VIRGINIA DEPARTMENT OF SOCIAL SERVICES

YMCA SACC at Berkeley Elementary School
5979 Partlow Road
Spotsylvania, VA 22551
(540) 735-9622

Current Inspector: Donna Liberman (540) 359-5244

Inspection Date: Oct. 17, 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 20 Access to minor?s records 22.1 Background Checks Code

Comments:

An unannounced monitoring inspection was conducted on 10/17/22 from 7:30am to 8:00am with program staff. There were two children in care, supervised by two staff. Children were observed looking at microscope slides with staff, talking about meteorology, and listening to staff read a book called ?Weather?. Two child records were reviewed off-site at the Ron Rosner office on 10/7/22. Three staff records were also reviewed off-site at the Ron Rosner office on 10/7/22 and a review of required on-site documentation was conducted on 10/17/22. Staff reported that there were no medications on-site for children, but the program had one staff with current certification in Medication Administration Training (MAT) on-site. 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 10/25/22. Plans of correction should include steps to correct the noncompliance with the standard, and measures to prevent the noncompliance from occurring again.

Violations:

Standard #:	22.1-289.035-B-2
Description:	Based on review of three staff records, the program did not obtain documentation of the results of a fingerprint-based criminal background check for each staff member prior to their first date of employment. Evidence: The fingerprint results on record for Staff #3, with an employment date of 8/9/22, were dated 8/16/22.
Plan of Correction:	Fingerprint results will be received prior to hiring.
Standard #:	22.1-289.035-B-4
Description:	Based on review of three staff records and interview with the Director, the program did not obtain the results of a sex offender registry check from all states in which staff members have resided within the past five years prior to employment, or the results of a central registry check from all states in which staff members have resided within the past five years within 30 days of employment. Evidence: The record for Staff #3, with an employment date of 8/9/22, contained documentation that the staff member had lived in North Carolina within the past five years. There was no documentation of the results of a sex offender registry check or a central registry check from North Carolina on record for the staff.
Plan of Correction:	Out of state background check results will be received within the required timeframe.
Standard #:	8VAC20-770-60-B
Description:	Based on review of three staff records, the program did not obtain documentation of a completed sworn disclosure statement for each staff prior to their first date of employment. Evidence: 1. The sworn statement on record for Staff #1, with an employment date of 7/5/22, was dated 8/5/22. 2. The sworn statement on record for Staff #3, with an employment date of 8/9/22, was dated 8/18/22.
Plan of Correction:	Sworn statements will be signed prior to the first day of employment.
Standard #:	8VAC20-770-60-C-2
Description:	Based on review of three staff records, the program did not obtain the results of a search of the central registry within 30 days of employment for each staff member. Evidence: 1. The record for Staff #3, with an employment date of 8/9/22, did not contain results of a search of the central registry. 2. The record for Staff #2, with an employment date of 5/31/22, contained documentation of central registry results dated 8/3/22.
Plan of Correction:	Central registry will be completed within 30 days of employment.
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. Evidence: 1. The TB results on record for Staff #1, with an employment date of 7/5/22, were dated 7/25/22. 2. The TB results on record for Staff #2, with an employment date of 5/31/22, were dated 8/28/22. 3. The TB results on record for Staff #3, with an employment date of 8/9/22, were dated 8/17/22.
Plan of Correction:	TB results will be obtained prior to hiring.
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 within 90 calendar days of employment by each staff member. Evidence: The VDOE-sponsored orientation course on record for Staff #2, with an employment date of 5/31/22, was dated 10/4/22.
Plan of Correction:	VDOE-sponsored orientation will be obtained within the first 90 days of employment.
Standard #:	8VAC20-780-540-C
Description:	Based on observation and interview with staff, the program did not ensure that all required items were in the first aid kit. Evidence: The first aid kit did not include tweezers, a First Aid Manual, or triangular bandages.
Plan of Correction:	Batteries were purchased for radio and flashlight.
Standard #:	8VAC20-780-540-E
Description:	Based on observation and interview with staff, the program did not ensure that all required non-medical emergency supplies were obtained. Evidence: There was no working, battery-operated flashlight or working, battery-operated radio on-site.
Plan of Correction:	The first aid kit will have all necessary supplies.