VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Young Men's Christian Association of Greater Richmond-Manchester
7540 Hull Street Road
North chesterfield, VA 23235
(804) 441-3512

Current Inspector: Sharon Curlee (804) 840-8312

Inspection Date: March 9, 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. 8VAC20-820 SANCTIONS. 8VAC20-820 HEARINGS PROCEDURES. 8VAC20-770 BACKGROUND CHECKS 22.1 EARLY CHILDHOOD CARE AND EDUCATION

Comments:

A renewal inspection was conducted on March 9, 2023. The inspector was on site from approximately 7:30 am until 9:15 am. The director was present and assisted with the inspection. There were 26 children present, ranging in ages from five years to eleven years, with three staff supervising. Children were observed playing games, coloring, constructing with cubes and legos and playing with action figures. Later children loaded the bus for school. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies and nutrition. A total of six child records were reviewed. Four staff records were reviewed virtually on March 13, 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. If you have questions regarding this inspection, please contact the licensing inspector. Sharon Curlee, Licensing Inspector Office of Child Care Health and Safety Division of Early Childhood Care and Education 804-840-8312 Sharon.curlee@doe.virginia.gov *The violation notice was amended on 03/22/2023. A copy of the updated notice has been provided to the Licensee.

Violations:

Standard #:	22.1-289.035-B-4
Description:	Based on a review of four staff records, the center did not obtain the results of a search of the child abuse and neglect registry and an out of state criminal history name check from any state in which one staff member had resided in the preceding five years within the required time frame. Evidence: 1. The record for Staff #2, employed 11/18/2021, indicated the staff had resided in another state outside of Virginia within the last five years. 2.The record did not contain the results of a search of the child abuse and neglect registry from that state. There was no documentation of a follow up within 45 days requesting the status of the request.
Plan of Correction:	Per a member of management: We are fixing this with HR and fixing process moving forward.
Standard #:	8VAC20-770-60-C-2
Description:	Based on a review of four staff records and interviews, the center did not ensure that three staff member had a central registry finding within 30 days of employment. Evidence: 1. The record for Staff #1, employed on 06/24/2021, contained the results of a central registry finding dated 08/16/2021 exceeding 30 days from the date of employment. The record did not contain documentation of any further contact or follow up as to the status of the request and the staff has been continuously employed. 2. The record for Staff #2, employed on 11/18/2021, contained the results of a central registry finding dated 01/04/2022 exceeding 30 days from the date of employment. The record did not contain documentation of any further contact or follow up as to the status of the request and the staff has been continuously employed. 3. The record for Staff #3, employed on 11/02/2021, contained the results of a central registry finding dated 12/15/2021 exceeding 30 days from the date of employment. The record did not contain documentation of any further contact or follow up as to the status of the request and the staff has been continuously employed.
Plan of Correction:	Per a member of management: These are being corrected (out of state) and we have since fixed process for 30 day follow up.
Standard #:	8VAC20-780-130-A
Description:	Based on review of six children?s records and interview, the center did not obtain documentation of immunizations required by the State Board of Health before the child attended the center. Evidence: 1.The record of child #6, enrolled 08/22/2022, did not contain documentation of immunizations exceeding the first day of attendance. 2. The director stated the record did not have documentation of immunizations.
Plan of Correction:	Per the director: I will contact the parents and have them upload the missing immunization information.
Standard #:	8VAC20-780-140-A
Description:	Based on revied of six children?s records and interview, the center did not obtain documentation of a physical examination for one child?s record before the child?s attendance or within 30 days after the first day of attendance. Evidence: 1. The record of child #6. Enrolled 08/22/2022, did not contain documentation of a physical examination exceeding 30 days from the first day of attendance. 2. The director stated the child?s record did not contain documentation of a physical.
Plan of Correction:	Per the director: I will contact the parents and have them upload the missing documentation of a physical.
Standard #:	8VAC20-780-60-A
Description:	Based on review of six children?s records, the center did not obtain all required documentation for four children?s records. Evidence: 1. The record of child #1 did not contain the work phone number for the two parents listed 2. The record for child #2 did not contain the name, address, and phone number for two emergency contacts. The record also did not contain the work phone number for each parent listed. 3. The record for child #4 did not contain the name, address, and phone number for two emergency contacts. The record also did not contain the work phone number and place of employment of the two parents listed. 4. The record of child #5 did not contain the name, address, and phone number for two emergency contacts. 5. The record for child #6 did not contain the work phone number and place of employment of the two parents listed.
Plan of Correction:	Per the director: I will contact the parents and have them complete all missing information.
Standard #:	8VAC20-780-60-A-8
Description:	Based on review of children?s records, the center did not obtain a written care plan for each 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 #1, with a diagnosed food allergy, did not have a written allergy care plan. 2. The record of child #4, with a diagnosed food allergy, did not have a written allergy care plan.
Plan of Correction:	Per the director: I will contact the parent and request they provide allergy care plans for the food allergies.
Standard #:	8VAC20-780-80-B-2
Description:	Based on interviews and documentation review, the center did not notify the department within two business days of a serious injury to a child that required outside medical attention while under the center's supervision. Evidence: During the 03/09/2023 renewal inspection, interviews and review of an injury report dated 02/20/2023, determined the following: 1. The director stated that on 02/20/2023, child# 9 ran into another child while playing dodgeball receiving a cut above the eye. 2. The director stated the parent of Child# 9 was notified of the incident on 02/20/2023. The child was taken to the doctor on 02/20/2023 by the parent where the child received stiches above the eye for the cut. 3. During the 03/09/2023 inspection, the director confirmed they did not notify the department within two business days that child #9 was seen by the doctor as a result of the 02/20/2023 incident.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-190-A-3
Description:	Based on review of staff records and interview, the center did not ensure the assigned program director met program director qualifications. Evidence: 1. The record of staff #1, identified as the center?s program director, contained documentation of completing 62 college credits of which 11 semester hours were in a child related subject when 48 semester hours of college credits of which 12 semester hours are in a child related subject is required. 2. A member of management acknowledged staff #1 did not have any additional credits hours in a child related subject and did not meet director qualifications.
Plan of Correction:	Per a member of management: We are adding a new site director to be there 50 percent of the time until active site director can fulfill their education.
Standard #:	8VAC20-780-510-P
Description:	Based on observation and interview, the center did not ensure when a medication authorization expired, the parent was notified that the medication needs to be picked up within 14 days or the parent must renew the authorization. Medications not picked up by the parent within 14 days will be disposed of by the center. Evidence: 1. The medication authorization for child #8 expired on 06/30/2022 and the medication was still on site. The director stated the parent had not been notified that the authorization had expired. 2. The medication authorization for child #11 had a duration date of 09/02/2022 through 09/02/2023. The authorization was only signed by the parent and did not have a physician?s signature; therefore, the authorization was only valid for 10 days. The authorization expired on 09/12/2023 and the medication was still on site exceeding 14 days.
Plan of Correction:	Per the director: I will contact the parents and have them complete a new authorization form or take the medication home.
Standard #:	8VAC20-780-550-D
Description:	Based on review of the drill log and interview, the center did not implement a monthly practice evacuation drill. Evidence: The drill log did not have any practice evacuation drills documented. The director stated that evacuation drills had not been conducted this school year and that there was no documentation of conducted drill for the past 12 months.
Plan of Correction:	Per the director: I have scheduled drill on the calendar as reminders. The first drill is scheduled for March 21, 2023. I will make sure drills are conducted every month.
Standard #:	8VAC20-780-550-E
Description:	Based on review of the drill log and interview, the center did not practice a minimum of two shelter in place drill in the past year. Evidence: The drill log did not have documentation of any shelter in place drills in the past 12 months. The director stated that they had not conducted any shelter-in-place drill in the past 12 months.
Plan of Correction:	Per the director: I have scheduled drills on the calendar as a reminder. I will make sure two drills are completed.
Standard #:	8VAC20-780-550-F
Description:	Based on review of the drill log and interview, the center did not ensure lockdown procedures were practiced at least annually. Evidence: The drill log did not have documentation of a lockdown drill in the past 12 months. The director stated a lockdown drill had not been conducted in the past 12 months.
Plan of Correction:	Per the director: I have scheduled drills on the calendar as a reminder. I will make sure one drill is completed each year.