VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Lilly Grace LLC
1908 West Club Lane
Richmond, VA 23226
(804) 282-4482

Current Inspector: Sharon Curlee (804) 840-8312

Inspection Date: Jan. 27, 2025

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 63.2 Child Abuse & Neglect 22.1 Early Childhood Care and Education 20 Access to minor?s records During the inspection, the inspector reviewed the areas listed above to include standards found out of compliance during the previous inspection. Unless otherwise noted as a violation within this inspection report, the provider was in compliance with the standards reviewed. If there were any serious injuries or fatalities related to a violation, the details will be included in the description of the violation.

Technical Assistance:

Effective January 1, 2025, the VDOE will begin determining compliance with ? 22.1-289.057 of the Code of Virginia, which is legislation passed by the General Assembly in 2020. The law requires all licensed child day programs, religious exempt child day centers that serve preschool age children, and certified preschools to test potable drinking water. The law requires that programs submit their plans and test results to the Virginia Department of Health Office of Drinking Water (VDH ODW) and the Superintendent. If the results of the testing indicate elevated lead levels, the program shall remediate, retest, and resubmit results to VDH ODW and the Superintendent. There is an additional alternative bottled water option that comes with additional requirements. The statutory requirement can be found online at https://law.lis.virginia.gov/vacode/title22.1/chapter14.1/section22.1-289.057/. Resources are now available for providers on the "What's New" webpage on the ChildCareVA website at https://www.childcare.virginia.gov/providers/what-s-new.

Comments:

An unannounced, on-site monitoring inspection was initiated on January 27, 2025, and completed on January 27, 2025, as a part of the licensure period. The on-site inspection began at 2:30 pm and ended at 4:30 pm. The inspector reviewed compliance in the areas listed above. There were 17 children present and four staff. The inspector reviewed five children?s records and four staff records on-site. This inspection included document review, tour of the facility, interviews, and observations. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations are documented on the violation notice issued to the program. Please complete the plan of correction (POC) and date to be corrected sections for each violation cited on the violation notice. Specify how the violation will be or has been corrected. Submit your POC within five business days from today, which will be the close of business on February 18, 2025. A POC submitted after this date will not appear on the public website.

Violations:

Standard #:	8VAC20-780-160-A
Description:	Each staff member shall submit documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with the children. Staff #1, employed for three years, did not have documentation of a tuberculosis screening. The record of staff #3, employed for four months, did not have documentation of a tuberculosis screening.
Plan of Correction:	Per the Director: Owner and director have put a system in place to ensure all paperwork is completed and in the file.
Standard #:	8VAC20-780-70
Description:	The center shall keep a record for each staff that contains all required information. The record of staff #1, identified as a program leader, not contain did not contain documentation to demonstrate that the individual possessed the education required by the job position. The record of staff #3, employed for four months, did not contain documentation that two or more references as to character and reputation as well as competency were checked before employment or volunteering.
Plan of Correction:	Per the Director: Staff #1 has been advised to bring in proof of education. Owner and director will hold each other accountable for ensuring all files are complete and together.
Standard #:	8VAC20-780-240-E
Description:	The center shall ensure staff complete orientation training in first aid and cardiopulmonary resuscitation (CPR), as appropriate to the age of the children in care within 30 days of the first day of employment. Staff #3, employed for four months, did not have documentation of CPR and first aid training.
Plan of Correction:	Per the Director: Have a system set up to keep track of dates. Reached out to trainer. Received cards on 01/30/ for training done in Dec.
Standard #:	8VAC20-780-240-I
Description:	Documentation of orientation training shall be kept by the center in a manner that allows for identification by individual staff member, is considered part of the staff member's record, and shall include all required elements. Staff #3, employed for four months, did not have documentation of orientation training.
Plan of Correction:	Per the Director: Owner will do orientation and director will check to ensure all is completed and documented.
Standard #:	8VAC20-780-340-F
Description:	Children under 10 years of age shall always be within actual sight and sound supervision of staff. Staff #2 opened the entrance door for the inspector at arrival. The inspector followed staffed #2 across the main classroom past the director?s office where the director was, and into the small classroom where two infants were in their cribs. The door leading into the classroom was closed. Both infants were awake and had been left alone.
Plan of Correction:	Per the Director: Owner and director held a training with staff to cover ratios, compliances and which staff should be where to ensure ratio's are met. Director oversees daily.
Standard #:	8VAC20-780-350-B-1
Description:	The center shall maintain the required staff to child children ratio for children birth up to 16 months of age. The required staff-to-children ratio for children birth up to 16 months is one staff for every four children. 1. At the inspector?s arrival, 2:30 pm, staff #3 and staff #4 were observed supervising ten children (youngest child three months old). 2. Two infants, both under 16 months of age, were alone in a classroom when the required ratio was one staff to every four infants.
Plan of Correction:	Per the Director: Owner and director held a training with staff to cover ratios, compliances and which staff should be where to ensure ratio's are met. Director oversees daily.
Standard #:	8VAC20-780-510-P
Description:	When an authorization for medication expires, the facility shall notify parents that the medication must be picked up within 14 days of the authorization expiring or that a new authorization should be completed. Medication for child #5 was onsite, but the medication authorization had expired over two months ago. The medication had not been administered past the expiration of the authorization. The authorization had not been renewed and the medication was not returned or disposed of as required.
Plan of Correction:	Per the director: Do monthly checks on medication forms. Send home any medications we don't have proper forms for. Parent took medication. Dr. sent letter, no longer need.
Standard #:	8VAC20-780-540-E
Description:	The center shall maintain one working, battery-operated radio in each building used by children and any camp location without a building. The battery-operated radio did not work.
Plan of Correction:	Per the director: We bought a NOAA weather radio.