VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Young Men's Christian Association of the Virginia Peninsulas
361 Walnut St
Warsaw, VA 22572
(804) 333-3510

Current Inspector: Susan Ellington-Sconiers (804) 588-2368

Inspection Date: March 16, 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 HEARINGS PROCEDURES. 8VAC20-770 Background Checks (8VAC20-770) 20 Access to minor?s records 22.1 Background Checks Code, Carbon Monoxide 63.2 Child Abuse & Neglect

Technical Assistance:

Assure that first aid and CPR training documentation verifies that the training is appropriate to the age of children in care. Assure the orientation and training documentation is signed by the staff receiving the orientation. Review child intake information and physical examination results to assure accuracy of child?s emergency medication needs.

Comments:

A renewal inspection was conducted on 03/16/2023 from approximately 12:20 p.m. to 4:00 p.m. There were 13 children present ranging from age 6 to 10 years old and 2 staff supervising. The inspector reviewed compliance in the areas of administration, qualifications and training, physical plant, staffing and supervision, programming, medication, special care and emergencies, and nutrition. Five child (5) records and three (3) staff records were reviewed. The information gathered during the inspection determined violations with applicable standards or law. A violation notice was issued. 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, 03/31/2023. Please specify how the deficient practice will be or has been corrected. Your plan of correction should 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 preventive measure(s). If you have any questions related to this inspection, please contact Inspector Susan Ellington-Sconiers, at 804-588-2368 or susan.ellington-sconiers@doe.virginia.gov.

Violations:

Standard #:	22.1-289.058
Description:	Based on observation, provider failed to ensure the center was equipped with at least one carbon monoxide detector. Evidence: No carbon monoxide was located in the area used by the program.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-40-J
Description:	Based on interview, the provider failed to update annually the injury prevention procedures based on documentation of injuries and a review of the activities and services. Evidence: The program director acknowledged that the injury prevention procedures had not been reviewed annually.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-60-A
Description:	Based on child record review, the provider failed to ensure that four of five records contained required documentation. Evidence: Record for C2, enrolled 03/15/2023 did not document the name, address, and phone number for two emergency contacts. Record for C3, enrolled 02/20/2023, C4, enrolled 11/08/2022, and C5, enrolled 11/08/2023 did not document proof of the child?s identity, immunizations, and physical examination (nothing in the record).
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-70
Description:	Based on record review, the provider did not ensure three of three staff records contained all the required documentation. Evidence: The records for S1, employed 09/06/2022, S2, employed 11/04/2022, S3, employed 06/06/2022 did not document information about any health problems that may interfere with fulfilling the job responsibilities.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-240-A
Description:	Based on record review, the provider did not ensure that one of three staff completed the Virginia Department of Education (VDOE) sponsored orientation course within 90 calendar days of employment. Evidence: The record for S3, employed 06/06/2022 did not document completion of the 10-hour VDOE orientation course.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-260-A
Description:	Based on interview, the provider failed to provide the licensing representative an annual fire inspection report from the appropriate fire official having jurisdiction. Evidence: The fire inspection available during the inspection was dated 03/08/2022. The annual inspection should have been completed by 03/08/2023. There was no updated fire inspection available for review during the inspection.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-260-B
Description:	Based on interview, the provider failed to provide the licensing representative an annual health department inspection report from the appropriate health official having jurisdiction. Evidence: The last health inspection was dated 01/12/2022. The annual inspection should have been completed by 01/12/2023. There was no updated health inspection available for review during the inspection.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-530-A
Description:	Based on interview and record review, the provider did not ensure that at least one staff in each area where children are present shall have current cardiopulmonary resuscitation (CPR) and first aid certification. Evidence: Record for S3 did not contain current certification in CPR and first aid. The record for S2 did not document certification until 03/14/2023. The program director confirmed that when S2 and S3 worked together between 01/16/2023 and 03/14/2023 no staff were CPR and first aid certified.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-550-E
Description:	Based on interview, the provider failed to ensure that shelter in place procedures shall be practiced a minimum of twice per year. Evidence: The program director was unable to locate documentation showing that the shelter in place procedures were practiced.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-550-F
Description:	8VAC20-550.F Based on interview, the provider failed to ensure that lockdown procedures shall be practiced at least annually. Evidence: The program director was unable to locate documentation showing that the lockdown procedures were practiced.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-550-G
Description:	Evidence: The emergency drill documentation dated October 2022 ? February 2023 did not document the weather conditions during the drills and the method used for notification of the drills.
Plan of Correction:	Not available online. Contact Inspector for more information.