Peppertree Montessori at Lake Montclair
5167 Waterway Drive
Dumfries, VA 22025
(703) 763-0003
Current Inspector: Cathy Aylor (540) 222-6352
Inspection Date: Dec. 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.
8VAC20-820 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
32.1 Report by person other than physician
63.2 Child Abuse & Neglect
- Technical Assistance:
-
1. Reviewed repeat violations and the need to immediately address them to ensure on going compliance.
2. Discuss need to audit files more closely.
3. Reviewed medication standards
4. Reviewed requirements for children with diagnosed food allergies.
- Comments:
-
An unannounced monitoring inspection was conducted today with the director from 11:05 am to 1:05 pm. There were twenty one children present with 6 staff providing supervision. The ages of the children ranged from 5 months to 5 years.
The Licensing Inspector was able to observe the children eating lunch and the infants playing on the floor with staff. Six staff files and five children's files were reviewed as well as medications for two children. The areas of non compliance are outlined on the violation notice.
- Violations:
-
Standard #: 22.1-289.011-F Description: Repeat violation:
Based on observation, it was determined that the most recent findings ( 8/23) were not posted in a conspicuous place on the premises.Plan of Correction: Not available online. Contact Inspector for more information.
Standard #: 22.1-289.035-B-4 Description: Based on a review of staff files and interviews with the administrative staff, it was determined that there was no out of state background checks for staff who lived outside of Virginia in the last five years.
Evidence:
Staff B was hired on 10/5/23 and required an out of state child abuse and neglect background check from New York. The check needed to be requested by 11/5/23 which it had not.Plan of Correction: Not available online. Contact Inspector for more information.
Standard #: 8VAC20-770-60-C-2 Description: Based on a review of staff files and interviews with administrative staff, it was determined that one staff did not have a central registry finding within 30 days of employment.
Evidence:
There was no central registry finding on file for staff A who was hired on 11/2/23.Plan of Correction: Not available online. Contact Inspector for more information.
Standard #: 8VAC20-770-70-A Description: Based on a review of six staff files and interviews with administrative staff, it was determined that all required components were not kept on file at the time of hire.
Evidence:
Staff A did not have references on file, staff A was hired on11/2/23.Plan of Correction: Not available online. Contact Inspector for more information.
Standard #: 8VAC20-780-130-A Description: Based on a review of five children's files and interviews with administrative staff, it was determined that all children did not have immunization information on file at the time of attendance.
Evidence:
Child A and B did not have immunization information on file. Both children enrolled on 7/31/23.Plan of Correction: Not available online. Contact Inspector for more information.
Standard #: 8VAC20-780-140-A Description: Based on a review of five children files and interview with administrative staff, it was determined that two children did not have physicals on file within one month of enrollment.
Evidence:
Child A and D did not have physicals on file. Both children enrolled on 7/31/23.Plan of Correction: Not available online. Contact Inspector for more information.
Standard #: 8VAC20-780-60-A-8 Description: Repeat Violation:
Based on a review of recordkeeping and interviews with administrative staff, it was determined that there were no written allergy care plans on file for those children with diagnosed food allergies.
Evidence:
Child A has a peanut allergy, child B has a egg and nut allergy and child C has a dairy allergy. None of these children had allergy care plans on file.Plan of Correction: Not available online. Contact Inspector for more information.
Standard #: 8VAC20-780-240-A Description: Repeat Violation:
Based on a review of staff files and interviews with administrative staff, it was determined that the VDOE sponsored orientation course was not completed within 90 days of employment.
Evidence:
Staff C was hired on 9/4/23 and did not have the VDOE orientation training.Plan of Correction: Not available online. Contact Inspector for more information.
Standard #: 8VAC20-780-240-B Description: Repeat Violation:
Based on a review of six staff files and interviews with administrative staff, it was determined that not all staff completed the orientation training prior to working alone with children and no later than seven days of the date of assuming job responsibilities.
Evidence:
Staff A ( hired 11/2/23), staff B ( hired 10/5/23), staff C ( hired 9/4/23), and staff D ( hired 11/14/23) did not have orientation training.Plan of Correction: Not available online. Contact Inspector for more information.
Standard #: 8VAC20-780-240-D Description: Based on a review of 6 staff files and interviews with administrative staff, it was determined that all staff were not provided in writing the center's policies and procedures prior to working alone with children and within 7 days of assuming job responsibilities.
Evidence:
Staff A was not provided written policies and procedures in writing. Staff A was hired on 11/2/23.Plan of Correction: Not available online. Contact Inspector for more information.
Standard #: 8VAC20-780-510-E Description: Based on a review of medications and interviews with administrative staff, it was determined that the center did not have documentation from the parent or physician for a long term medication.
Evidence:
Child A had Epinephrine on file however the center did not have parental or physician authorization to have this medication on site.Plan of Correction: Not available online. Contact Inspector for more information.
Standard #: 8VAC20-780-550-E Description: Based on a review of recordkeeping and interviews with administrative staff, it was determined that the center has not practiced shelter in place procedures a minimum of twice per year.
Evidence:
The last shelter in place drill was conducted on 10/21/22.Plan of Correction: Not available online. Contact Inspector for more information.
Standard #: 8VAC20-780-550-F Description: Based on a review of recordkeeping and interviews with administrative staff, it was determined that lockdown procedures were not practiced at least annually.
Evidence:
The last documented lockdown drill was dated 11/4/22.Plan of Correction: Not available online. Contact Inspector for more information.
Disclaimer:
A compliance history is in no way a rating for a facility.
The online compliance history includes only information after July 1, 2003. In addition, the online compliance history includes information regarding adverse actions that may be the subject of a pending appeal. An adverse action is not final until a provider has exhausted or waived all due process rights. For compliance history prior to July 1, 2003, or information regarding the status of pending adverse actions, please contact the Licensing Inspector listed in the facility's information. The Virginia Department of Social Services (VDSS) is not responsible for any errors in or omissions from the compliance history information.
