VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Everbrook Academy
11675 Chapel Springs Road
Bristow, VA 20136
(571) 428-5059

Current Inspector: Cathy Aylor (540) 222-6352

Inspection Date: Aug. 8, 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. 22.1 Background Checks Code, Carbon Monoxide.

Comments:

An unannounced monitoring inspection was initiated on 8/8/2023 from 8:45am to 11:45am with program staff. There were 86 children in care initially, ranging in age from two-months to 10-years-old, supervised by 13 staff. More children and staff arrived throughout the inspection. The children were observed getting ready for breakfast; eating cereal, bananas, and milk; having free play; having their diapers changed; participating in circle time and singing songs; playing on the playground; and working in structured centers. Five child records and four staff records were reviewed. The Center has many staff with current certification in CPR and First Aid, as well as staff trained in Daily Health Observation Training. Ten medications and authorization forms were reviewed and the center has multiple staff current in Medication Administration Training (MAT). Required postings were observed. The attendance, menu, and emergency drill log were reviewed. The most recent Fire Inspection on file was dated 7/24/2023 and the most recent Health Inspection on file was dated 6/5/2023. The inspection was continued on 8/11/2023 from 8:00am to 1:45pm with a local agency due to documentation reviewed during the 8/8/2023 inspection. Interviews were conducted, documentation was reviewed, and a classroom was observed on-site via video screening. This portion of the inspection was closed on 9/6/2023. If you have questions regarding this inspection, please contact the Licensing Inspector, Laura Brindle, at laura.brindle@doe.virginia.gov or 540-905-2062. Please complete the "Plan of Correction" and "Date to be Corrected" areas on the Violation Notice for each violation cited and return to me by close of business on 9/27/2023. Plans of correction should include steps to correct the noncompliance with the standard, and measures to prevent the noncompliance from occurring again.

Violations:

Standard #:	22.1-289.035-B-4
Description:	Based on review of four staff records, the center did not obtain the results of a criminal history record check from all states in which staff members have resided within the past five years prior to employment, or the results of a central registry check from all states in which staff members have resided within the past five years within 30 days of employment. Evidence: 1. The record for Staff #1, with an employment date of 3/13/23, contained documentation that the staff had lived in Connecticut within the past five years, but there were no central registry results from Connecticut on record for the staff member. 2. The record for Staff #2, with an employment date of 5/1/23, contained documentation that the staff had lived in South Carolina within the past five years, but the criminal history check from South Carolina was dated 6/14/23, and there were no central registry results from South Carolina on record for the staff.
Plan of Correction:	On 8/8/23 DM reviewed VA state regulation along with process for obtaining criminal history checks for any employee that indicates they have lived outside of VA in the past 5 years. Additionally, out of state criminal record requests were submitted for Staff #1 on 8/8/23 and Staff #2 on 8/8/23. School management will review all files upon start date to ensure all necessary documents are in file.
Standard #:	8VAC20-780-60-A-8
Description:	REPEAT Based on review of five child records, the center did not obtain a written care plan for each child with a diagnosed food allergy, to include instructions from a physician regarding the food to which the child is allergic and the steps to be taken in the event of a suspected or confirmed allergic reaction. Evidence: The record for Child D contained documentation that the child has a diagnosed food allergy to fish and other seafood. There was no allergy care plan on record for Child D.
Plan of Correction:	A written care plan including steps to be taken in event of a suspected allergic reaction was received for the 5 children diagnosed with food allergies. DM reviewed LCG's Child Allergy Procedures with the management team on 8/8/23. School management will review children's files no less than quarterly to ensure that they are up-to-date and complete.
Standard #:	8VAC20-780-80-B
Description:	Based on review of documentation and interview, staff failed to immediately report suspected child abuse in accordance with 63.2-1509 of the Code of Virginia. Evidence: 1. A document in the record for Staff #1 stated that on 3/27/23 management received a call from a parent who said they observed via center cameras Staff #1 ?being handsy? with Child F, a 23-month-old, at naptime and ?[Staff #1] was observed picking up the child and `slamming? the child down on the cot.? Management did not report the incident to Child Protective Services as required. 2. In approximately July 2023 and on another occasion ?several months before?, Staff #5 reported that they caused two different children to have bloody lips from putting them onto their cots ?too roughly? during nap time. Staff #1 witnessed the incident in approximately July 2023 and did not report it.
Plan of Correction:	On 8/8/23 DM reviewed VA state regulation regarding Mandated Reporting with management team. Additionally on 8/30/23 all staff received Mandated Reporting training. School management will continuously train all staff on Mandated Reporting beginning of start date and as well as yearly training.
Standard #:	8VAC20-780-280-B
Description:	Based on observation, the center did not ensure that hazardous substances, such as cleaning materials, insecticides, and pesticides, were kept in a locked place using a safe locking method that prevented access by children. Evidence: On 8/8/23, a glass cleaning solution and an ant and roach spray, both containing the warnings ?Caution? and ?Keep out of reach of children?, were observed on a shelf in an unlocked closet in the ?Junior K/Schoolage? classroom.
Plan of Correction:	Chemicals were locked in cabinet on day of inspection. All staff received a retraining on VA state regulation regarding hazardous materials and substances on 8/8/23. During this training management had an open discussion regarding challenges with ensuring chemicals and hazardous items are locked up when not in use by staff.
Standard #:	8VAC20-780-410-1
Description:	Based on review of documentation and interviews, staff used a forbidden action, rough handling, with children in care. Evidence: 1. A document in Staff #1?s record indicated that on 3/27/23, the staff member was observed by a parent via the center cameras ?being `handsy? with a child at nap time? and ?was observed picking up the child and `slamming? the child down on the cot?. Interview revealed the child was Child F, a 23-month-old. 2. A document in Staff #1?s record indicated that on 5/31/23, two members of management observed via camera, Staff #1 ?grab a child by their wrist and lift them into the air to place them on their cot.? Interview revealed the child was Child G, a 23-month-old. 3. Interviews revealed that Toddler room staff, Staff #1 and Staff #5, were ?probably too rough? when they were putting children down for naps and on two different occasions Staff #5 caused bloody lips on two different children by putting them onto their cots too roughly.
Plan of Correction:	On 8/30/23 all staff received retraining on LCG's behavior guidance policy. Staff #1 received note to file on 3/27/23 and Corrective Action on 5/31/23 & Staff #5 note to file on 9/20/23.
Standard #:	8VAC20-780-500-A
Description:	Based on observation, the program did not ensure that staff washed their hands with soap and running water: before and after helping a child use the toilet; before and after a diaper change; and after any contact with body fluids. Evidence: On 8/8/23 in the ?Twos? classroom, Staff #6 member was observed assisting four different children in the restroom before washing their hands. Staff #6 removed one child?s diaper/pull-up, assisted them in the restroom, put on a clean diaper/pull-up and sent the child to wash their hands, then moved on to assist three other children in the same manner. Staff #6 did not wash their own hands in between children.
Plan of Correction:	On 8/8/23 management completed a retraining on VA state regulation and LCG policy & procedures regarding handwashing.
Standard #:	8VAC20-780-500-B
Description:	Based on observation, the program did not ensure that children younger than three years were changed on a changing table or countertop designated for changing. Evidence: On 8/8/23 in the ?Twos? classroom, Staff #6 was observed changing the diapers/pull-ups of four two-year-old children while they stood in the restroom doorway.
Plan of Correction:	On (8/8/2023) management completed a retraining on VA state regulation and LCG policy & procedures regarding diaper changing for all children under the age of three.
Standard #:	8VAC20-780-550-P
Description:	Based on review of documentation and interviews, the center did not maintain a written record of children's serious and minor injuries in which entries are made the day of occurrence. Evidence: Interviews revealed two children obtained minor injuries-bloody lips- when Staff #5 placed them roughly on their cots during nap time. One incident was reported to have occurred in approximately July 2023. The other incident was reported to have occurred several months before that. There were no injury reports documented for children in the injury log for either incident.
Plan of Correction:	An incident report was completed on 9/20/23. Parent was given a copy of incident report and signed on 9/20/23. All staff received a retraining on incident reporting on 8/30/23. School management will remind all staff that an incident that happens must be reported to management and an incident report filled out and signed by parent.
Standard #:	8VAC20-780-560-J
Description:	Based on observation, the center did not ensure that tables were sanitized before use for feeding. Evidence: On 8/8/23 at approximately 8:50am in the ?Junior K/Schoolage? classroom, the tables were not sanitized before children sat down to eat breakfast at the tables.
Plan of Correction:	On 8/8/23 all staff received a retraining on VA state regulation and LCG Cleaning & Sanitizing Procedures.