Evidence: 1) The center's emergency drill log for 2022 was reviewed. The most recent shelter-in-place procedures were practiced on 07/29/22. 2) During interview, a member of management reported the shelter-in-place procedures were not practiced a second time in 2022.
Plan of Correction:	Per the Center: "Shelter in place drill completed as of 7/15/23. Going forward, CD, AD and any office personnel will use the center calendar reminder system to complete shelter in place semi-annually."
Standard #:	8VAC20-780-550-G
Description:	Based on a review of documentation and interview, the center did not maintain documentation of an emergency evacuation drill that included the required components. Evidence: 1) The emergency evacuation drill noted for May 23, 2023, only included the date, and time of the drill, and the number of staff and children participating. Documentation should include: 1. Identity of the person conducting the drill; 2. The date and time of the drill; 3. The method used for notification of the drill; 4. The number of staff participating; 5. The number of children participating; 6. Any special conditions simulated; 7. The time it took to complete the drill; 8. Problems encountered, if any; and 9. For emergency evacuation drills only, weather conditions. 2) During interview, a member of management confirmed the evacuation drill was not documented with the required information.
Plan of Correction:	Per the Center: "All emergency drill information will be filed in on day of the drill. CD, AD, and all office personnel will have access to calendar system to ensure drills are recorded fully on day they occur."
Standard #:	8VAC20-780-550-P
Description:	Based on a review of documentation,, the center did not ensure that written injury records contained the required information. Evidence: Three written injury records were reviewed. The following documentation was missing - Injury record #1 did not contain documentation of the date and time when parents were notified; any future action to prevent reoccurrence of the injury; and documentation on how parent was notified. The center should maintain a written record of children's serious and minor injuries in which entries are made the day of occurrence. The record shall include the following: date and time of injury; name of injured child; type and circumstance of the injury; staff present and treatment; date and time when parents were notified; any future action to prevent reoccurrence of the injury; staff and parent signatures or two staff signatures; and documentation on how parent was notified.
Plan of Correction:	Per the Center: "Injury reports will be reviewed by office staff before filing away. CD and AD will review reports monthly to ensure compliance."