VIRGINIA DEPARTMENT OF SOCIAL SERVICES

YMCA-SACC and Summer Camp at Lewis & Clark
18101 Clark & York Boulevard
Ruther glen, VA 22546
(804) 448-9622

Current Inspector: Florence Martus (804) 389-0157

Inspection Date: May 16, 2019 , May 24, 2019 and June 21, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-185 ADMINISTRATION. 22VAC40-185 STAFF QUALIFICATIONS AND TRAINING. 22VAC40-185 STAFFING AND SUPERVISION. 22VAC40-185 SPECIAL CARE PROVISIONS AND EMERGENCIES. 22VAC40-191 Background Checks (22VAC40-191) 63.2(17) License & Registration Procedures

Technical Assistance:

n/a

Comments:

The licensing inspector conducted an unannounced complaint inspection in response to a complaint that was received by the department on 04/23/2019 regarding concerns of the center's administration, supervision of children, background checks, and special services. The investigation was initiated on 05/16/2019 and completed on 07/08/2019. On 05/16/2019, the inspector was on site on from 3:57pm to 4:50pm. Interviews with staff were completed, observations were made at the center, and documentation reviewed. On 05/24/2019, the inspector was on site conducting additional interviews and reviewing documentation from 1:50pm to 3:15pm. Additional interviews were conducted on 06/21/2019. The preponderance of the evidence gathered during the investigation supports part of the allegation, therefore the complaint is determined to be valid. Additional areas of noncompliance not related to the complaint were cited. See the violation notice for more details. 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 the date of receipt. 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 standards, 2) measures to prevent the noncompliance from occurring again, and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). If you have any questions about this inspection, please contact the licensing inspector, Florence Martus, at (804) 662-9772.

Violations:

Standard #:	22VAC40-185-70-A
Complaint related:	No
Description:	Based on a review of records on 05/24/2019, the center did not obtain all required information for one out of three staff records reviewed. Evidence: 1) The record for Staff #1, hired on 04/03/2019, does not have documentation of two references. Each staff record shall include documentation that two or more references as to character and reputation as well as competency were checked before employment or volunteering.
Plan of Correction:	Per the Center: "The checklist referenced above will ensure that all staff files are complete and accurate."
Standard #:	22VAC40-185-530-A
Complaint related:	No
Description:	Based on a review of records, observation, and interview, the center did not ensure that there shall be at least one staff member trained in first aid, cardiopulmonary resuscitation, and rescue breathing as appropriate to the age of the children in care who is on the premises during the center's hours of operation and also one person on field trips and wherever children are in care. Evidence: 1) The record for Staff #1, hired on 04/03/2019, does not contain documentation that the staff member is trained in first aid, cardiopulmonary resuscitation, and rescue breathing. 2) During interview, Staff #4 reported that Staff #1 does not have current certification in first aid or cardiopulmonary resuscitation, and rescue breathing. 3) The licensing inspector observed Staff #1 transporting children alone from school during the inspection on 05/16/2019.
Plan of Correction:	Per the Center: "All staff files will contain applicable training records. All staff will or has received training for their position. Staff member who transported a child received a disciplinary warning. Only staff who has been approved as drivers will transport children in YMCA vehicles."
Standard #:	22VAC40-191-60-C-2
Complaint related:	Yes
Description:	Based on a review of documentation and interview on 05/24/2019, the center did not discontinue employment for one staff when the central registry findings were not obtained within 30 days of employment. Evidence: 1) The record for Staff #1, hired on 04/03/2019, did not contain the results of a central registry findings. 2) During interview, Staff #4 confirmed the central registry findings for Staff #1 were not on file and could not be located. Staff #1 was still employed on the date of inspections on 05/16/2019 and 05/24/2019.
Plan of Correction:	Per the Center: "A checklist has been devised to ensure all staff files are complete on dates they need to be."