VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Family Center YMCA on Granby
2901 Granby Street
Norfolk, VA 23504
(757) 965-2322

Current Inspector: Nanette Roberts (757) 404-2322

Inspection Date: Dec. 28, 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. 8VAC20-770 Background Checks (8VAC20-770) 22.1 Background Checks Code, Carbon Monoxide

Technical Assistance:

The most recent license and inspection reports are posted on the wall outside of the entrance into the unlicensed child watch program. This is potentially misleading to members as they may infer from these postings, that the on-site child watch program is part of the licensed child care program which it is not.

Comments:

An unannounced renewal inspection was conducted on 12/28/2022 from 10:25 am - 12:30 pm. At the time of entrance there were 6 school age children in care with 2 staff. Children were observed engaged in organized games with staff. Table games and lunch was additionally reviewed. Records reviewed for 4 staff and 3 children in care. 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-4
Description:	Based on record review, the center failed to obtain a copy of the results of a search of the child abuse and neglect registry or equivalent registry from any state in which the individual has resided in the preceding five years. Evidence: 1. Staff 3 and staff 4 lack the results of an out-of-state central registry search from a state they resided in within the past 5 years.
Plan of Correction:	Staff will receive a CRS. All pending hires will require a CRS prior to onboarding and uploaded in staff file.
Standard #:	8VAC20-780-160-A
Description:	Based on record review, the center failed to ensure that documentation of the TB screening shall be been completed with in the last 30 calendar days of employment and prior to coming into contact with children. Evidence: 1. TB screenings for staff 3 and staff 4 were obtained after employment. a. The TB screening for staff 3 was obtained on 10/28/2022 which is after the hire date of 5/3/2022. b. The TB screening for staff 4 was obtained on 10/28/2022 which is after the hire date of 8/1/2022.
Plan of Correction:	TB authorizations will be provided prior to onboarding. TB results will be provided upon employment and entered into staff files.
Standard #:	8VAC20-780-60-A
Description:	Based on record review, the center failed to ensure that children's records contain all of the required elements. Evidence: 1. The enrollment record for child 2 lacked the name, address and telephone number of two emergency contacts if the parent can not be reached. 2. The enrollment record for child 1 lacked the name, address and telephone number of a second emergency contact in the event that the parent can not be reached.
Plan of Correction:	Documenting system: Playerspace will be audited by Youth Development Director. Participants files will be updated and reflect emergency contacts needed. Participant's families will be asked for 4 emergency contacts in the event file does not meet licensing requirements.
Standard #:	8VAC20-780-70
Description:	Based on record review and interview, the center failed to ensure that staff records shall contain all of the required elements. Evidence: 1. When the inspector arrived the two staff present, staff 1 and staff 2, stated that emergency contact information was not available for any of the staff working in the licensed child care program. 2. The first date of employment was not documented in the employment file of staff 1, staff 2 and staff 3.
Plan of Correction:	Staff information will be updated and/or collected and placed in licensing binder accessible to staff within program. Program Director will update staff files to reflect the first day of employment.
Standard #:	8VAC20-780-245-J-3
Description:	Based on record review and interview, the center failed to ensure any child for whom emergency medications (such as albuterol, glucagon, and epinephrine auto injector) have been prescribed shall always be in the care of a staff member with medication administration training. Evidence: 1. None of the staff caring for children during the inspection had certification in medication administration training. a. Staff 1 stated that she did not have MAT training. Staff 2 stated she did not have MAT training. 2. There was one child in care, child 1, who required an emergency medication, as needed.
Plan of Correction:	Staff on-site will receive proper training with handling medications through MAT-IS. All medications will be documented and labeled correctly. Medication binder will be documented and be managed properly. Medication intake forms will be given to participants needing medication during program operations.
Standard #:	8VAC20-780-260-B
Description:	Based on interview, the center failed to ensure that after the first license, annual approval from the health department shall be provided, or approvals of a plan of correction, for meeting requirements for water supply and sewage disposal. Evidence: 1. Staff 5 stated an annual inspection from the Norfolk Health Department was not available for the facility or the outdoor swimming pool. a. The outdoor swimming pool is utilized during the summer months.
Plan of Correction:	Director will request most up to date Health inspection from Norfolk Health Department. Health inspection will be posted on licensing board.
Standard #:	8VAC20-780-270-A
Description:	Based on observation, the center failed to ensure that outside equipment of the center shall be maintained in a safe condition. Evidence: 1. Two areas of plastic coating, measuring approximately 6 - 9 inches in length, were torn and disconnected from the outdoor play structure stairs. a. These areas of torn plastic are unsecured in such a way at to create a trip hazard for children.
Plan of Correction:	Inspection will be rendered by YMCA facilities and properties director. Issues with equipment will be reported and corrected by YMCA facilities and properties. Playground currently not is use until weather permits and playground will be repaired prior to Spring 2023.
Standard #:	8VAC20-780-280-B
Description:	Based on observation, the center failed to ensure that hazardous substances such as cleaning materials, insecticides, and pesticides shall be kept in a locked place using a safe locking method that prevents access by children. Evidence: 1. When the inspector arrived at 10:25 am a quart of bleach, a gallon of hand sanitizer and a 33.8oz container of hand sanitizer was observed placed on the counter in the kitchenette area of the classroom. a. This counter is within easy reach of the children in care. 2. The cabinet, located above the kitchen counter, was unlocked. Six bottles of disinfectant/cleaning agents were stored in this cabinet. 3. A bottle of sanitizing agent was observed on top of the refrigerator.
Plan of Correction:	Hazardous materials will be labeled and kept in locked cabinets.
Standard #:	8VAC20-780-340-A
Description:	Based on interview, the center failed to ensure that when staff are supervising children, they shall always ensure their care and protection. Evidence: 1. The center failed to provide for care and protection of 6 school age children as demonstrated by the following: a. When the inspector arrived at 10:25 am, staff 1 stated they had no access to children's records and staff emergency contact information. b. Staff 1 also stated she did not have access to the first aid kit, battery operated radio and flashlight. 2. Staff 1 additionally stated that no administrative staff, for the child care program, had been on site that day and it was not know when any administrative staff would arrive.
Plan of Correction:	Monthly turn-ins will be provided to Regional YD to ensure proper audits are completed to ensure the quality of First Aid Kit and drills are being conducted. Staff will be required to maintain child health histories with emergency contact information on site during operational hours. Staff will review staff orientation checklist to be abreast of all items and duties required to ensure the safety and wellness of the program.
Standard #:	8VAC20-780-340-B
Description:	Based on interview, the center failed to ensure that during the center's hours of operation, one adult on the premises shall be in charge of the administration of the center. This person shall be either the administrator or an adult appointed by the licensee or designated by the administrator. Evidence: 1. When the inspection arrived at 10:25 am, staff 1 and staff 2, stated no one was in charge of the program. a. Both staff stated they were not in charge and their only responsibility was to care for the children. 2. Both staff stated that no administrative staff had been present since the program opened at 6:30 am. 3. Administrative staff 5 arrived at approximately 11:00 am.
Plan of Correction:	A staff person meeting the qualifications of Program Director will be assigned to Y on Granby.
Standard #:	8VAC20-780-430-K
Description:	Based on observation, the center failed to ensure that provision shall be made for an individual place for each child's personal belongings. Evidence: 1. Children's backpacks, coats and lunch containers were observed stored on tables and chairs in the child care room. a. These items were placed in such a way that they were not separated as the belongings were directly beside / touching other belongings and some items were spilling onto the floor.
Plan of Correction:	Designated spaces will be assigned for all participants. Items will be purchased to defined spaces.
Standard #:	8VAC20-780-500-A
Description:	Based on observation, the center failed to ensure that children's hands shall be washed with soap and running water or disposable wipes after eating meals. Evidence: 1. Children did not wash their hands after completion of lunch. a. The inspector observed children going directly to an activity in the classroom after discarding lunch trash.
Plan of Correction:	Snack and supper expectations will be reviewed with staff. Staff will be training by Regional Director.
Standard #:	8VAC20-780-510-G
Description:	Based on observation, the center failed to ensure that medication shall be labeled with the child's name. Evidence: One prescription medication, for child 1, was not labeled with the child's name.
Plan of Correction:	Medication in program will be labeled and documented within medication binder.
Standard #:	8VAC20-780-510-I
Description:	Based on observation and interview, the center failed to obtain written authorization for a parent for administration of prescription medication. Evidence: 1. Written authorization from the parent of child 1 was not obtained for one prescription medication. a. Staff 1 stated that they had not obtained written authorization for this medication.
Plan of Correction:	All participants seeking medical attention requiring medication will receive a medication intake form completely in its entirety. All forms will be reviewed and only received by MAT certified staff.
Standard #:	8VAC20-780-510-L
Description:	Based on observation, the center failed to ensure that medication shall be kept in a locked place using a safe locking method that prevents access by children. Evidence: 1. One prescription medication, for child 1, was stored inside of her backpack. a. Staff 1 stated she did not have a locked place to store the medication.
Plan of Correction:	Medication will be placed in locked medication box and/or locked cabinet.
Standard #:	8VAC20-780-540-E
Description:	Based on interview and observation, the center failed to ensure that there was one working battery-operated radio in each building used by children. Evidence: 1. There was not a working battery-operated radio available during the inspection. 2. Staff 5 stated the batteries were not working.
Plan of Correction:	Monthly turn-in will ensure the completion of a through inspection/inventory checklist for first aid kit. Radio will be provided with batteries.
Standard #:	8VAC20-780-550-G
Description:	Based on interview, the center failed to ensure that documentation shall be maintained of emergency evacuation, shelter-in-place, and lockdown drills. Evidence: 1. Staff 5 stated there was no written documentation on file to demonstrate that emergency practice drills had been conducted for fire, lockdown and shelter-in-place.
Plan of Correction:	Center will ensure documentation is maintained on licensing board in high traffic area located within licensed childcare program. Drills will be conducted every 30 days and reviewed by Youth Development Director through monthly turn-in system; system used to monitor drills.
Standard #:	8VAC20-780-560-G
Description:	Based on observation, the center failed to ensure that when food is brought from home the food container shall clearly dated and labeled in a way that identifies the owner. Evidence: 1. Four lunch containers reviewed were not dated. 2. 1 of the 4 reviewed lacked any name label.
Plan of Correction:	Lunch tags will be provided upon arrival of participants. Lunch tags will be adhered to belongings with names and dates.