VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Bright Beginnings, Inc. - Forest Lakes
1610 Regent Street
Charlottesville, VA 22911
(434) 973-8414

Current Inspector: Kelly Adriazola (804) 840-8245

Inspection Date: Nov. 28, 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. 8VAC20-770 Background Checks (8VAC20-770) 22.1 Background Checks Code, Carbon Monoxide

Comments:

An unannounced non-mandated monitoring inspection, under the supervision of the Licensing Administrator, was conducted on-site November 28, 2023 and concluded remotely December 1, 2023. The director was available during the inspection. There were 79 children present, ranging in ages from 7 months to 5 years, with 15 staff supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies and nutrition. A total of 7 child records and 7 staff records were reviewed. Information gathered during the inspection determined non-compliance with applicable standards or law and violations were documented on the violation notice issued to the program. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it to me within 5 business days from today. Please specify how the deficient practice will be or has been corrected. Your plan of correction should contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measures. Please do not use staff names; list staff by positions only.

Violations:

Standard #:	8VAC20-780-160-A
Description:	Based on record review, the center failed to ensure that a staff member submitted documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with children. Evidence: 1. The record for staff #2, hired on 05/15/2023, did not contain documentation of a negative tuberculosis screening.
Plan of Correction:	Effective immediately, the program director will ensure that the results of a negative tuberculin screening has been completed within the last thirty calendar days of the date of employment for all staff persons and is submitted prior to the staff person having contact with children. The program will request and require documentation certifying the negative results, which shall include the date the test was given and is signed by a physician, physician?s designee or an official of the local health department. If the date on the certification is not within the thirty days from the date of employment, the employee will not be permitted to start work and will be required to be retested and have negative test results prior to having contact with children. As noted above, administration will create and keep up to date, a checklist of all documentation required by licensing and applicable statute to be included in each staff person?s file, noting staff person?s date of hire. The TB test results will be an entry on the checklist. When the negative results of the TB test are received, admin will note the date of the test to ensure it is within the 30-day timeframe prior to the employee starting work. As noted in the previous paragraph, if the negative test results were not within the 30 days of start of work, the employee will not be permitted to start employment. To ensure further compliance, the director will review staff files immediately and on a regular basis to ensure all necessary documentation has been included in each staff persons file.
Standard #:	8VAC20-780-160-C
Description:	Based on record review, the center failed to ensure that at least every two years from the date of the initial screening or testing, staff members obtained and submitted the results of a follow-up tuberculosis screening. Evidence: 1.The record for staff #3 contained TB results dated 05/10/2021. The follow-up screening was not obtained until 09/04/2023.
Plan of Correction:	Effective immediately, the program director will ensure that at least every two years from the date of the initial screening or testing, staff members obtain and submit the result of a follow up negative tuberculosis (TB) screening. The program will request and require documentation certifying the negative results, which shall include the date the test was given and is signed by a physician, physician?s designee or an official of the local health department. Administration has created and will keep up to date, a checklist of TB screening requirements for all staff, including the date of the initial negative TB screening and the two-year due date for which a new negative TB screening must be obtained and submitted. This will remind the administration of upcoming TB test requirements who can in-turn notify staff that a new TB test must be obtained and submitted. In the event a new negative TB test is not obtained and submitted by said due date, staff will not be permitted to report to work. To ensure further compliance, the director will review staff files immediately and on a regular basis to ensure all necessary documentation has been included in each staff persons file, including documentation related to negative TB tests and requirements for same.
Standard #:	8VAC20-780-40-E
Description:	Based on observation and document review, the licensee failed to ensure that the center?s activities and services were maintained in compliance with the center?s own policies and procedures that are required by these standards. Evidence: 1.Per the center?s Playground Safety Procedures: ?Supervision on the playground is active. Staff must stand, interact, and circulate to ensure all children are playing safely. A combination of supervision ?zones? with some staff also circulating the playground is to be used. - A staff member must always monitor and assist children while on playground equipment. -Staff must spread out into zones to maintain full visualization of the entire playground, and to be sure children are not exiting the playground or reentering the building on their own. -If a single staff member is supervising the playground, that staff member must limit children from playing in areas that are not in line of sight of that staff member. -Teachers must not congregate.? 2. Upon driving into the parking lot while arriving at the center, the Licensing Inspector (LI) and Licensing Administrator (LA)observed a group of children and two staff on the playground. The two staff were standing face-to-face at the top of the hillside, engaged in conversation amongst themselves. After circling the parking lot, the LI and LA observed that the two staff remained standing face-to-face engaged in conversation while children were observed at the bottom of the hillside. One child was punched approximately three times by another child and a different child was pushed to the ground. The LA intervened by calling attention to the activities of the children to the staff, who had been engaged in conversation amongst themselves for approximately two minutes.
Plan of Correction:	Bright Beginnings shall ensure that licensing regulations related to playground safety/supervision and their own policies and procedures related to playground supervision will be followed. Staff have been reminded that playground supervision must be active in nature and that staff must stand, interact and circulate to ensure all children are playing safely. Play zones have been reviewed with staff, staff has been informed that all zones must be covered and that staff is not to stand together or congregate while on the playground. Some staff must also be circulating the playground to be able to immediately stop any rough play or unsafe play that may pose a risk to children. Staff have also been reminded that they must monitor and assist children using playground equipment, and that in the event a staff member is supervising the playground alone, said staff member will limit the play areas so that children are not permitted to play outside of the staff member?s line of sight. In order to ensure continued compliance going forward, playground safety and supervision will be addressed again at the next staff meeting and periodically so that it remains a top priority to staff. A list of playground safety/supervision zones and safe practices will be placed at all doorways that access playground(s) no later than Monday, December 18, 2023. This will serve as reminders to staff of the importance of active supervision while engaged in outdoor play. Additionally, the director or other designated supervisor will periodically visit the playground while children are outside playing to ensure staff are following regulations and Bright Beginnings policies related to playground safety. If any non-compliance is observed, violating staff member will immediately face disciplinary action, up to and including termination, should it be warranted.
Standard #:	8VAC20-780-70
Description:	Repeat VIolation Based on record review, the center failed to ensure that a staff record contained documentation to demonstrate that the individual possesses the education, certification, and experience required by the job position, and orientation and training as required in 8VAC20-780-240 and 8VAC20-780-245. Evidence: 1. The record for staff #3, Program Leader, did not contain documentation that the staff fulfilled a high school program completion or the equivalent.
Plan of Correction:	Effective immediately, the program director will ensure that all staff records contain the necessary documentation to demonstrate the individual possesses the education, certification, and experience required by the job description, and orientation and training as required in licensing regulations. A checklist of requirements for all staff members, including the necessary documentation to demonstrate the staff person possesses the education, certification, and experience required by the job description, as well as staff orientation and training, has been created and included in each staff person?s file. A staff person will not be permitted to report to work unless all documentation, etc., as required by licensing regulations, has been obtained and included in a staff person?s file. The program director will periodically review staff files to ensure nothing is missing from the person?s file and all necessary documentation has been obtained. Any non-compliance will immediately be corrected. In order to further ensure continued compliance, said checklist will be utilized with all new hires. This will ensure that the new staff member?s file contains the necessary documentation as required by licensing. Should any documentation, training or certifications be missing, the staff person will not be permitted to report to work until all documentation has been obtained. Additionally, the director will periodically review all staff files to ensure they contain the necessary documentation.
Standard #:	8VAC20-780-280-B
Description:	Repeat Violation Based on observation, the center failed to ensure that hazardous substances, such as cleaning materials, insecticides, and pesticides shall be kept in a locked place using a safe locking method that prevents access by children. Evidence: 1. The door to the cabinet above the sink in the Tiger room was open and unlocked. The cabinet contained a bottle of Comet Classic Foam Cleaner with Bleach, a spray bottle labeled ?Bleach Water? dated 11/27, and a spray bottle labeled ?Table Bleach? dated 11/17. Staff working in the Tiger room verified that both spray bottles contained a bleach mixture. 2. There is not a lock on the door to the kitchen, located in the main hallway. A cabinet under a sink, which did not have a locking method, contained a spray bottle of Simple Green and a bottle of Proface ready to Use Heavy Duty Degreaser, both labels indicated ?Keep Out of Reach of Children?. The kitchen also contained unlocked bottle of Dawn Ultra, label indicating ?Keep Out of Reach of Children? and a spray bottle labeled Antibacterial Cleaner.
Plan of Correction:	Effective immediately, Bright Beginnings shall ensure that all hazardous substances, such as cleaning materials, shall be kept in a locked place using a safe locking method that prevents access by children. Effective immediately, the director met with all staff members to remind them of the necessity that all hazardous materials, insecticides and pesticides must be kept in locked cabinets. Additionally, the director inspected each classroom to be sure that locks were available on all cabinet doors where such materials may be stored and demonstrated to staff the proper use of said locks. Going forward and to ensure continued compliance in the future, the regulation regarding hazardous materials and proper storage in locked cabinets will be reviewed with staff members periodically and with any new staff upon hire. ?Back up? replacement safety locks for all cabinets, drawers and doors have been purchased and will be available should a safety lock break or become inoperable. Classroom teachers have been advised of their responsibility to notify the Director immediately if there is a need for a new safety lock. Additionally, the facility director will periodically visit each classroom to ensure that all hazardous materials are being stored properly in locked cabinets. Although not anticipated, any non-compliance will immediately be addressed. Additionally, a deadbolt lock has been installed on the kitchen door to prevent access by children.
Standard #:	8VAC20-780-340-A
Description:	Based on observation and interview, the center failed to ensure when staff are supervising children, they shall always ensure their care, protection, and guidance. Evidence: 1. In the lion's infant room, two children were observed sleeping in bouncy chairs. Child #6 was observed asleep with a blanket covering him up to his chin and a stuffed animal resting against his face. Another child was observed sleeping with a bib attached around his neck. 2. According to The American Academy of Pediatrics website "infants need to sleep on their backs on a firm, flat non-inclined surface without soft bedding. Keep soft objects, such as pillow-like toys, quilts, comforters, and loose bedding, such as blankets away from the infant's sleep area to reduce the risk of SIDS and suffocation." 3. Administration confirmed the babies should not have had a blanket, stuffed animal, or bib on while sleeping.
Plan of Correction:	Effective immediately, Bright Beginnings staff shall ensure that when staff are supervising children, they shall always ensure their care, protection and guidance. The director reviewed all crib and sleep regulations/requirements with staff persons that care for children under 12 months of age, focusing on safe sleep practices. Staff were specifically advised that children are not permitted to sleep in bouncy chairs. In keeping with safe sleep practices, staff was also advised that blankets and other soft objects are not permitted in cribs and that bibs must be removed prior to placing a child in a crib to sleep. To ensure continued compliance going forward, a list of safe sleep practices will be prepared and the director shall ensure that said list is posted in each room that children under the age of 12 months are cared for. This will serve as a reminder and as a reference for new hires or substitutes to ensure that safe sleep practices are being followed. The director will visit each ?under 12-month-old? room weekly, to ensure continued compliance with safe sleep practices. Additionally, a note will be sent home to all parents of attending children who are under the age of 12 months, reminding parents that blankets, stuffed animals, etc. should not be sent in as a sleep aid for children. Additionally, going forward, the program director will periodically review and/or retrain staff as needed on safe sleep practices, ensuring staff adheres to safe sleep standards/requirements.
Standard #:	8VAC20-780-350-Q
Description:	Based on documentation and interview, the center failed to ensure that written assessments were completed by the program director and program leader before choosing to assign a child to a different age group. Evidence: 1. Documentation from the records of children #1, 2, 3, 4, and 5, all age two and assigned to the 3 year old group, contained written assessments that had designated spaces for two teacher signatures and two parent signatures. These assessments were not signed by the program director at the time of inspection. 2. Interview with the program director confirmed that she did not conduct the assessments of the children with the program leader.
Plan of Correction:	Effective immediately the program director will ensure that written assessments are completed by both the program director and program leader before choosing to assign a child to a different group. Said regulation and requirement have been reviewed by the director and in-turn the director has reviewed said regulation and requirement with staff. Anytime a staff member initiates or intends a move of a child to a different group, an assessment will immediately be scheduled on a date and time that both the program director and program leader can participate, ensuring both signatures. No child will be moved to another group without the director and leader reviewing the assessment to make sure both parties have participated in the assessment and have signed the related paperwork. If the assessment lacks both signatures, the child will not be permitted to move to the alternate group until the assessment and signatures are in compliance. Going forward, to ensure continued compliance, the regulation and requirements related to assigning children to different groups, will be reviewed with all staff at the start of the school year and periodically throughout the year, and will be reviewed with new teachers/programleaders upon hire.
Standard #:	8VAC20-780-500-A
Description:	Based on observation, the center failed to ensure children's hands are washed with soap and running water after toileting. Evidence: In the Cheetah classroom, child #12 was observed exiting the restroom without washing his hands. Staff #4 confirmed the child used the restroom and staff were unaware the child's hands were not washed.
Plan of Correction:	Effective immediately, Bright Beginnings staff will ensure that children?s hands are washed with soap and running water after toileting. All staff have been reminded of the requirement that children?s hands must be washed with soap and running water after toileting. Staff will periodically review hand washing requirement and procedure with children in their care so that children do not forget to wash hands after toileting. Staff will ask children if hands have been washed after the child has used the restroom. No child will be permitted to play or partake in other activities after toileting unless their hands have been washed. In order to ensure continued compliance, the director or other admin person will ?drop-in? to classrooms ensure proper handwashing is taking place. Staff will periodically be reminded to review hand washing procedures and requirements with children. Although not anticipated, any non-compliance will be immediately addressed.