VIRGINIA DEPARTMENT OF SOCIAL SERVICES

YMCA of the Virginia Peninsulas - A.T. Johnson
18849 Kings Highway
Montross, VA 22520
(804) 493-8163

Current Inspector: Cindy Horne (804) 297-4469

Inspection Date: June 17, 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 20 Access to minor's records 22.1 Early Childhood Care and Education 32.1 Report by person other than physician 63.2 Child Abuse & Neglect

Technical Assistance:

n/a

Comments:

The licensing inspector conducted an unannounced monitoring inspection on Friday, June 17th, 2022 from 10:10am to approximately 11:21am. There were a total of seven children in care in the direct care of two staff members. During the inspection, the children and staff were observed participating in a variety of activities. Staff were observed having positive interactions with the children. All areas of the facility used by the children including classrooms, hallways, the gym, and bathrooms were inspected. The required postings were reviewed and found to be in compliance. The center is equipped with toys and supplies and items were available to the children. During the inspection, six children?s records and four staff records were reviewed. Additional information was later submitted to the inspector and was reviewed virtually. 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 four staff records and interviews, the center did not ensure one staff obtained fingerprint results prior to hire. Evidence: 1) The fingerprint results in the record for Staff #4, hired on 05/11/22, were dated 05/16/2022. 2) During interview, a member of management confirmed the fingerprint results were not obtained prior to hire for Staff #4.
Plan of Correction:	Corrected. In the future, fingerprints will be obtained prior to hire.
Standard #:	8VAC20-770-60-C-2
Description:	Based on a review of four staff records and interviews, the center did not ensure that two staff members had a central registry finding within 30 days of employment. Evidence: 1) The record for Staff #1, hired on 05/11/22, did not contain the results of a central registry finding. 2) The record for Staff #4, hired on 05/11/22, did not contain the results of a central registry finding. 3) During interviews, a member of management confirmed the results of the central finding for Staff #1 and Staff #4 have not been received to date. The record did not contain documentation of any further contact, and the staff have been continuously employed.
Plan of Correction:	The requests have been submitted. Management reached out to HR to follow up with the Office of Background Investigation. In the future, any follow up with OBI will be documented when a central registry is not received within 30 days of employment.
Standard #:	8VAC20-780-130-A
Description:	Based on a review of six children?s records and interviews, the center did not obtain documentation that two children had received the immunizations required by the State Board of Health before the child can attend the center. Evidence: 1) The record for Child #1, enrolled on 05/23/22, were dated 06/01/22. 2) The immunizations in the record for Child #5, enrolled on 06/08/22, were dated 06/08/22. 3) During interviews, a member of management confirmed the immunizations for Child #1 and for Child #5 were not received prior to the children?s attendance.
Plan of Correction:	In the future, immunizations will be obtained before a child can attend the center.
Standard #:	8VAC20-780-160-A
Description:	Based on a review of four staff records and interview, the center did not ensure two staff members had documentation of a negative tuberculosis (TB) screening within the required time frame. Evidence: 1) The TB screening in the record for Staff #1, hired on 05/11/22, was dated 07/31/21. 2) The TB screening in the record for Staff #4, hired on 05/11/22, was dated 06/08/22. 3) During interviews, a member of management reported the TB screening for Staff #1 and for Staff #4 were not obtained within the required time frame. Documentation of the screening shall be submitted at the time of employment and prior to coming into contact with children or completed within the last 30 calendar days of the date of employment.
Plan of Correction:	In the future, staff will provide a negative TB screening within the required time frame.
Standard #:	8VAC20-780-60-A
Description:	Based on a review of six children?s records and interview, the center did not ensure one child?s record contained all the required information and did not keep at the center a separate record for one child enrolled. Evidence: 1) The record for Child #5, enrolled on 06/06/22, did not contain two emergency contacts. The record for each child enrolled should contain the name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached. 2) During the inspection on 06/17/22, staff interviewed reported the record for Child #6, enrolled on 06/13/22, was not available for review because it was not kept on-site. Child #6 was present during the inspection on 06/17/22.
Plan of Correction:	The missing emergency contacts will be obtained and the record for Child #6 will be transferred to the facility.
Standard #:	8VAC20-780-70
Description:	Based on a review of four staff records and interviews, the center did not ensure that two records contained the required information. Evidence: 1) The record for Staff #1, hired on 05/11/22, did not contain documentation of orientation training. 2) The record for Staff #4, hired on 05/11/22, did not contain documentation of orientation training. 3) During interview, a member of management reported the orientation training was completed, but documentation could not be located.
Plan of Correction:	The missing documentation will be filed.
Standard #:	8VAC20-780-80-A
Description:	Based on observations and interviews, the center did not maintain a written record of daily attendance that documented the departure of each child in care as it occurs. Evidence: 1) During the inspection on 06/17/2022, seven children were observed in care. 2) A review of the center's daily attendance record did not document that Child #6 was present at the center. 3) During interviews, staff reported Child #6 has not been added to the system and his attendance could not be documented. Child #6 was enrolled on 06/13/22 and present during the inspection on 06/17/22.
Plan of Correction:	Staff reminded to maintain a written record of all children in attendance.