VIRGINIA DEPARTMENT OF SOCIAL SERVICES

YMCA SACC at Cedar Forest Elementary School
3412 Massaponas Church Road
Fredericksburg, VA 22408
(540) 993-3416

Current Inspector: Donna Liberman (540) 359-5244

Inspection Date: Oct. 4, 2022

Complaint Related: No

Areas Reviewed:

8VAC20-780 Administration. 8VAC20-780 Staff Qualifications and Training. 8VAC20-780 Staffing and Supervision. 8VAC20-780 Programs. 8VAC20-780 Special Care Provisions and Emergencies. 8VAC20-780 Special Services. 8VAC20-770 Background Checks 22.1 Background Checks Code

Technical Assistance:

Technical Assistance was provided to the Director regarding the program?s allergy list.

Comments:

An unannounced renewal inspection was conducted on 10/4/22 from 7:00am to 7:45am with program staff. There were 10 children in care at the start of the inspection and seven more arrived during the inspection. The children ranged in age from five-years-old to ten-years-old, supervised by three staff. Children were observed having free play with program staff with the site?s toys. Three child records and three staff records were reviewed for on-site documentation on 10/4/22 and additional documentation was reviewed at the program?s main office on 10/7/22. The staff reported that there was no medication on-site for enrolled children, but the center has one staff with current certification in Medication Administration Training (MAT). The attendance and emergency drill log were reviewed. The first aid kit, flashlight, and battery operated radio were observed. If you have questions regarding this inspection, please contact the Licensing Inspector, Laura Brindle, at laura.brindle@doe.virginia.gov or 540-905-2062. Please complete the "Plan of Correction" and "Date to be Corrected" areas on the Violation Notice for each violation cited and return to me by close of business on 10/12/22. Plans of correction should include steps to correct the noncompliance with the standard, and measures to prevent the noncompliance from occurring again.

Violations:

Standard #:	8VAC20-780-160-A
Description:	Based on review of three staff records, the program did not ensure that each staff member submitted documentation of a negative tuberculosis (TB) screening at the time of employment and prior to coming into contact with children; and that the documentation had been completed within the last 30 calendar days prior to the date of employment. Evidence: 1. The TB test on record for Staff #1, with an employment date of 7/27/22, was dated 4/18/22. 2. The TB test on record for Staff #3, with an employment date of 11/29/21, was dated 12/13/21.
Plan of Correction:	In the future, prior to hiring anyone for employment, I will ensure TB test are done.
Standard #:	8VAC20-780-240-A
Description:	Based on review of three staff records, the program did not ensure that the Virginia Department of Education-sponsored orientation course was completed by each staff member within 90 calendar days of employment. Evidence: The certificate on record for the VDOE-sponsored orientation course for Staff #3 was dated 9/21/22; the employment date for Staff #3 was 11/29/21.
Plan of Correction:	In the future, the VDOE orientation will be done within 90 calendar days.
Standard #:	8VAC20-780-240-B
Description:	Based on review of three staff records, the program did not ensure that staff completed orientation training for their position prior to the staff member working alone with children and no later than seven days of the date of assuming job responsibilities. Evidence: The orientation documentation for Staff #1, with a start date of 8/15/22, was dated 9/23/22.
Plan of Correction:	In the future, orientation will be completed prior to the staff member being alone with children or within 7 days.
Standard #:	8VAC20-780-240-E
Description:	Based on review of three staff records, the program did not ensure that staff completed orientation training in first aid and cardiopulmonary resuscitation (CPR), as appropriate to the age of the children in care, within 30 days of the first day of employment. Evidence: The record for Staff #1, with an employment date of 7/27/22, contained documentation of CPR orientation training dated 9/23/22. The record for Staff #2, with an employment date of 2/23/22, did not contain documentation of CPR orientation. The record for Staff #3, with an employment date of 11/29/21, did not contain documentation of CPR orientation.
Plan of Correction:	In the future, all required trainings that is needed within 30 days will be completed.