VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Young Men's Christian Association of Greater Richmond - Bellwood
9536 Dawnshire Road
N. chesterfield, VA 23237
(804) 743-3600

Current Inspector: Heather Dapper (804) 625-2304

Inspection Date: April 27, 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 (8VAC20-770)

Comments:

An unannounced monitoring inspection was conducted on-site on April 27, 2022 and concluded remotely April 29, 2022. The director was available during the inspection. There were 11 children present, ranging in ages from 6 years 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 and nutrition. The inspector requested staff records to review remotely. A total of 9 child records, 1 injury report, 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. 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 #:	8VAC20-770-60-B
Description:	Based on a review of staff records and interview on April 29, 2022, the center did not ensure to obtain a sworn statement from each staff prior to employment. Evidence: 1. The record of staff #3 (hired 3/8/22) did not contain documentation of a sworn statement. 2. Administration acknowledged the sworn statement was not complete.
Plan of Correction:	We have information to staff to redo form.
Standard #:	8VAC20-770-60-C-2
Description:	Based on a review of staff records and interview on April 29, 2022, the center did not ensure that each staff record reviewed contained a central registry finding within 30 days of employment. Evidence: 1. The record of staff #2 (hired 11/17/21) contained documentation of central registry results dated 1/4/22. 2. The record of staff #3 (hired 3/8/22) contained documentation of central registry results dated 4/18/22. 3. Administration acknowledged the central registry checks were late.
Plan of Correction:	We have been working on a better process to fix this moving forward.
Standard #:	8VAC20-780-60-A
Description:	Based on a review of records and interview on April 27, 2022, the center did not ensure that each child's record contained the required information. Evidence: 1. Per administration the record of child #2 was not on-site and not accessible electronically. 2. The record of child #3 (enrolled 6/24/21) contained documentation of a physical and immunizations dated 10/12/21. 3. The record of child #4 did not contain documentation of a date of enrollment and last date of attendance. Administration stated the child was expelled from the program. Administration was unable to access child's electronic file. 4. The record of child #6 did not contain documentation of a date of enrollment. 5. The record of child #9 did not contain documentation of a date of enrollment.
Plan of Correction:	We will be fixing all child file issues and making sure to fix our process so we collect all items before enrollment.
Standard #:	8VAC20-780-70
Description:	Based on a review of staff records and interview on April 27, 2022, the center did not ensure all the required information shall be kept for each staff. Evidence: 1. Documentation of the minimum requirements of staff records to be kept on-site (name, address, phone number of a person to be notified in an emergency and information about any health problems that may interfere with fulfilling job responsibilities) were not present at the center. Administration confirmed the center did not have this information on-site. 2. The record of staff #1 (hired 12/13/21) did not contain documentation of program director qualifications.
Plan of Correction:	We will make sure all staff have the staff information sheet on site moving forward.
Standard #:	8VAC20-780-550-D
Description:	Based on an interview with administration and record review on April 27, 2022, the center did not ensure to implement a monthly practice evacuation drill. Evidence: 1. Administration reported that no fire drills have been conducted since she arrived at the center in December 2021. 2. Documentation of the last fire drill recorded was dated February 9, 2022.
Plan of Correction:	We will make sure to document all monthly drills.
Standard #:	8VAC20-780-550-P
Description:	Based on a review of records and interview on April 27, 2022, the center did not ensure that written records of children's serious and minor injuries contained all the required information. Evidence: 1. An incident report for child #1 did not contain documentation of treatment received, the date and time when parents were notified, any future action to prevent recurrence of the injury, and documentation on how the parent was notified. 2. Administration acknowledged the missing components.
Plan of Correction:	We will fix our incident report log and maintain same day documentation.