VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Family Center YMCA on Granby
2901 Granby Street
Norfolk, VA 23504
(757) 965-2322

Current Inspector: Nanette Roberts (757) 404-2322

Inspection Date: May 10, 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. 8VAC20-770 Background Checks (8VAC20-770) 22.1 Background Checks Code, Carbon Monoxide

Technical Assistance:

Technical assistance was provided in the following areas of the standards: Background checks, Program Leader qualifications, supervision, medication, first aid/emergency supplies, carbon monoxide detector, and allergies.

Comments:

An unannounced monitoring inspection was conducted on 5/10/22 from 3:30pm - 4:45pm. During the inspection there were 25 school age children in care with one staff. Children were observed participating in various activities in the classrooms, an eating snack. Records were reviewed for five children and one staff. Medication, transportation, emergency procedures, and emergency supplies were reviewed during the inspection. Information gathered during the inspection determined non-compliance(s) with applicable standards or law and violations were documented on the violation notice issued to the program, and were discussed during the exit interview.

Violations:

Standard #:	8VAC20-780-140-A
Description:	Based on a review of five children's records, it was determined that the facility did not ensure that each child in attendance had a completed physical within one month of attendance. Evidence: 1. The record for child #1 did not contain a physical examination. 2. Staff #1 (Program Director) confirmed that the record for child #1 did not contain a physical examination, and had been enrolled for more than 30 days.
Plan of Correction:	The facility responded: The parents of child #1 will be asked to provide a physical examination.
Standard #:	8VAC20-780-160-C
Description:	Based on a review of five staff records, it was determined that the facility did not ensure that at least every two years from the date of the first initial screening or testing, staff members shall obtain and submit the results of a follow-up tuberculosis screening. Evidence: 1. The record for staff #1, contained documentation of TB screening that was dated 12/11/19. 2. Staff #1 (Program Director), reviewed his record, confirmed that an updated TB screening had not been received.
Plan of Correction:	The facility responded: Staff #1 is scheduled to complete an updated TB screening on 5/13/22.
Standard #:	8VAC20-780-60-A
Description:	Based on a review of five children's records and interview, it was determined that the facility did not ensure that they maintain and keep at the center a complete record for each child enrolled that contains all required information. Evidence 1. The record for child #1 did not contain the addresses for both emergency contacts. 2. The record for child #2 did not indicate whether or not the child had previously attended child care. 3. The record for child #3 did not contain the two emergency contacts and did not indicate whether or not the child had previously attended child care. 4. The record for child #4 did not contain two complete emergency contacts. 5. The record for child #5 did not contain the addresses for the two emergency contacts. 6. Staff #1 (Program Director) confirmed that the records for each child reviewed did not contain all of the required information.
Plan of Correction:	The facility responded: The parents of each child will be asked to provide the missing information.
Standard #:	8VAC20-780-80-A
Description:	Based on a review of documentation and interviews, it was determined that the licensee did not ensure that a written record of daily attendance that documents the arrival and departure of each child in care as it occurs is maintained. Evidence: 1. The document used for recording attendance of the children in care did not record the arrival and departure of each child as it occurs. 2. Staff #1 (Program Director) confirmed that the current document used for attendance did not document arrival and departure as it occurs.
Plan of Correction:	The facility responded: We will implement a new attendance record that documents arrival and departure as it occurs.
Standard #:	8VAC20-780-260-A
Description:	Based on a review of documentation and interview, it was determined that the facility did not ensure that an annual inspection report from the appropriate fire official having jurisdiction was completed. Evidence: 1. The most recent annual fire inspection report inspection available for viewing during the inspection was dated 1/12/21. 2. Staff #1 (Program Director) confirmed that the annual fire inspection report had not been completed.
Plan of Correction:	The facility responded: We will contact the Fire Marshal to schedule the annual inspection.
Standard #:	8VAC20-780-340-C
Description:	Based on observation and interviews, it was determined that the facility did not ensure that during the stated hours of operation, there always shall be on the premises when one or more children are present one staff member who meets the qualifications of a program leader or program director and an immediately available staff member, volunteer or other employee who is at least 16 years of age, with direct means for communication between the two of them. Evidence: 1. The Licensing Inspector arrived to the facility at 3:30pm and observed staff #1 alone with 25 school age children. 2. When asked if there were any other staff present, staff #1 (Program Director) stated no because two staff quit and he was working alone.
Plan of Correction:	The facility responded: Additional staff will be sent to ensure we have a minimum of two staff at all times children are present.
Standard #:	8VAC20-780-350-B-5
Description:	Based on on observation and interviews, it was determined that the licensee did not ensure that for children, from the age of eligibility to attend public school through eight years, one staff member for every 18 children is maintained at all times children are in care. Evidence: 1. The Licensing Inspector observed staff #1 working alone in the main classroom with 25 children, so the facility was not maintaining the required 1 staff for every 18 children. 2. Staff #1 (Program Director) confirmed that the facility did not maintain the required staff-to-child ratio.
Plan of Correction:	The facility responded: We had two staff quit . An additional staff will be sent to the center going forward to ensure we maintain the required staff-to-child ratio.
Standard #:	8VAC20-780-530-A-2
Description:	Based on a review of one staff records and interviews, it was determined that the licensee did not ensure that there shall be at least two staff members trained in first aid, cardiopulmonary resuscitation, and rescue breathing as appropriate to the age of the children in care who is on the premises during the center's hours of operation and also one person on field trips and wherever children are in care. Evidence: 1. Staff #1 was working at the facility alone during the inspection. 2. Staff #1 (Program director) confirmed that there was not two staff working during the inspection that had a current certification in cardiopulmonary resuscitation (CPR) and First Aid.
Plan of Correction:	The facility responded: Two staff quit, so additional staff from other locations will be sent to assist untill new permanent staff are in place.
Standard #:	8VAC20-780-540-E
Description:	Based on a review of the emergency supplies at the center, it was determined that the licensee did not ensure that there is one working battery-operated radio in each building used by children. Evidence: 1. There was not a working battery-operated radio available during the inspection. 2. Staff #1 (Program Director) confirmed that there was not a working battery-operated radio available for viewing during the inspection.
Plan of Correction:	The facility responded: We will purchase a new battery powered radio.
Standard #:	8VAC20-780-550-G
Description:	Based on a review of the emergency drill log and interview, it was determined that the licensee did not ensure that the center shall maintain a record of the dates of the practice drills for one year. Evidence: 1. The emergency drill log did not have documentation to indicate an emergency evacuation drill was completed for the month of April 2022. 2. Staff #1 (Program Director) stated that an emergency evacuation drill had been completed during the month of April 2022, but that he had not documented it on the emergency drill log.
Plan of Correction:	The facility responded: We will ensure that we document each emergency practice drill on the emergency drill log.
Standard #:	8VAC20-820-120-E-2
Description:	Based on observation and interview, it was determined that the facility did not ensure that the findings of the most recent inspection of the facility were posted on the premises. Evidence: 1. The results from the most recent inspection (12/7/21) was not posted anywhere in the facility. 2. When asked if the results from the most recent inspection were posted, staff #1 (Program Director) confirmed that the results were not posted.
Plan of Correction:	The facility responded: Inspections for the site are posted on the parent board and are current and up to date.