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YMCA SACC at Bowling Green Elementary
17502 New Baltimore Road
Milford, VA 22514
(804) 448-9622

Current Inspector: Florence Martus (804) 389-0157

Inspection Date: March 7, 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 (8VAC20-770)
22.1 Background Checks Code, Carbon Monoxide

Technical Assistance:
n/a

Comments:
A renewal inspection was initiated on 03/07/2022 and concluded on 03/23/2022. The facility submitted documentation to the inspector on 03/07/2022 and the inspector conducted an unannounced inspection on-site on 03/08/2022 from approximately 4:10pm to 4:55pm. On 03/08/2022, there were 8 children present with two staff directly supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, special care and emergencies and nutrition. A total of three child records and two 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 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).

Violations:
Standard #: 8VAC20-780-40-K
Description: Based on interviews, the center has not developed written procedures for prevention of shaken baby syndrome or abusive head trauma, including coping with crying babies, safe sleeping practices, and sudden infant death syndrome awareness.

Evidence: 1) During interview, a member of management reported the required written procedures for prevention of shaken baby syndrome or abusive head trauma have not been developed.

Plan of Correction: Per the Center: "1) Management was notified regarding an update to the policy region-wide and they are working on modifying the procedures. 2) In the future, policies will be updated sooner per licensing requirements. 3) [Management]"

Standard #: 8VAC20-780-70
Description: Based on observations and a review of documentation on 03/08/22, the center did not ensure that the required information for each staff was kept at the center.

Evidence: 1) During the inspection, Staff #1 and Staff #2 were observed at the center. 2) The emergency contact information and information about any health problems which may interfere with fullfilling the job responsibilities were not observed at the center for Staff #2 (DOH: 01/17/20). The center should maintain at the center the name, address and telephone number of a person to be notified in an emergency and information about any health problems which may interfere with fulfilling the job responsibilities for each staff member.

Plan of Correction: Per the Center: "1) Emergency contact info is kept at the central site, but not at the daily site. Moving forward, this information will be
kept at the daily site for all staff. 2) In the future, staff files at the daily site will contain emergency contact info for staff working. 3) [Director]"

Standard #: 8VAC20-780-350-F
Description: Based on interviews, the center has not developed a written policy and procedure that describes how the center will ensure that each group of children receives care by consistent staff or team of staff members.

Evidence: 1) During interview, a member of management reported the center is practicing care by consistent staff, but written policies and procedures are not listed in official policy format.

Plan of Correction: Per the Center: "1) Management is working to revise policies and staff handbooks to include practices of care by consistent staff. 2) In the future, a review will be conducted to update policies sooner per licensing requirements. 3) [Management]"

Standard #: 8VAC20-780-550-B
Description: Based on a review of documentation, the center's emergency preparedness plan does not contain all the required information.

Evidence: 1) The center's emergency preparedness plan was reviewed, the plan did not include procedural components for the continuity of operations to ensure that essential functions are maintained during an emergency.

Plan of Correction: Per the Center: "1) Review of the EPP will be conducted and the component that includes continuity of operations for essential functions during and emergency will be added. 2) In the future, a 30-day review will be conducted w/ EPP plans to ensure they are consistently being updated. 3) [Management]"

Disclaimer:

A compliance history is in no way a rating for a facility.

The online compliance history includes only information after July 1, 2003. In addition, the online compliance history includes information regarding adverse actions that may be the subject of a pending appeal. An adverse action is not final until a provider has exhausted or waived all due process rights. For compliance history prior to July 1, 2003, or information regarding the status of pending adverse actions, please contact the Licensing Inspector listed in the facility's information. The Virginia Department of Social Services (VDSS) is not responsible for any errors in or omissions from the compliance history information.

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