VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Young Men's Christian Association of Greater Richmond - CECLA
15501 Harrowgate Road
Chester, VA 23831
(804) 474-4405

Current Inspector: Sharon Curlee (804) 840-8312

Inspection Date: Feb. 15, 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. 8VAC20-770 Background Checks (22VAC40-191) 22.1 Early Childhood Care and Education

Technical Assistance:

n/a

Comments:

A renewal inspection was initiated on 02/15/2022 and concluded on 02/28/2022. The facility submitted documentation to the inspector on 02/15/2022 and the inspector conducted an unannounced inspection on-site on 02/16/2022 from approximately 3:40pm to 5:50pm. There were 21 children present with four staff directly supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies and nutrition. A total of three child records and three 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.

Violations:

Standard #:	22.1-289.035-B-2
Description:	Based on a review of three staff records and interview, the center did not ensure that one staff member obtained a fingerprint based background check determination letter prior to employment. Evidence: 1) The fingerprint determination letter in the record for Staff #2, hired on 09/27/21, was dated 12/10/21. 2) During interviews, a member of management confirmed the fingerprint based background check determination letter for Staff #2 was received after Staff #2 began employment.
Plan of Correction:	Moving forward, all staff members will be required to have a fingerprint based background check determination letter prior to hire.
Standard #:	8VAC20-770-60-B
Description:	Based on a review of three staff records and interview, the center did not ensure one staff member had a completed sworn statement or affirmation prior to hire. Evidence: 1) The sworn statement in the record for Staff #2, hired on 09/27/21, was dated 10/11/21. 2) During interview, a member of management confirmed the sworn statement for Staff #2 was completed after Staff #2 began employment.
Plan of Correction:	Moving forward, all staff will be required to complete a sworn statement prior to hire.
Standard #:	8VAC20-770-60-C-2
Description:	Based on a review of three staff records and interview, the center did not have a central registry finding within 30 days of employment for one staff. Evidence: 1) The record for Staff #2, hired on 09/27/21, did not contain the results of a central registry finding. 2) During interview, a member of management reported the central registry findings for Staff #2 have not been received to date.
Plan of Correction:	Moving forward, all staff will be required to have a central registry finding within 30 days of employment.
Standard #:	8VAC20-780-160-C
Description:	Based on a review of four staff records and interview, the center did not ensure one staff submitted the results of a follow-up tuberculosis screening at least every two years from the date of the first initial screening or testing. Evidence: 1) The most recent tuberculosis screening in the record for Staff #1, hired on 02/04/20, was dated 01/28/20. 2) During interview, a member of management confirmed a follow-up tuberculosis screening or testing was not on file for Staff #1.
Plan of Correction:	The staff member resubmitted a current tuberculosis screening on 03/08/2022.
Standard #:	8VAC20-780-550-D
Description:	Based on record review and interview, the center did not implement a monthly practice evacuation drill. Evidence: 1) The licensing inspector observed that the monthly practice drill for November 2021 was completed in December 2021. 2) A member of management confirmed an evacuation drill was not conducted in November 2021. The center shall implement a monthly practice evacuation drill and a minimum of two shelter-in-place practice drills per year for the most likely to occur scenarios.
Plan of Correction:	Moving forward, the center will conduct a monthly evacuation drill as required.