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: July 24, 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 SANCTIONS. 8VAC20-820 HEARINGS PROCEDURES. 8VAC20-770 BACKGROUND CHECKS 22.1 EARLY CHILDHOOD CARE AND EDUCATION

Comments:

An unannounced, on-site monitoring inspection was initiated on July 24, 2024 and completed on July 24, 2024. The on-site inspection began at 2:15 pm and ended at 4:00 pm. The inspector reviewed compliance in the areas listed above. There were 23 children present and four staff. The inspector reviewed six children?s records and five staff records on-site. This inspection included document review (i.e. Injury logs, policies and procedures, emergency drill logs, medication administration logs, authorization forms), 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 deficient practice will be or has been corrected. Submit your POC within five (5) business days from today, which will be the close of business on 08/26/2024. A POC submitted after this date will not appear on the public website.

Violations:

Standard #:	8VAC20-780-160-C
Description:	Based on review of staff records and interview, the center did not obtain the results of a follow-up tuberculosis screening at least every two years from the date of the initial screening or testing. Evidence: The most recent tuberculosis screening for staff #1 was dated 07/10/2022, exceeding two years. The director stated a follow-up tuberculosis screening had not been done.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-245-A
Description:	Repeat Based on review of five staff records, the center did not ensure two staff annually completed a minimum of 16 hours of training appropriate to the age of children in care. Evidence: 1. The record of staff #2, employed 07/07/2007, contained documentation of 14.5 hours of annual training for the period of 07/07/2023 through 07/06/2024, when 16 hours was required. 2. The record of staff #3, employed 06/20/2023, contained documentation of two hours of annual training hours for the period 06/20/2024 through 06/19/2024 when 16 hours was required. 3. The record of staff #4, employed 06/13/2023, contained documentation of two hours of annual training hours for the period 06/13/2024 through 06/12/2024 when 16 hours was required. 4. The director stated she did not have any additional documentation of training for staff #3 and staff #4.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-350-I
Description:	Based on observation and interview, the center did not ensure for children ages 16 months through preschool age, during the designated rest period, when children are resting or in an inactive state, the following rest period ratios are permitted: Children 16 through 24 months of age: one staff per 10 children. Evidence: 1. A total of 12 children ages16 months through two years were observed napping in the toddler classroom with one staff at approximately 2:15 pm. An additional staff was needed to meet the the toddler nap ratio of 1:10. 2. The director confirmed the toddler classroom was over ratio and stated the second staff had gone on break.
Plan of Correction:	Not available online. Contact Inspector for more information.