VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Guidepost Montessori at Burke
6000 School House Woods Rd.
Burke, VA 22015
(571) 404-6991

Current Inspector: Sarah Marbert (703) 479-4678

Inspection Date: Aug. 28, 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 (8VAC20-770) 20 Access to minor?s records 22.1 Background Checks Code, Carbon Monoxide 63.2 Child Abuse & Neglect

Technical Assistance:

Discussed with Head of School: *Over-The-Counter medication must have a completed medication authorization form, not a topical ointment form and return when no longer administered. (Child no longer enrolled) *Room ratio for the Children?s House rooms. *Staff interactions with children.

Comments:

An unannounced renewal visit was conducted toady. Children were observed playing on the playground, involved in a wide variety of activities in the rooms, washing hands, and during rest time. 5 staff and 7 child records were reviewed. See Violation Notice for non-compliances cited. Emergency evacuation drills, emergency supplies, first aid supplies, first aid/CPR certifications, menu and rest cot spacing were all in compliance today. A new safety feature has been added to the playground equipment to prevent injuries or entrapment. Model forms provided to the Head of School: injury reports, injury prevention plan (sample form) and a staff file checklist. Page 2 of the submitted renewal application was provided to the Interim Head of School in order to be amended. If you have questions regarding this information you may contact me at (703) 479-4678 or at Sarah.Marbert@doe.virginia.gov. LI was present today from 10:30 AM- 3:21PM

Violations:

Standard #:	22.1-289.011-F
Description:	Based on observation, the most recent inspection was not posted. Evidence: The inspection posted was dated 2/24/23. The most recent inspection was conducted on 7/19/23.
Plan of Correction:	Updated inspection report was posted promptly.
Standard #:	22.1-289.035-B-4
Description:	Based on a review of records, one staff record did not contain documentation of an out-of-state criminal history search for a residence held within the past 5 years. Evidence: 1 of 5 staff records reviewed did not contain a Criminal History Search for a residence in another state within the past 5 years. (Staff B)
Plan of Correction:	A new out of state criminal history search was conducted for this staff member promptly.
Standard #:	8VAC20-770-60-B
Description:	Repeat Violation Based on a review of records, staff records did not contain documentation of a completed Sworn Disclosure Statement (SDS) prior to employment. Evidence: 1. Staff A?s SDS was signed 8/28/23. DOH:7/31/23 2.Staff B?s SDS was signed 8/28/23. DOH: 8/7/23. 3. Staff C had no SDS on file during the inspection. DOH: 8/16/23
Plan of Correction:	3. 8VAC20-770-(BC)-60-C-2 Facility began use of the updated sworn disclosure form and verified completion by all staff as of 9.21.23.
Standard #:	8VAC20-770-60-C-2
Description:	Repeat Violation Systemic Deficiency Based on a review of records, one staff record did not contain the results of a completed Central Registry Search within 30 days of employment. Evidence: Staff D's record contained the results of a completed Central registry Search for a different business entity, not for this facility.
Plan of Correction:	Although results were on file for a Central Registry search for a sister school, a new search was initiated for the facility to meet licensing requirements.
Standard #:	8VAC20-780-160-A
Description:	Repeat Violation Based on a review of records, staff records did not contain documentation of a negative tuberculosis screening prior to employment and completed within the previous 30 calendar days. Evidence: 5 records reviewed. 1.Staff A- results were dated 8/9/23. DOH:8/7/23. 2. Staff C- no results were on file.
Plan of Correction:	Review of records was conducted for all staff, and all Tuberculosis screenings needed were scheduled as of 9.22.23.
Standard #:	8VAC20-780-40-J
Description:	Based on a review of documents and staff statement, there was no annual update available for review of the injury prevention plan. Evidence: The injury prevention plan could not be located during the inspection. No update could be located.
Plan of Correction:	With new school leadership now in place, this plan will be reviewed and updated promptly.
Standard #:	8VAC20-780-60-A
Description:	Repeat Violation Systemic Deficency Based on a review of records, child records did not include all required components. Evidence: 6 child records were reviewed. 1.One child?s allergy action plan was not updated annually. Form is dated 5/13/22. (Child 4) 2.Documentation of viewing children?s proof of birth documents was missing. (Children 1,2,5,6) 3.Parent?s work address/phone (Children 2,3) 4.Annual update to the child?s record (Child 2- record is dated 8/8/22) (Child 5- record is dated 4/1/22)
Plan of Correction:	A complete audit of child records will be conducted to identify and correct any missing information.
Standard #:	8VAC20-780-70
Description:	Based on a review of records, staff records did not contain all required documentation. Evidence: 1.Staff A?s record did not contain documentation of: employment application, address, phone number, 2 references checked prior to employment. 2. Staff C?s record did not contain documentation of an emergency contact?s information.
Plan of Correction:	All staff records will be reviewed and updated for completion with new Head of School.
Standard #:	8VAC20-780-210-A
Description:	Based on a review of records, one record did not contain documentation of qualifications for their position. Evidence: Staff B?s record does not contain documentation of qualifications for a lead position.
Plan of Correction:	Staff B?s position does not require the requested qualifications, which will be added as obtained.
Standard #:	8VAC20-780-240-B
Description:	Based on a review of records, staff records did not contain documentation of orientation having been conducted prior to the employee working alone with children or within 7 days of assuming job responsibilities. Evidence: 5 staff records reviewed. 3 of 5 records did not contain documentation of orientation. *Staff A: Date of Hire (DOH):7/31/23 *Staff B: DOH-8/7/23 *Staff C: DOH ? 8/16/23
Plan of Correction:	These 3 staff members will be re-trained with documentation completed NLT 9.29.23.
Standard #:	8VAC20-780-320-B
Description:	Based on observation, the restrooms provided for children with warm running water that exceeded 120 degrees Fahrenheit (F). Evidence: 1. The Toddler room bathroom water temperature registered 122.5 degrees F. 2. The Children?s House bathroom water temperature registered 127.5 degrees F.
Plan of Correction:	The hot water heated was adjusted to ensure a comfortable hot water temperature.
Standard #:	8VAC20-780-340-A
Description:	Repeat Violation Based on observation the center failed to ensure care, protection and guidance for a child in care. Evidence: A 15-month-old child was observed sitting on the wet ground on the playground for approximately 15 minutes while their class was outside. The child was unable to move or extricate themselves from the seated position. Staff were not physically or verbally engaged with the child while the Licensing Inspector was on the playground. When asked why the child was sitting against the wall, staff stated, ?she doesn?t walk?.
Plan of Correction:	Facility reviewed this deficiency with staff immediately. Differentiation during outdoor activities for this child was discussed following inspection with options to include: bringing a picnic blanket outside for child?s comfort while they explore near peers and adults, when the ground is wet, holding the child in arms to change locations periodically and enjoy different parts of the outdoor play area.
Standard #:	8VAC20-780-340-F
Description:	Repeat Violation Systemic Deficiency Based on direct observation, children under 10 years of age where not kept in actual sight and sound supervision. Evidence: At 1:40pm there was no staff person present in the Toddler 2 room when the LI entered the room. Staff A was gone from the room for approximately 1-2 minutes.
Plan of Correction:	The staff member in this instance was helping a child in the classroom restroom after a bowel movement, and was reminded immediately after the inspection of the importance of maintaining actual sight and sound by asking another adult to visually monitor the classroom or bringing all children for diapering together in the future. Additionally, facility reviewed this policy with all staff in writing on 9.21.23.
Standard #:	8VAC20-780-350-C
Description:	Repeat Violation Systemic Based on observation, when the center had on-going mixed age groups, the staff-to-child ratio applicable to the youngest child was not maintained. Evidence: At 1:40pm the Toddler 2 classroom was observed to have 8 children present resting on cots. The group contained one child that was 15 months old; therefore, a ratio of 1:4 was required (infant ratios). Infant ratios do not double during rest time.
Plan of Correction:	The child in this instance was newly enrolled and to be 16 months old by the week following the inspection. Center will no longer start toddlers prior to the date on which they are officially 16 months old to ensure established ratios are appropriate by regulation.
Standard #:	8VAC20-780-350-Q
Description:	Based on a review of records, child records did not contain documentation of a written assessment to assign a child to a different age group. Evidence: 2 children were moved from the Toddler room to the Children?s House room prior to their third birthday. 1. Child #2 has no assessment on file documenting the move was appropriate. 2. Child #3?s assessment does not document the child developmental level, and was not signed by the lead teacher in the classroom to which the child was moved.
Plan of Correction:	Move-up forms were updated to include the signature of the receiving teacher for future transitions to Children?s House and assessment completed for Child 2.
Standard #:	8VAC20-780-510-F
Description:	Repeat Violation Systemic Deficiency Based on a review of medication authorizations medications at the center do not have authorizations available. Evidence: 2 medications at the center do not have any authorizations available for review. (Child 6)
Plan of Correction:	Permission forms have been requested from the child?s parent. Facility will follow up until received,
Standard #:	8VAC20-780-510-I
Description:	Repeat Violation Systemic Deficiency Based on observation, medication was not in the original, labeled container. Evidence: Two Epi-pens at the center did not have a prescription label attached. (Child 6)
Plan of Correction:	New medication with attached prescription label requested. Facility will follow up until received.
Standard #:	8VAC20-780-550-P
Description:	Repeat Violation Systemic Deficiency Based on a review of reports, injury reports did not contain all required information. Evidence: 8 injury reports were reviewed. 1.8 reports did not contain documentation of the time of parent notification. 2. 1 of 8 did not contain documentation of the date of the injury.
Plan of Correction:	Updated injury forms were provided to staff which make it easier to include all required information. Admin staff will review all reports for completion, to include the date, before providing to parents and filing for the facility?s records.