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: March 14, 2024

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. Consultation provided on additional components of orientation training as of 10/21- see standard 240.C and the need for staff to complete orientation training prior to working alone with children and no later than seven days of the date of assuming job responsibilities.- see standard 240.B 2. Your written record of children with serious and minor injures shall include a section titled future action to prevent recurrence of the injury- see standard 550.P 3. You need to make sure you put into place a way to ensure all phone cords are kept out of reach of the children 4. Make sure you are clearly documenting the date of employment for each staff in their file.

Comments:

An unannounced monitoring inspection was conducted today with the Administrative staff from 8:00 am to 10:45 am. There were 41 children present with 10 staff providing supervision. The ages of the children ranged from 5 months to 10 years. Medications for 7 children were reviewed as well as allergy care plans for 6 children. A sample of 8 injury/accident reports were reviewed as well. Seven staff and six children's files were reviewed during this inspection as well as a sample of injury/accident reports. The fire inspection was dated 7/24/23 and the health inspection was dated 6/5/23. The areas of non compliance are outlined on the violation notice.

Violations:

Standard #:	22.1-289.035-A
Description:	Based on interview and a review of staff files, it was determined that a repeat background check was not obtained every five years from the original background check. Evidence: Staff B's Sworn Disclosure Statement was dated 1/11/19.
Plan of Correction:	Staff B completed her sworn disclosure on March 14, 2024. We are now in compliance. A staff file tracking spreadsheet has been created. Moving forward a member of management will monitor for expiration dates on a monthly basis to ensure continued compliance.
Standard #:	22.1-289.035-B-2
Description:	Based on interview and a review of staff files, it was determined that fingerprint background checks for staff were not obtained prior to employment. Evidence: Staff A's Fingerprint background check was dated 9/5/23, Staff A was employed on 8/28/23. Staff C's Fingerprint background check was dated 11/3/23. Staff C was employed on 10/23/23.
Plan of Correction:	A new hiring process has been established. Moving forward all VA State required documentation will be required on file prior to a new staff member 1st day of employment. As of March 14, 2024, a paperwork appointment will be scheduled to ensure all paperwork is on 1and prior to day 1.
Standard #:	8VAC20-780-270-A
Description:	Based on observation, it was determined that the center was not maintained in a clean and safe condition. Evidence: 1. The Licensing Inspector (LI) observed the phone cords to the wall-mounted phones hanging in reach of the children in the toddler, two year old, early preschool, pre-k # 1, pre-k #2 and Jr-K classrooms. The cords are a strangulation hazard. 2. The LI observed dried food and liquid stains and rust on the outside of the kitchen refrigerator and freezer.
Plan of Correction:	1. Sending for Desk Review 2. Sending for Desk Review
Standard #:	8VAC20-780-280-B
Description:	Repeat Violation: Based on observation, it was determined that hazardous substances were not kept locked to prevent access by children. Evidence: 1. Key's were stored in the Laundry room and Kitchen door locks. The keys were accessible to the children. There were hazardous substances stored in the laudry and kitchen to include sanitizing tablets, stainless steel cleaner, disinfectant solutions ad multipurpose sanitizer sprays. 2. The LI observed on a shelf in an unlocked closet in the Pre-K 2 classroom adhesive remover and foam soap- both had warnings and cations on the label. 3. The LI observed on a shelf in an unlocked closet in the Pre-K 1 classroom bottles of sanitizing and disinfectant agents with cautions and warnings listed on the label. 4. The LI observed above the sink in an unlocked cabinet in the Early Preschool room a soap foam, which had warnings on the label..
Plan of Correction:	1. All keys were removed from the door handles and hung out of the reach of children. We communicated this expectation with each staff member on March 14, 2024 to ensure understanding that keys must be hung out of reach and not left in the door lock. Management will conduct daily checks to ensure keys are always hung up and out of reach. 2. Sending for Desk Review 3. Sending for Desk Review 4. Sending for Desk Review