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: Feb. 24, 2022

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. 8VAC20-820 THE LICENSE. 8VAC20-820 THE LICENSING PROCESS. 8VAC20-770 Background Checks (22VAC40-191) 20 Access to minor?s records 22.1 Early Childhood Care and Education 32.1 Report by person other than physician 63.2 Child Abuse & Neglect

Comments:

This inspection was conducted by licensing staff partially using an alternate remote protocol, including telephone contacts and documents review. The inspector was on site on 02/24/2022 from 4:10 pm to 4:55 pm. A renewal inspection was initiated on 2/24/2022 and concluded on 03/01/2022. There were 23 children present, ranging in ages from 5 to 10 years, with 2 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, 3 staff records, and 5 board member 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. 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 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 #:	22.1-289.035-B-2
Description:	Based on record review and interview, the center did not ensure to obtain the results of a fingerprint background check for one staff prior to the first date of employment as required. Evidence: 1. The record of staff #1 (DOH:9/23/2019) contained the results of a fingerprint background check dated 10/8/2019. 2. Administration acknowledged that the background check was completed after the first date of employment.
Plan of Correction:	will work on corrections for the future.
Standard #:	22.1-289.035-B-4
Description:	Based on record review and interview, the center did not ensure to obtain the results of an out of state sex offender registry background check for one staff hired prior to 7/1/2020 by 12/31/2020 as required. Evidence: 1. The record of staff #1 (DOH: 9/23/2019) contained a sworn statement that indicated that the staff resided outside of the state within the preceding 5 years. 2. The record contained an out of state sex offender check dated 3/12/2021. The check was required to be completed by 12/31/2020. 3. Administration acknowledged that the out of state background check was completed late.
Plan of Correction:	will work on corrections for the future.
Standard #:	8VAC20-770-60-B
Description:	Based on record review and interview, the center did not ensure to obtain a completed sworn statement for one staff prior to employment as required. Evidence: 1. The record of staff #2 (DOH:5/12/2021) contained a sworn statement dated 4/26/2021. The questions were not completed by the staff member. 2. Administration acknowledged that the sworn statement was incomplete.
Plan of Correction:	corrected with staff today. Put in his file for future use.
Standard #:	8VAC20-770-60-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 one staff. Evidence: 1. The record of staff #1 (DOH: 09/23/2019) contained the results of a central registry finding dated 1/6/2020. 2. Administration acknowledged that the central registry findings were not received within the required time frame.
Plan of Correction:	will work on corrections for the future
Standard #:	8VAC20-780-60-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: 08/23/2021), child #2 (DOE:08/23/2021) and child #3 (DOE: 10/11/2021) 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 incomplete and the records for each child did not contain the required 2 designated people to call if the parents could not be reached.
Plan of Correction:	Going to contact families to get a second contact that is not the parents.
Standard #:	8VAC20-780-540-C
Description:	Based on observation and interview, the center did not ensure to maintain a first aid kit that contained all of the required supplies. Evidence: 1. The first aid kit did not contain a thermometer. 2. Administration acknowledged that the first aid kit was missing a thermometer.
Plan of Correction:	corrected. New thermometer on site.