VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Young Men's Christian Association of Greater Richmond-JB Watkins
501 Coalfield Road
Midlothian, VA 23114
(804) 474-4405

Current Inspector: Jennifer Moore (540) 430-0384

Inspection Date: Jan. 30, 2023

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. 8VAC20-820 THE LICENSING PROCESS. 8VAC20-770 Background Checks (8VAC20-770) 20 Access to minors records 22.1 Background Checks Code, Carbon Monoxide 22.1 Early Childhood Care and Education

Comments:

An unannounced renewal inspection was initiated on 1/30/2023 and concluded on 2/01/2023. The inspector was on site on 1/30/2023 from approximately 3:55 to 5:30 pm. There were 31 children present, ranging in ages from 5 to 11 years, with 3 staff supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies, nutrition and background checks. A total of 5 child records, 5 staff records and 6 officer records were reviewed. Staff records were reviewed remotely on 1/31/2023. 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. Please complete the plan of correction and date to be corrected for each violation cited on the violation notice and return it to me within 5 business days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word corrected is not acceptable. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measures. Please do not use staff names; list staff by positions only.

Violations:

Standard #:	8VAC20-770-60-C-2
Description:	Based on a review of five (5) staff records and interview, the center did not ensure that one (1) staff had a central registry finding within 30 days of employment as required. Evidence: 1. The record of staff #5 (date of employment: 6/2/2022) contained a central registry finding dated 1/12/2023. 2. Administration acknowledged that the finding was not received with 30 days of employment.
Plan of Correction:	We have since corrected our process for proof of CRS within our department.
Standard #:	8VAC20-780-140-A
Description:	Based on a review of five (5) child records and interview, the center did not ensure that one (1) child had a physical examination by or under the direction of a physician: 1. Before the child's attendance; or 2. Within 30 days after the first day of attendance. Evidence: 1. The record of child #1 (date of attendance: 12/8/2022) did not contain a physical. 2. Administration acknowledged that the physical record was not received within the required time frame.
Plan of Correction:	We will fix all child records and work with parents to correctly complete.
Standard #:	8VAC20-780-60-A
Description:	Based on a review of five (5) child records and interview, the center did not ensure that four (4) records contained the required information. 1. The record of child #1 (date of attendance 12/8/2022) did not contain the name address, and phone number of two designated people to call in an emergency if a parent could not be reached. The record of child #2 (date of attendance: 9/2/2022) did not contain the name address, and phone number of two designated people to call in an emergency if a parent could not be reached. The record of child #3 (date of attendance: 1/25/2023) did not contain the name address, and phone number of two designated people to call in an emergency if a parent could not be reached. The record of child #4 (date of attendance: 8/22/2022) did not contain the name address, and phone number of two designated people to call in an emergency if a parent could not be reached. 2. Administration acknowledged that the records were incomplete.
Plan of Correction:	We will work on fixing all information so it is correct and complete.
Standard #:	8VAC20-780-60-A-8
Description:	Based on review of documentation and interview, the center did not ensure to obtain a written care plan for one (1) child with a diagnosed food allergy, to include instructions from a physician regarding the food to which the child is allergic and the steps to be taken in the event of a suspected or confirmed allergic reaction. Evidence: 1. The record of child #2 (date of attendance: 9/2/2022) contained written documentation from the child's physician and parent that the child had diagnosed food allergies. The record did not contain the required written care plan. 2. Administration acknowledged that the child did not have a written care plan.
Plan of Correction:	We will make sure students have proper allergy action plans
Standard #:	8VAC20-780-70
Description:	Based on a review of five (5) staff records and interview, the center did not ensure that three (3) staff had a complete record. Evidence: 1. Administration identified staff #4 (date of employment: 7/7/2022) as a program leader. The record was missing documentation that the staff possessed the certification and training required by job position. Administration identified staff #5 (date of employment: 6/2/2022) as a program leader. The record was missing documentation that the staff possessed the certification and training required by job position. The record of staff #2 (date of employment: 12/8/2022) was missing documentation of orientation training. 2. Administration acknowledged that the 24 hours of training and orientation had not been documented.
Plan of Correction:	We are working for a better process for all trainings. We will make sure these staff finish all required trainings on time. Orientation training is required before working with kids. We will be fixing this process for our entire department.
Standard #:	8VAC20-780-240-A
Description:	Based on observation and interview, the center did not ensure that staff completed the Virginia Department of Education-sponsored orientation course within 90 calendar days of employment as required. Evidence: 1. The record(s) of staff #1 (date of employment: 8/26/2022), staff #4 (date of employment: 7/7/2022) and staff #5 (date of employment: 6/2/2022) did not contain documentation of course completion. 2. Administration acknowledged that the staff did not have the certificates.
Plan of Correction:	This will be completed asap for those staff.
Standard #:	8VAC20-780-240-E
Description:	Based on a review of five (5) staff records and interview, the center did not ensure that two (2) 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 as required. Evidence: 1. The records of staff #2 (date of employment: 12/8/2022) and staff #3 (date of employment: 11/29/2022) did not contain documentation of orientation training in first aid and cardiopulmonary resuscitation (CPR). 2. Administration acknowledged that the training was not completed.
Plan of Correction:	They have been enrolled in CPR/FA class.
Standard #:	8VAC20-780-540-D
Description:	Based on observation and interview, the center did not ensure that the required emergency supplies were available. Evidence: 1. A ice pack or cooling agent was not available during the inspection. 2. Administration acknowledged that they were unable to locate one.
Plan of Correction:	We will order some immediately.
Standard #:	8VAC20-780-550-G
Description:	Based on observation and interview, the center did not ensure that documentation of emergency evacuation, shelter-in-place, and lockdown drills were maintained. Evidence: 1. An evacuation drill was not documented in December of 2022 as required. One (1) of the two (2) required shelter in place drills in 2022 was not documented. A 2022 lockdown drill was not documented. 2. Administration stated that the drills were conducted by the center but not documented.
Plan of Correction:	We will make sure all drills are completed timely for each site.