VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Lilly Grace LLC
1908 West Club Lane
Richmond, VA 23226
(804) 282-4482

Current Inspector: Sharon Curlee (804) 840-8312

Inspection Date: July 27, 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. 8VAC20-820 THE LICENSE. 8VAC20-820 THE LICENSING PROCESS. 8VAC20-820 SANCTIONS. 8VAC20-820 HEARINGS PROCEDURES. 8VAC20-770 BACKGROUND CHECKS 22.1 EARLY CHILDHOOD CARE AND EDUCATION

Comments:

An unannounced renewal inspection was conducted today, July 27, 2023. The inspector was on site from approximately 8:40 am until 11:10 am. The director was present and assisted in the inspection. There were 20 children present, ranging in ages from three months to two and a half years, with four staff. Later additional two additional staff arrived. Upon the inspector?s arrival, children were napping. Two infants were in the swing. Later children played with toys on the mat and had a snack. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies and nutrition. A total of five child records and eight staff records were reviewed. Information gathered during the inspection determined non-compliance with applicable standards or law and violations were documented on the violation notice issued to the program. If you have questions regarding this inspection, please contact the licensing inspector. Sharon Curlee, Licensing Inspector Office of Child Care Health and Safety Division of Early Childhood Care and Education 804-840-8312 Sharon.curlee@doe.virginia.gov

Violations:

Standard #:	22.1-289.035-A
Description:	Based on review of eight staff records and interview, the center did not ensure one staff obtained up-dated background checks every five years. Evidence: 1. The record for staff #4 (employed 02/19/2013) contained the results of a fingerprint national criminal record check dated 05/31/2018, exceeding five years. 2. The director confirmed the fingerprint national criminal record check for staff #4 had not yet been obtained
Plan of Correction:	Per the director: I will get with staff and have them update the background check.
Standard #:	8VAC20-770-60-C-2
Description:	Based on review of eight staff records and interview, the center did not obtain the results of the central registry background report within 30 days of employment. Evidence: 1. The record of staff #1, employed 04/05/2022, contained the results of a central registry report dated 06/07/2023, exceeding 30 days from employment. 2. The director stated an original central registry check could not be located.
Plan of Correction:	Per the director: Going forward we will send the request off for background checks at the time or hire and follow up within 30 days for the status.
Standard #:	8VAC20-770-70-A
Description:	Based on review of staff records, the center did not obtain all required documentation for each staff record. Evidence: The record of staff #1 (employed 04/05/2022), did not contain documentation to demonstrate the individual possesses the education required by the job position. The director stated staff #1 is a program leader.
Plan of Correction:	Per the director: I have requested the staff provide a copy of their education for the record.
Standard #:	8VAC20-780-160-A
Description:	Based on review of eight staff records, the center did not obtain documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with children for three staff. The documentation must have been completed within the last 30 calendar days prior to employment. Evidence: 1. The record of staff #1, employed 04/05/2022, contained documentation of a negative tuberculosis screening dated 04/27/2022, exceeding the date of employment. 2. The record of staff #2, employed 06/20/2023, contained documentation of a negative tuberculosis screening dated 07/11/2023, exceeding the date of employment. 3. The record of staff #3 employed 06/13/2023, contained documentation of a negative tuberculosis screening dated 06/27/2023, exceeding the date of employment.
Plan of Correction:	Per the director: Going forward we will require staff provide their TB screening prior to hire.
Standard #:	8VAC20-780-40-E
Description:	Based on observation and review of the license, the licensee did not ensure operational responsibilities, including compliance with the terms of the current license issued by the department. Evidence: During the inspection on 07/27/2023, the licensing inspector observed four infants sleeping in cribs in classroom #1. The current license stipulates: ?Room 1- A maximum of three cribs/3 children at any one time?.
Plan of Correction:	Per the director: I will remove a crib from the room to ensure no more than three children are in the room at a time.
Standard #:	8VAC20-780-245-C
Description:	Based on review of eight staff records, the center did not ensure one staff completed a minimum of 16 hours of training appropriate to the age of the children in care annually. Evidence: The record of staff #7, did not contain documentation of 16 hours of training for the period of 01/05/2022 through 01/04/2023. The director stated staff #7 had not completed any training during the annual period
Plan of Correction:	Per the director: We will ensure staff complete 16 hours of training each year.
Standard #:	8VAC20-780-270-A
Description:	Based on observations, the center did not maintain all areas and equipment in a clean, safe, and operable condition. Evidence: 1. The metal lattice seats of two adult size chairs on the playground have pieces that are broken exposing a sharp edge that could snag the skin of a child in care. 2. A child size plastic picnic table on the playground has multiple holes on the top where small fingers could enter. The holes have rough edges that could snag the skin of a child in care.
Plan of Correction:	Per the director: I will remove the items from the playground today.
Standard #:	8VAC20-780-350-B-1
Description:	Based on observation and interview, the center did not maintain the required staff to children ratio for children birth up to 16 months of age. Evidence: 1. The required staff-to-children ratio for children birth up to 16 months is one staff for every four children. At approximately 8:45 am on July 27, 2023, nine children ages5 months through 16 months were observed in care with two staff member supervising. 2. The director stated additional staff would be arriving soon. The third staff arrived at 9:25 am. The director acknowledged the infant class was out of ratio.
Plan of Correction:	Per the director: I will adjust staff schedules to accommodate the arrival times of the children to ensure we are at ratio.