VIRGINIA DEPARTMENT OF SOCIAL SERVICES

YMCA SACC at Cedar Forest Elementary School
3412 Massaponas Church Road
Fredericksburg, VA 22408
(540) 993-3416

Current Inspector: Florence Martus (804) 389-0157

Inspection Date: Oct. 30, 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. 8VAC20-770 Background Checks (8VAC20-770) 22.1 Background Checks Code

Technical Assistance:

Discussed that caring for a child with a diagnosed food allergy that has emergency medication prescribed, but no medication on site is a high risk situation.

Comments:

An unannounced monitoring inspection was conducted from 3:45 ? 4:30pm with staff. There were 25 children, ranging from five years to nine years of age, present with two staff supervising. Children were observed transitioning from the gym to the cafeteria, taking attendance, and playing in small groups while waiting to go outside. Two onsite staff records and two onsite child records were reviewed at the time of the inspection along with the daily attendance record, emergency drill log, written list of food allergies, sensitivities and dietary restrictions, and the required posted information. Two emergency medications and authorization forms were reviewed; one staff member on site has current Medication Administration Training (MAT) certification. Two staff records were reviewed off site at the YMCA office on 9/6/2023 and two child records were reviewed virtually. Please complete the columns for "Plan of Correction" and "Date to be Corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office by 4:00pm on Tuesday, 11/21/2023. If you have further questions about this inspection please contact Donna Liberman at 540-359-5244 or Donna.Liberman@doe.virginia.gov.

Violations:

Standard #:	8VAC20-780-40-L
Description:	Based on review of documentation and staff interviews, the facility failed to inform all staff who work with children of children's allergies, sensitivities and dietary restrictions. Evidence: when asked if there were any children with allergies, sensitivities or dietary restrictions staff #3 stated, "I don?t know." Two children in attendance have diagnosed food allergies.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-60-A
Description:	Based on review of two child records, not all records contained all required information. Evidence: the record for child #1, with a diagnosed food allergy, did not contain a written care plan that included instructions from a physician regarding the steps to be taken in the event of a suspected or confirmed allergic reaction.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-70
Description:	Based on review of two staff records, not all records contained all required information. Evidence: the record for staff #2 (date of hire: 12/30/2022), who was acting as a lead teacher, did not have documentation to demonstrate that the individual possesses the education, certification, and experience required by the job position. The record for staff #3 did not contain the name, address and telephone number of a person to be notified in an emergency.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-80-A
Description:	Based on review of the written attendance record, it was determined that the facility did not ensure that the written record of daily attendance documents the arrival and departure of all children in care as it occurs. Evidence: At approximately 3:45pm, 25 children were observed, however 26 children were listed as present on the attendance sheet.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-200-A
Description:	Based on review of documentation, and an interview with staff, the facility failed to have a qualified program director regularly on site at least 50% of the facility's hours of operation. Evidence: there is no documentation that the two staff on site are director qualified. Staff stated that director qualified staff are not on site regularly, 50% of the time.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-340-D
Description:	Based on review of documentation, and observation, the facility failed to ensure that in each grouping of children at least one staff member who meets the qualifications of program leader shall be regularly present. Evidence: neither staff onsite had documentation of program leader qualifications in their record.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-510-G
Description:	Based on review of two medications, the facility failed to ensure that medication was labeled with the child's name. Evidence: there were two medications on site for child #2 that were not individually labeled with the child's name.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-510-H
Description:	Based on review of two medications, the facility failed to ensure that medication was in the original container with the direction label attached. Evidence: there was one medication on site for child #2 that was not in the original container with the direction label attached.
Plan of Correction:	Not available online. Contact Inspector for more information.