VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Cardinal Montessori School
1424 G Street
Woodbridge, VA 22191
(703) 491-3810

Current Inspector: Angela Dudek (804) 629-8167

Inspection Date: Nov. 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. 8VAC20-770 Background Checks 20 Access to minor?s records 22.1 Background Checks Code, Carbon Monoxide 32.1 Report by person other than physician 63.2 Child Abuse & Neglect

Technical Assistance:

Technical Assistance: Provided consultation on the following: 8VAC20-780-340F Adjoining rooms, with a door or a window between the rooms, does not meet the intent of the standard so these rooms should each be considered separate rooms. Staff may not sit in a doorway or at a window and supervise adjoining rooms. The intent of the standard is to ensure that that there will always be a staff person who can see and hear and respond to the children in care. Staff shall always practice active supervision of sleeping and awake/active children by regularly moving about the room to ensure all of the children in care are within ?actual sight and sound? supervision at all times. 8VAC20-780-350 O Each of the adjoining rooms must meet the standards for a mixed balanced age group.

Comments:

An unannounced monitoring inspection was conducted together with another inspector on 11/08/2023 from 9:55am to 1:25pm as the result of a self-reported incident of inappropriate touching between 2 children. Documentation was reviewed, interviews were conducted, the classroom was observed, and video footage was reviewed. There were 4 violations cited directly related to the incident and 6 violations cited unrelated to the incident that were discovered during the process of the investigation. Areas of non-compliance are identified in the Violation Notice. Please complete the columns for "Plan of Correction" and "Date to be Corrected" for each violation cited on the Violation Notice, and then return a signed and dated copy to the licensing office by 5pm on 12/12/23. Please email me at angela.dudek@doe.virginia.gov with any questions.

Violations:

Standard #:	22.1-289.035-B-2
Description:	Based on review of 2 staff records, the center did not obtain documentation of the results of a national fingerprint background check prior to date of hire. Evidence: The record for Staff #1 (Date of Hire 10/4/23), did not contain documentation of a fingerprint background check.
Plan of Correction:	Employee made an appointment to get fingerprint completed on 11/08/23, we received results on date of hire. 11/13/23.
Standard #:	63.2-1509-A
Description:	Based on staff interview and documentation, the center failed to report a suspected incident of child abuse or neglect to Child Protective Services (CPS) immediately as required. Evidence: 1)On 10/26/23, Staff in room #6 were made aware by another child of an incident of possible abuse or neglect that had occurred at the center. 2)Staff reviewed video footage upon being made aware of the incident and confirmed that there was suspected abuse or neglect. 3)Staff decided to not report the incident to CPS until they had completed their own investigation internally and reported the incident to CPS on 11/6/23.
Plan of Correction:	Had all staff members (head of school, administrators, teachers and assistants) complete the online CSW5692:Mandate Reporters by 11/30/23.
Standard #:	8VAC20-770-60-B
Description:	Based on review of 2 staff records, the center did not obtain documentation of a completed sworn disclosure statement for each staff prior to date of hire. Evidence: The record for Staff #1 (date of hire 10/4/23) did not contain documentation of a completed sworn disclosure statement.
Plan of Correction:	Employee had completed the sworn disclosure statement on 10/03/23, but it was not in the employee file. It was Immediately added to f!le.
Standard #:	8VAC20-770-60-C-2
Description:	Based on review of 2 staff files, the center did not obtain documentation that a central registry search was completed by the end of the 30th day of employment. Evidence: The record for Staff #1 (Date of Hire 10/4/23) did not contain documentation that a central registry search was completed within 30 days of employment.
Plan of Correction:	The central registry search was submitted and received, by search was completed by 10/26/23. It was not in the employee file. It was added once inspector left.
Standard #:	8VAC20-780-160-A
Description:	Based on review of 2 staff records, the center did not obtain documentation of a negative tuberculosis (TB) test or screening for staff at the time of employment and prior to contact with children and within 30 days prior to employment. Evidence: The file for Staff #1 (date of hire 10/4/23) did not contain documentation of a negative tuberculosis (TB) test or screening within 30 days prior to hire. The TB test on file was dated 10/7/23.
Plan of Correction:	Employee did complete the TB screening on 10/07/23. It was not on file. Once inspector left it was added.
Standard #:	8VAC20-780-70
Description:	8VAC20-780-70 Based on review of 2 staff records and interview with staff, the center did not obtain all of the required documentation for staff records. Evidence: 1)The center did not have documentation for Staff #1 (date of hire 10/4/23) that two or more references as to character and reputation as well as competency were checked before employment. The references on file were dated 10/9/23. 2) The center did not have documentation for Staff #1 of a name, address and telephone number of someone to be contacted in an emergency.
Plan of Correction:	We had the employee references completed on 10/9/23, but it was not in the employee file. Corrected and added to the file on 11/8/23.
Standard #:	8VAC20-780-240-B
Description:	Based on review of 2 staff records and interview with staff, the center did not ensure that staff complete orientation prior to the staff member working alone with children and no later than 7 days of the date of assuming job responsibilities. The files for Staff #1 (date of hire 10/4/23) did not contain documentation of orientation as required.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-340-A
Description:	Based on interviews with staff and review of video footage, the center failed to ensure the care, protection and guidance of all children in care. Evidence: On 10/26/23, Child #1 (age 5) and Child #2 (age 5) were completing an assignment together on the floor in room #6 (ages 3-5) and one of the children was inappropriately touching the other child. This behavior went on for approximately 8 minutes. The behavior only stopped when another child informed the teacher in the classroom of the behavior.
Plan of Correction:	Once the inspector left we fully reviewed with the staff in each classroom state policy of Supervision of Children (8VAC20-780-340 A-J) including, but not limited to when staff are supervising children, they shall always ensure their care, protection and guidance. NO EXCEPTIONS.
Standard #:	8VAC20-780-340-F
Description:	Based on staff interviews and review of video footage, the failed to ensure that children under 10 years of age always be within actual sight and sound supervision of staff. Evidence: On 10/26/23, there was an incident of inappropriate touching in room #6 between 2 children. The classroom is made up of 2 combined rooms that are open to each other by 2 large doorways. The children involved in the incident were completing an assignment on the floor behind some tables where staff members could not see the children. There was only 1 staff member in the room and the staff member spent the majority of the time on the opposite side of the classroom from where the incident took place which left the children out of sight and sound off and on for approximately 20 minutes.
Plan of Correction:	Once the inspector left we fully reviewed with the staff in each classroom state policy of Supervision of Children (8VAC20-780-340 A-J) including, but not limited to Children under 10 years of age always shall be within actual sight and sound supervision of staff, NO EXCEPTIONS.
Standard #:	8VAC20-780-350-O
Description:	Based on documentation and video footage, the center failed to ensure that they maintained a ratio of 1 staff member for every 14 children for a balanced-mixed-age grouping of children. Evidence: On 10/26/23, there were 22 children in classroom #6 with 1 teacher for approximately 15 minutes.
Plan of Correction:	Once the inspector left we fully reviewed with the staff 8VAC20-780-35(A-Q) including but not limited to The ratio for balanced-mixed-age groupings of children shall be one staff member for every 14 children. NO EXCEPTIONS.