VIRGINIA DEPARTMENT OF SOCIAL SERVICES

YMCA SACC at Battlefield Elementary School
11108 Leavells Road
Fredericksburg, VA 22407
(540) 735-9622

Current Inspector: Donna Liberman (540) 359-5244

Inspection Date: Oct. 5, 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

Comments:

An unannounced monitoring inspection was conducted on 10/5/22 from 6:15am to 7:00am with program staff. There were six children in care during the inspection, supervised by two staff. Children were observed playing a group game with a ball and having free play with program staff. Three child records and two staff records were reviewed for on-site documentation on 10/5/22 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. 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 10/13/22. Plans of correction should include steps to correct the noncompliance with the standard, and measures to prevent the noncompliance from occurring again.

Violations:

Standard #:	8VAC20-770-60-C-2
Description:	Based on review of two staff records, the program did not obtain the results of a search of the central registry within 30 days of employment for one staff member. Evidence: The record for Staff #1, with an employment date of 7/29/22, did not contain documentation of the results of a search of the central registry.
Plan of Correction:	Central Registration has been received and put in file for the staff member.
Standard #:	8VAC20-780-60-A
Description:	Based on review of three child records, the center did not obtain all of the required documentation for child records. Evidence: The record for Child B did not contain the name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached.
Plan of Correction:	Parent will have information uploaded on line by the end of 10/21/22.
Standard #:	8VAC20-780-240-E
Description:	Based on review of two 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 #2, with an employment date of 4/7/22, did not contain documentation of CPR orientation.
Plan of Correction:	Beginning with any new hire, CPR orientation will be given and documented.
Standard #:	8VAC20-780-340-C
Description:	Based on review of two staff records, the program did not ensure that there was always one staff member on the premises who met the qualifications of a program leader or program director during the stated hours of operation when one or more children were present. Evidence: Staff #1 and Staff #2 were observed on-site on the morning of 10/5/22. The records for Staff #1 and Staff #2 do not contain documentation that either staff is qualified as a program leader or program director. The records for Staff #1 and Staff #2 indicate they are ?PL1s? which is an aide position.
Plan of Correction:	Staff has begun additional training to become a PL2 (ProgramLeader).
Standard #:	8VAC20-780-550-F
Description:	Based on review of documentation, the center did not ensure that lockdown procedures were practiced at least annually. Evidence: The Licensing Inspector reviewed the emergency drill log and there was no documentation of a lockdown drill practiced during the previous or current school year.
Plan of Correction:	A lock down drill will be conducted and logged by 10/31/22