VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Boar's Head Inn
200 Wellington Drive
Charlottesville, VA 22903
(434) 972-6072

Current Inspector: Michelle Argenbright (540) 848-4123

Inspection Date: April 14, 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 20 Access to minor?s records 22.1 Background Checks Code, Carbon Monoxide 63.2 Child Abuse & Neglect 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:

Children's hands shall be washed with soap and running water or disposable wipes before and after eating meals or snacks. Children's hands shall be washed with soap and running water after toileting.

Comments:

An unannounced, on-site renewal inspection was initiated on April 14, 2025 and completed on April 17, 2025. The on-site inspection began at 11:50 a.m. and ended at 1:15 p.m. The inspector reviewed compliance in the areas listed above. There were nine children present and two staff. The inspector reviewed six children?s records on-site and two staff records electronically on April 17, 2025. This inspection included tour of facility, record review, observations, and interviews. 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 April 25, 2025. A POC submitted after this date will not appear on the public website.

Violations:

Standard #:	22.1-289.035-A
Description:	The center is required to have employees undergo a background check every five years. The most recent central registry check for staff #1 was overdue by three months & for staff #2 was overdue by two months. The sworn statement for staff #1 was overdue by four months. The fingerprint background check for staff #1 was overdue by four months.
Plan of Correction:	All background check components (central registry, fingerprint, and sworn statement) are being processed for staff #1 and #2. We are revising our HR checklist to track expiration dates more proactively.
Standard #:	8VAC20-780-130-E
Description:	The center shall obtain documentation of additional immunizations once every six months for children under the age of two years. The records for child 1, child 2 and child 4 do not have updated immunization records.
Plan of Correction:	Families of children #1, #2, and #4 have been contacted to provide updated immunization records. Files will be updated once received. Future immunization reviews will be added to our semi-annual audit schedule.
Standard #:	8VAC20-780-150-B
Description:	Immunizations and physical examination reports for children shall include the date of the physical examination and dates immunizations were received and shall be signed by a physician, his designee, or an official of a local health department. The immunizations and physical for child #3 were not signed or dated by a physician, his designee, or an official of a local health department.
Plan of Correction:	Child #3's family has been contacted to submit a signed and dated form from the child's pediatrician. We have implemented a checklist for verifying form completion upon enrollment.
Standard #:	8VAC20-780-350-B-1
Description:	SYSTEMIC DEFICIENCY The required ratio for children ages birth up to 16 months is one staff per four children. Staff #2 was in a classroom alone with six children (youngest child 14 months old) from approximately 10:30 a.m. to 10:45 p.m. when two more children arrived (youngest 8 months old) for a total of eight children. A second staff and an additional child arrived at 11:00 a.m. for a total of nine children (youngest 8 months) for approximately 45 minutes.
Plan of Correction:	We have adjusted staff scheduling to ensure proper ratios are consistently met. We have implemented a new overlap system to guarantee coverage during staff transitions and lunch breaks. Staff were retrained on ratio requirements and reporting expectations and adding staff to meet those demands.
Standard #:	8VAC20-780-550-E
Description:	Shelter in place procedures shall be practiced a minimum of twice per year. One shelter in place practice drill was conducted in 2024.
Plan of Correction:	A second shelter-in-place drill has been scheduled for May 2025 to meet the annual requirement moving forward. A recurring calendar has been created to ensure future compliance.
Standard #:	8VAC20-780-550-F
Description:	Lockdown procedures shall be practiced at least annually. No lockdown drill was conducted in 2024.
Plan of Correction:	A lockdown drill has been scheduled for May 2025. A compliance calendar will now track and document drill frequency and staff participation.
Standard #:	8VAC20-780-550-P
Description:	The center shall maintain a written record of children's serious and minor injuries in which entries are made the day of occurrence. The record shall include the time when parents were notified. Out of the three injury reports reviewed two did not contain the time parents were notified.
Plan of Correction:	All staff have been retrained on injury documentation protocols. A revised injury report template now includes a designated section for notification time.
Standard #:	8VAC20-780-560-G
Description:	When food is brought from home, the food container shall be sealed and clearly dated and labeled in a way that identifies the owner. A bottle full of milk, two water bottles and two lunch boxes were not dated or labeled with the identity of the owner.
Plan of Correction:	Parents will be notified of the updated labeling policy. A signage reminder has been posted at check-in. Staff will complete daily checks to ensure compliance.