VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Guidepost Montessori at Ashburn Village
21711 Shellhorn Rd
Ashburn, VA 20147
(571) 210-7707

Current Inspector: Lisa Hudson (571) 389-2459

Inspection Date: Sept. 14, 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 HEARINGS PROCEDURES. 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 the concern of repeated and systemic violations that have been found during the licensing period. Discussed the importance of navigating and accessing the center's electronic files in an efficient way to ensure access during the licensing inspections. Please forward the annual health and fire inspection for review. As mentioned, please reach out to the local health department regarding the recent remediation on your building due to the humidity.

Comments:

An unannounced Renewal inspection was conducted today. The center was temporarily closed due to maintenance concerns and re-opened on 09/11/2023. Only the Children's House class have transitioned back to this center with plans to transition the remaining children within the next week. A total of 8 children with 3 staff were onsite during the inspection. Observation of all of the classrooms, to include one that is currently occupied, Children's House in addition to the remaining unoccupied classrooms. The children were outside playing on the playground at the beginning of the inspection. They were climbing the playground structure, running around together and interacting with staff. They transitioned to inside where they were observed going upstairs to the second floor while holding onto the stair rails. Hand washing was observed and the children broke into smaller groups of activities. Large world maps were on the floor where the children were interacting with the activity of placing pieces of continents onto the maps. Some cursive writing was also being performed by some children. One medication onsite and was reviewed along with 6 staff files and 3 children's files. Repeated violations have been found during the past 2 years of the licensing period. New Head of School on board, qualifications were verified during this inspection. This inspection occurred between 10am and 1:35pm. Please email me at: lisa.hudson@doe.virginia.gov with any questions.

Violations:

Standard #:	22.1-289.035-B-4
Description:	REPEAT Based on review of staff records, one background check was not obtained. Evidence: Staff #1 was hired on 06/05/2023. An out of state Central Registry search result has not been obtained.
Plan of Correction:	The missing out of State Central Registry Search submitted 9/22/2023
Standard #:	8VAC20-770-60-B
Description:	Based on staff record review, one additional background check was not on file for one staff. Evidence: Staff #4 was hired on 08/14/2023. A Sworn Statement was not found for this staff.
Plan of Correction:	Sworn statement was completed on 8/14/2023 and included in digital file, but was not located during visit. A copy has been added to the staff member's printed file.
Standard #:	8VAC20-780-160-A
Description:	Based on staff record review, a TB screening was not obtained prior to hire for 1 staff. Evidence: Staff #4 was hired on 08/13/2023. The TB risk assessment was dated 09/13/2023.
Plan of Correction:	This non-compliance was discovered and addressed by the facility before inspection. Staff member had provided a TB screening prior to start, but the screening provided was dated more than 30 days prior to their state. An updated sreening was provided 9.13.23
Standard #:	8VAC20-780-160-C
Description:	REPEAT Based on staff record review, subsequent TB risk screenings were not obtained every two years. Evidence: 1.Staff #2?s last documented TB screening was dated in 05/2021. 2. Staff #3?s last documented TB screening was dated 06/2021. 3.Staff #5?s last documented TB screening was in 05/2021.
Plan of Correction:	Staff #2 will complete an updated TB screening prior to returning to the facility. Staff # 3 Completed TB screening 9/22/2023 Staff #5 had TB screening updated 5/04/2023 but documentation was on site. This has been added to their file for easy access in future inspections.
Standard #:	8VAC20-780-70
Description:	Based on staff record review, 5 out of 5 staff records reviewed were incomplete. Evidence: Staff #1, 2, 3, 4 and 5?s records did not contain at least 2 references that included: dates of contact; names of persons contacted, the firms contacted, results and the signature of person making call.
Plan of Correction:	All staff files contained 2 written reference letters that were obtained prior to employment.
Standard #:	8VAC20-780-245-A
Description:	Based on review of training documentation, annual training was not obtained. Evidence: No documentation of annual training was found for Staff #2 and #3.
Plan of Correction:	Documentation of annual training for all staff will be updated and added to their file
Standard #:	8VAC20-780-260-A
Description:	Based on review of documentation, reports were not provided to the Licensing representative during the inspection. Evidence: A fire inspection report was not found.
Plan of Correction:	Most recent fire inspection has been added to licensing binder
Standard #:	8VAC20-780-260-B
Description:	Based on review of documentation, reports were not provided to the Licensing representative during the inspection. Evidence: Annual approval from the Health Department was not provided. The last documented health department approval was dated in 2021.
Plan of Correction:	Health department inspection will be scheduled the week of 9/25
Standard #:	8VAC20-780-270-A
Description:	REPEAT Based on observation of the children?s house playground, areas on the playground equipment was not maintained in a safe condition. Evidence: 1.The wooden beam across the top of the small slide on the children?s house playground equipment was splintered and cracked. 2.The area at the base of the building in between the two HVAC systems have areas without mulch causing large holes presenting a potential injury to children.
Plan of Correction:	Wood beam will be sanded down where splintered and cracked. Additional playground mulch has been scheduled for delivery to increase resilient surfacing and fill any holes
Standard #:	8VAC20-780-280-B
Description:	REPEAT Based on observation of the center, a hazardous substance was found unlocked. Evidence: A cleaning product labeled keep out of reach of children was found unlocked in the bathroom located in the Children?s House Classroom.
Plan of Correction:	A cabinet has been installed to house all products that need to be kept out of children's reach.
Standard #:	8VAC20-780-330-B
Description:	REPEAT Based on observation of the Children?s House playground, resilient surfacing did not comply with the National Safety for Playground standards. Evidence: All fall zones located on the children?s house playground (the around and directly underneath the rock-climbing wall and the base of each slide) did not have sufficient resilient surfaci
Plan of Correction:	Additional playground mulch was ordered and scheduled for delivery on 9/22/2023
Standard #:	8VAC20-780-420-E-3
Description:	Based on child record review, staff failed to receive parent confirmation annually that their child record was up to date. Evidence: An annual confirmation was not received from parents for Child #1, 2 and 3 that their child?s record was up to date
Plan of Correction:	Annual paperwork update is scheduled to be sent to all parents the week of 9/25/2023 with a required completion date of 10/2/2023
Standard #:	8VAC20-780-500-B
Description:	Based on one staff statement, a diapering area is not used for a child under the age of 3 years. Evidence: 1.One child who is under the age of 3 years wears a pull up. 2. A diapering surface located on a changing table or counter is not used when changing the child. 3. The trashcan located in the bathroom in the Children?s House classroom is used for disposing paper towels, trash, and soiled diapers/pull ups. The receptacle does not prevent staff or children?s hands from touching the receptacle.
Plan of Correction:	All children currently enrolled in this program are fully potty-trained and diapers and pull-ups are not in use, so a diapering area is not provided. Student belongings, including a pullup, may have accidentally transferred over from their previous classroom.
Standard #:	8VAC20-780-510-E
Description:	REPEAT Based on review of medication, the center failed to follow their own policy on medication administration. Evidence: A prescribed medication authorization for Child #1 did not include the duration of the authorization.
Plan of Correction:	Current form on file signed by physician on 8/8/2023 states at the top that it is for the current school year. Since school year was not listed, an additional form has been requested by parents.
Standard #:	8VAC20-780-510-I
Description:	REPEAT/SYSTEMIC Based on review of medication onsite, one medication was not properly labeled. Evidence:? A prescribed medication for child #1 did not have a pharmacy label attached.
Plan of Correction:	Pharmacy label was promptly requested from parents, and has been provided for medication.
Standard #:	8VAC20-780-550-B
Description:	Based on review of the emergency preparedness plan, the plan did not contain procedures components for a plan review and update. Evidence: 1.The center?s emergency preparedness plan did not include correct names of staff with responsibilities during an emergency. 2. The plan did not include the correct name of the child day center.
Plan of Correction:	Emergency preparedness plan has been updated to reflect current staff and center information.
Standard #:	8VAC20-780-550-E
Description:	Based on review of documented emergency drills, drills were not conducted. Evidence: No documentation found that 2 shelter in place drills were completed annually.
Plan of Correction:	Shelter in place drill scheduled for the week of 9/25/2023
Standard #:	8VAC20-780-550-F
Description:	Based on review of documented emergency drills, an annual drill was not conducted. Evidence: No documentation that an annual lock down drill was conducted.
Plan of Correction:	Lock down drill scheduled for the week of 9/25/2023
Standard #:	8VAC20-780-550-P
Description:	Based on review of injury reports, one report was incomplete. Evidence: An injury report dated 12/03/2021 for Child #2 did not include the time and method the parent was notified.
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.
Standard #:	8VAC20-780-560-F
Description:	Based on observation of the center, one required posting was not dated. Evidence: The snack menu posted upstairs was not dated.
Plan of Correction:	Snack menu has been updated with date, and posted in all required locations.
Standard #:	8VAC20-780-560-G
Description:	Based on observation of food brought from home, some food was not properly labeled. Evidence: Two lunch boxes located in the hallway outside of the Children?s House classroom was not labeled with the child?s name and date.
Plan of Correction:	Guide and parents were informed again of this requirement. Markers for labeling have been provided at drop off location to support compliance.