VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Young Men's Christian Association of Greater Richmond-Evergreen
1701 Evergreen Parkway
Midlothian, VA 23114
(804) 474-4405

Current Inspector: Jennifer Moore (540) 430-0384

Inspection Date: Nov. 9, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-185 ADMINISTRATION. 22VAC40-185 STAFF QUALIFICATIONS AND TRAINING. 22VAC40-185 PHYSICAL PLANT. 22VAC40-185 STAFFING AND SUPERVISION. 22VAC40-185 PROGRAMS. 22VAC40-185 SPECIAL CARE PROVISIONS AND EMERGENCIES. 22VAC40-185 SPECIAL SERVICES. 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-191 Background Checks (22VAC40-191) 20 Access to minor?s records 32.1 Report by person other than physician 63.2 Child Abuse & Neglect 63.2(17) License & Registration Procedures 63.2 Facilities & Programs.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol, including telephone contacts, documents review, and a virtual tour of the program. A monitoring inspection was initiated on 11/09/2021 and concluded on 11/12/2021. The director was contacted by telephone and a virtual inspection was conducted. There were 26 children present, ranging in ages from 5 to 11 years, with 3 staff supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies, nutrition and background checks. A total of 3 child records and 3 staff records were reviewed. Information gathered during the inspection determined non-compliance with applicable standards or law and violations were documented on the violation notice issued to the program. 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 today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word ?corrected? is not acceptable. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measures. Please do not use staff names; list staff by positions only.

Violations:

Standard #:	22VAC40-185-60-A
Description:	Based on record review and interview, the center did not ensure to keep a separate record for each child enrolled that contained all of the required information. Evidence: 1. The records of child #1 (DOE: 8/23/2021) and child #2 (DOE:08/23/2021) did not contain the name, address, and phone number of two designated people to call in an emergency if a parent could not be reached. 2. Administration acknowledged that the emergency contact information was missing.
Plan of Correction:	contact families to update their accounts
Standard #:	22VAC40-185-70-A
Description:	Based on record review and interview, the center did not ensure that a complete record was kept for one staff. Evidence: 1. The record of staff #1 (DOH: 09/30/2021) did not contain documentation of orientation training. 2. Administration acknowledged that the orientation training was conducted but not documented.
Plan of Correction:	turn in orientation form
Standard #:	22VAC40-185-540-C
Description:	Based on observation and interview, the center did not ensure that the first aid kit contained all of the required supplies. Evidence: 1. The first aid kit did not contain triangular bandages. 2. Administration acknowledged that they were missing.
Plan of Correction:	center bought supplies and delivered 11/11/21
Standard #:	22VAC40-185-540-E
Description:	Based on observation and interview, the center did not ensure that all required nonmedical emergency supplies were kept on site. Evidence: 1. The center did not have a working battery operated flashlight and a working battery operated radio. 2. Administration acknowledged that the supplies were missing.
Plan of Correction:	center bought supplies and delivered 11/11/21
Standard #:	22VAC40-191-60-C-2
Description:	Based on record review and interview, the center did not ensure to obtain the results of a central registry finding within 30 days of employment for two staff. Evidence: 1. The record of staff #1 (09/30/2021) did not contain the results of a central registry finding. The record of staff #2 (DOH:09/20/2021) contained the results of a central registry finding dated 10/27/2021. 2. Administration acknowledged that the central registry findings were not received within the required time frame.
Plan of Correction:	work with HR on start dates