VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Lighthouse Academy of Fredericksburg
10713 Tidewater Trail
Fredericksburg, VA 22408
(540) 372-9699

Current Inspector: Cindy Horne (804) 297-4469

Inspection Date: Nov. 15, 2024

Complaint Related: Yes

Areas Reviewed:

8VAC20-780 Administration. 8VAC20-780 Staff Qualifications and Training. 8VAC20-780 Physical Plant. 8VAC20-780 Staffing and Supervision. 8VAC20-780 Programs. 8VAC20-770 Background Checks 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.

Comments:

An unannounced inspection was initiated and completed on 11/15/2024 in response to a complaint received by the licensing office on 11/08/2024 relating to allegations of staffing and supervision. The inspector reviewed three children?s records and three staff records on site. This inspection included (document review (i.e. attendance record, posted license and posted previous inspection), tour of the facility, interviews, and observations. The preponderance of evidence gathered during the investigation supports the allegation; therefore, the complaint is determined to be valid. Information gathered during the inspection determined non-compliance with applicable standards or law and the 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 (5) business days from today, which will be the close of business on 12/04/2024. A POC submitted after this date will not appear on the public website.

Violations:

Standard #:	22.1-289.035-B-2
Complaint related:	No
Description:	Providers must obtain a completed national criminal background check prior to the employee's first day of employment. The national criminal background check for Staff #3, who has served as a substitute multiple times since the spring of 2023, was dated approximately four months after their first day of employment.
Plan of Correction:	Staff will no longer be in a classroom by herself. She will go to volunteer status only.
Standard #:	8VAC20-770-40-D-1-b
Complaint related:	No
Description:	The center is required to obtain a completed sworn statement prior to the employee's first day of employment. The sworn statement for Staff #3, who has served as a substitute multiple times since the spring of 2023, was dated approximately four months after their first day of employment.
Plan of Correction:	Staff will no longer be in a classroom by herself. She will go to volunteer status only.
Standard #:	8VAC20-780-70
Complaint related:	No
Description:	Staff records shall include: the name, address, and telephone number of a person to be notified in an emergency; documentation that two or more references were checked before employment; and information about any health problems that may interfere with fulfilling the job responsibilities. The record of Staff #3 did not include an emergency contact, two references, or information about any health problems. Staff #1 reported that the information was not obtained because Staff #3 was a volunteer. Staff #3 began volunteering for the center more than two years ago. Staff #2 reported that Staff #3 served alone as a substitute for her class on 11/14/2024. Staff #3 was responsible for four children (ages two years to three and a half years) from approximately 9:00 a.m. until 12:00 p.m. Staff #3 does not meet the definition of a volunteer. By serving as a substitute on 11/14/2024, Staff #3 was counted in the staff-to-children ratios. By serving alone as a substitute, Staff #3 was not in sight and sound supervision of other staff when working with the four children. As a result, Staff #3 shall be considered "staff" and shall meet staff requirements.
Plan of Correction:	Staff will no longer be in a classroom by herself. She will go to volunteer status only.
Standard #:	8VAC20-780-240-B
Complaint related:	No
Description:	Staff are to complete the VDOE sponsored online orientation course prior to the staff member working alone with children. Staff #3 served alone as a substitute for a classroom with four children on 11/14/2024. Staff #3 has not completed the orientation course.
Plan of Correction:	Staff will no longer be in a classroom by herself. She will go to volunteer status only.
Standard #:	8VAC20-780-245-A
Complaint related:	No
Description:	Staff shall complete annually a minimum of 16 hours of training appropriate to the age of children in care. Staff #1 reported that Staff #3 has served as substitute multiple times since the spring of 2023. Staff #3 has not completed annual training.
Plan of Correction:	Staff will no longer be in a classroom by herself. She will go to volunteer status only.
Standard #:	8VAC20-780-530-A-1
Complaint related:	No
Description:	(Repeat violation) At least one staff in each classroom shall have current certification in cardiopulmonary resuscitation (CPR) as appropriate to the age of the children in care. Staff #3 served alone as a substitute for a classroom with four children on 11/14/2024. Staff #3 does not have certification in CPR.
Plan of Correction:	Staff will no longer be in a classroom by herself. She will go to volunteer status only.
Standard #:	8VAC20-780-530-A-2
Complaint related:	No
Description:	(Repeat violation) At least one staff in each classroom shall have current certification in first aid. Staff #3 served alone as a substitute for a classroom with four children on 11/14/2024. Staff #3 does not have certification in first aid.
Plan of Correction:	Staff will no longer be in a classroom by herself. She will go to volunteer status only.