VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Young Men's Christian Association of Greater Richmond - Tuckahoe
9211 Patterson Avenue
Henrico, VA 23229
(804) 350-0647

Current Inspector: Susan Ellington-Sconiers (804) 588-2368

Inspection Date: June 21, 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) 22.1 Background Checks Code, Carbon Monoxide

Comments:

An unannounced monitoring inspection was conducted on-site June 21, 2022 and concluded remotely on June 23, 2022. The director was available during the inspection. There were 116 children present with 11 staff 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 10 child records and 10 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 #:	22.1-289.035-B-4
Description:	Based on a review of records and interview on June 23, 2022, the center did not obtain results of a check of the out-of-state sex offender registry prior to employment for each employee and did not request an out-of-state search of the child abuse and neglect registry or equivalent by the end of the 30th day of employment for each employee who has resided in any other state in the preceding five years. Evidence: 1. The record of staff #2 (hired 4/25/22) did not contain documentation of an out-of-state sex offender registry search and did not contain documentation of an out-of-state search of the child abuse and neglect registry. Staff #2 indicated living out-of-state in the previous five years on the staff's sworn disclosure statement. 2. Administration confirmed these searches were not completed.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-185-270-A
Description:	Based on observation on June 21, 2022, the center did not ensure areas and equipment of the center, inside and outside, shall be maintained in a clean, safe and operable condition. Evidence: The fence that runs along an embankment had two broken boards that were down and not attached to the fence post which left an opening that would be passable by children.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-770-60-B
Description:	Based on a review of staff records on June 23, 2022, the center did not ensure to obtain a Sworn Statement from each staff prior to employment. Evidence: 1. The record of staff #1 (hired 5/27/22), staff #5 (hired 6/15/22), staff #8 (hired 6/7/22), and staff #10 (hired 5/6/22) did not contain documentation of a sworn disclosure statement. 2. Administration acknowledged they were not done.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-770-60-C-2
Description:	Based on a review of staff records and interview on June 23, 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 #1 (hired 5/19/22) and staff #10 (hired 5/6/22) did not contain documentation of a central registry finding. 2. Administration acknowledged the findings were not complete.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-130-A
Description:	Based on a review of records on June 21, 2022, the center did not ensure to obtain documentation that each child has received the immunizations required by the State Board of Health before the child can attend the center. Evidence: The record of child #3 (enrolled 6/20/22) did not contain documentation of immunizations.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-160-A
Description:	Based on a review of staff records on June 23, 2022, the center did not ensure that each staff submit documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with children. Evidence: The record of staff #8 (hired 6/7/22) did not contain documentation of a tuberculosis screening.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-60-A
Description:	Based on a review of records on June 21, 2022, the provider did not ensure that each child's record contained the required information. Evidence: 1. The records of child #1, child #9, and child #10, each enrolled 6/20/22, contained documentation of one person to contact in an emergency. 2. The records of child #3, and child #4. each enrolled 6/20/22, did not contain documentation of two people to contact in an emergency. 3. The records of child #1, child #4, child #5, child #6, child #7, and child #10, each enrolled 6/20/22, did not contain documentation of the work phone number and place of employment for each parent who has custody. 4. Administration acknowledged the missing documentation.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-70
Description:	Based on a review of staff records and interview on June 21, 2022, the center did not ensure the name, address, and phone number of a person to be notified in an emergency and information about any health problems that may interfere with fulfilling the job responsibilities are kept at the center. Evidence: 1. The records of staff #1, staff #2, staff #6, staff #8, staff #9, and staff #10 did not contain documentation of an emergency contact person and health statement. 2. The record of staff #3 did not contain documentation of a health statement. 3. Administration confirmed the center did not have the requested documentation at the center.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-240-I
Description:	Based on a review of staff records and interview, on June 23, 2022, the center did not ensure to maintain documentation of orientation training for staff. Evidence: 1. The record of staff #1 (hired 5/27/22), staff #4 (hired 6/2/22), staff #8 (hired 6/7/22), staff #9 (hired 6/13/22), and staff #10 (hired 5/6/22) did not contain documentation of orientation. 2. Administration confirmed there was not documentation of orientation.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-540-D
Description:	Based on a review of records and interview on June 21, 2022, the center did not ensure to implement a monthly practice evacuation drill. Evidence: There was no documentation of a fire drill being practiced in April 2022. Administration stated a fire drill was not conducted in April 2022.
Plan of Correction:	Not available online. Contact Inspector for more information.