Elly Lafkin became an advocate for improving the system of background checks in Virginia for home child care after her daughter, Camden, died of Sudden Infant Death Syndrome in child care at the age of 3 months in May 2012. (Norm Shafer/THE WASHINGTON POST)

When the call came, it took Elly Lafkin a few minutes to realize that the voice sobbing incomprehensibly into the phone was her infant daughter’s babysitter. She was telling Lafkin to rush to Rockingham Memorial Hospital in Harrisonburg, Va.

By the time Lafkin arrived the morning of May 17, emergency medical workers had been giving her daughter CPR for 35 minutes. They’d shot epinephrine into her thigh four times and had tried again and again to restart her daughter’s heart, still no bigger than a walnut, with defibrillator paddles.

At the hospital, Lafkin pleaded with the doctors to not give up. “I screamed, ‘You can’t stop!’ ” she remembers. “ ‘You have to keep trying!’ ”

But at 12:27 p.m., they called Camden Lafkin’s death. She was 13 weeks and two days old.

The caregiver and Camden’s cause of death are under investigation, according to local Commonwealth’s Attorney Marsha Garst. Lafkin said she was told by investigators that marijuana and methamphetamines were found in the caregiver’s home. Lafkin has since paid for a thorough background search using the caregiver’s Social Security number and found five other names with a host of civil and criminal charges, including a felony charge for embezzlement. Court records show a number of violations on her five-year probation.

A photo of Elly Lafkin's daughter, Camden, hangs on the living room of her Shenandoah, Va., home on Feb. 25. Lafkin and her husband said this was one of their favorite photos of Camden. (Norm Shafer/THE WASHINGTON POST)

But before Camden’s death, there was no way for Lafkin to have known. In a state that is often reluctant to impose rules on small businesses, the caregiver was operating an unlicensed, unregulated, unmonitored and perfectly legal family day care.

Virginia is one of only eight states in the nation that allow family providers to care for up to six unrelated children, as well as any number of their own children, without a license. Providers are not required to pass background checks or get training on health, safety, safe sleeping practices or child development. No one inspects their sites for safety or quality.

The standards are so low that Alexandria and Fairfax and Arlington counties have imposed stricter rules of their own. All three jurisdictions require a license, permit or registration that includes background checks, fire-safety inspections and CPR and first-aid training.

But parents in the rest of the state are largely on their own.

“We trusted this lady with our child,” Lafkin said. “We didn’t realize that sending your child to an unlicensed, unregistered provider meant throwing her to the wolves.”

About 400,000 children in Virginia — half of all children under 12 estimated to be in child care — are in unregulated settings, said Sharon Veatch, executive director of Child Care Aware of Virginia, an advocacy organization.

“A lot of them are the younger ones, because there are really limited spaces for infants and toddlers,” Veatch said. “Unregulated care doesn’t necessarily mean it’s bad. But we just don’t know. And we don’t know where they are, so we can’t reach out to provide support and information on even simple things, like how to baby-proof your home.”

Day-care deaths in Virginia are rare. But three of the four children who died from suspected abuse or neglect while in day care in fiscal 2011 were in unregulated settings, according to the state Department of Social Services.

In 2012, two months before Camden’s death, 3-month-old Teagan Sample died in an unregulated day-care home in Prince William County. Twenty-three children were being cared for at Little Angels of the World by two women, who were charged with multiple counts of child endangerment.

Hundreds of cases of child abuse and neglect at unregulated day cares were referred by Child Protective Services to local investigators and prosecutors for further scrutiny in fiscal 2012, state records show.

Virginia law requires a background check of state police records and the child abuse registry for licensed caregivers only. Even so, it doesn’t require a federal fingerprint check nor a check of the sex offender registry before granting a license.

Because of what it calls Virginia’s “weak” standards, Child Care Aware of America has ranked the state at the bottom nationally for safety and quality of family day care.

Virginia also exempts any child-care centers or after-school programs operated by religious organizations, parks and recreation departments, public schools and even private karate clubs from meeting full child-care licensing standards, advocates said.

“In Virginia, we require someone who does your fingernails, cuts your hair or gives you a massage to go through hours of training, to supervise their experience and demonstrate their skills. They all have to be licensed. Yet we don’t require any of that for child-care providers, the people we are trusting our most valued possessions to,” Veatch said. “We require more from a dog groomer. That’s a tragedy.”

A search for affordable care

Elly Lafkin, then 24, and her husband, Cameron, thought they’d done everything right to find the best child care for their precious 8-week-old baby when Lafkin’s maternity leave ran out. In rural Shenandoah, far from her own family, Lafkin’s options were slim.

Lafkin had toured the only three licensed and accredited child-care centers within a 35-mile radius that accept infants. But the commute, the $150-a-week cost, long waiting lists and strict closing times made those options unworkable.

Lafkin, who worked in a pharmacy billing department, got lists of unlicensed family care providers from the local Department of Social Services. Nine out of 10 numbers were disconnected.

She crunched the numbers to see if she and her husband could afford for her to stay home. They couldn’t.

Then two friends recommended a grandmother who’d cared for children in her home for more than a decade near where Lafkin’s husband worked managing the pools at Massanutten Resort. The Lafkins ran a background check of state court records — they found only minor traffic violations — and interviewed the woman twice before agreeing to pay her $85 a week to care for Camden.

Lafkin said the caregiver assured her that she never had more than four children in her home at one time. On the morning Camden died, she had six. But, since one was a grandchild, Lafkin said, she was still operating in accordance with state law.

The caregiver’s attorney, Scott Hansen, declined to discuss Camden’s death. “As anything under current investigation, and while there’s any specter of legal action, be it civil of otherwise, it would just be imprudent to speak,” he said.

In the weeks after she buried her daughter, Lafkin became active in First Candle, a national nonprofit dedicated to reducing Sudden Infant Death Syndrome. But as details began to emerge about the investigation into Camden’s death, she has become determined to transform Virginia’s child-care laws.

“My daughter is never coming back,” said Lafkin, sitting in her living room surrounded by baby photos, Camden’s framed birth announcement with the black ink imprints of her tiny feet and the book that mourners signed at her funeral. “But other children might have a better chance if we could just get the laws changed.”

Stricter standards

What Lafkin wants is what the American Academy of Pediatrics recommends: training in health, safety and child development, licensing, background checks and regular inspections for any setting where children are cared for by anyone other than a close relative.

Both Maryland and the District of Columbia, which rank in Child Care Aware’s top 10 for family care standards, require caregivers to obtain a license as soon as they care for one unrelated child. A licensed family caregiver is required to undergo a background check and training in CPR, first aid and, in Maryland, emergency preparedness and child development. Licensed family care homes are inspected once a year in Maryland and twice a year in D.C.

At the very least, Lafkin said, she wants all caregivers in Virginia to be trained in safe sleeping practices.

A national education campaign to put babies to sleep on their backs on firm crib mattresses with tight-fitting sheets and no pillows or bumpers has reduced the number of SIDS deaths by 50 percent over the past two decades, according to the Centers for Disease Control and Prevention.

Lafkin said she’d “had words” with her caregiver when she discovered she had put Camden to sleep on an adult bed surrounded by a thick body pillow. The caregiver promised not to do it again, but Lafkin said she began feeling increasingly uncomfortable. When she learned in early May that her job would be outsourced, she said she decided to pull Camden out of that day care on June 1.

“My husband and I took Lamaze classes; we took new parent classes. We were very up to date on safe sleeping,” she said. “We were amazed that Camden’s provider was not.”

In January, Lafkin met with Virginia lawmakers to press her case. She didn’t get far with Sen. Steve Martin, a Republican from Chesterfield who chairs the education and health committee.

“He just said, ‘I would never put my children or children with someone I personally didn’t know,’ ” Lafkin said. “I’m glad he’s able to do that. That’s just not possible for most people. It was very discouraging.”

Martin, who is running for lieutenant governor, doesn’t believe lawmakers should change Virginia child-care laws.

“I can’t see us placing the same requirements on someone watching two or three children as someone who operates a full-blown child-care center,” he said. “We don’t license parents, either. Should we require a license if you’re watching your grandchild? Your niece and nephews? We do have these exemptions for religious institutions and for family caregivers. Parents need to be aware of that.”

The last substantive change in Virginia’s child-care standards, advocates said, came nearly 20 years ago when lawmakers agreed that family home caregivers could voluntarily register with the state, which requires a background check and some monitoring. A few years ago, lawmakers also agreed to require a federal fingerprint background check for licensed providers, but only if money became available.

“It was never implemented,” Veatch said. Instead, advocates have been working on a voluntary accreditation program to improve child-care quality.

Mother’s Day flowers

In the months since Camden died, Elly Lafkin has not changed a single thing in the nursery with lavender walls. Glow-in-the-dark stars and moons are scattered across the ceiling. Brightly colored board books line the bookshelf. The now desiccated pink roses from Lafkin’s only Mother’s Day lie on the table. The diaper genie is still packed with dirty diapers.“I know it’s stupid,” Lafkin said, “But I just can’t throw them away.”

On Valentine’s Day, the day her daughter would have turned 1, Lafkin took heart-shaped red balloons to her grave in the Mount Olivet Cemetery in the shadow of the Blue Ridge Mountains and sat on a bench reading to her. She promised she’d keep fighting to amend Virginia’s child-care laws.

“I have to do this to change things to better the world, or Camden will have died in vain,” Lafkin said, wiping tears. “One day, when I meet her again, I want to be able to look at her and say, ‘You died. But we did it.’ ”

Jennifer Jenkins contributed to this story.