VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Young Mens Christian Association of the Virginia Peninsulas-R.F.
301 Sentara Circle
Williamsburg, VA 23188
(757) 229-9622

Current Inspector: Christine Mahan (757) 404-0568

Inspection Date: April 3, 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 Hearing Procedures. 8VAC20-770 Background Checks 20 Access to minor?s records 22.1 Early Childhood Care and Education 63.2 Child Abuse & Neglect

Technical Assistance:

Discussed in detail attendance records related to 8VAC20-780-80 and the requirement for each group of children, the center shall maintain a written record of daily attendance that documents the arrival and departure of each child in care as it occurs.

Comments:

A monitoring inspection was initiated and concluded April 3, 2023. There were 16 children present, ranging in ages from age 2 to age 4, with 4 staff supervising. 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 5child records and 5 staff records were reviewed. 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. Contact Christine Mahan, Licensing Inspector with any questions (757) 404-0568

Violations:

Standard #:	22.1-289.035-B-2
Description:	Based on record review and staff interviews, the licensee did not ensure, all staff obtained a Criminal Records Check prior to the first day of employment Evidence: The following staff did not obtain a fingerprint as required. 1)Staff #1?s first date of employment was 6-1-2021 and there was not fingerprint check available for review. Staff #1 was observed working during the inspection. Staff #5 confirmed missing information.
Plan of Correction:	The fingerprint check has been located and placed in the staff's file.
Standard #:	8VAC20-770-40-D-1-b
Description:	Based on record review and staff interviews, the licensee did not ensure, all staff obtained a sworn statement prior to the first day of employment Evidence: Staff #4 did not have documentation of sworn statement in their record. Staff #1 was observed working on the day of the inspection and their first date of employment was 6-1-2021. Staff #5 confirmed missing information.
Plan of Correction:	The center has had all staff update their sworn disclosure statements and have been placed in their files.
Standard #:	8VAC20-780-130-A
Description:	Based on record review and staff interviews, the licensee did not ensure to obtain documentation that each child has received the immunizations required by the State Board of Health before the child can attend the center. Evidence: The following records), did not include documentation of required immunizations prior to attendance. 1)Child #1, (first date of attendance 10-5-2022) 2)Child #2 (first date of attendance 8-29-22 3)Child #3 (first date attendance 8-29-22) 4)Child #4 (first date attendance 8-29-22) 5)Child #5 (first date attendance 1-9-23) Staff #5 confirmed missing information.
Plan of Correction:	The center director has reached out to all parents to update their files with immunization records.
Standard #:	8VAC20-780-140-A
Description:	Based on record review and staff interviews, the licensee did not ensure to obtain documentation that each child has received a physical examination by or under the direction of a physician, before the child's attendance; or within 30 days after the first day of attendance. Evidence: The following records did not include documentation of a physical within 30 days of attendance. 1)Child #1, (first date of attendance 10-5-2022) 2)Child #2 (first date of attendance 8-29-22 3)Child #3 (first date attendance 8-29-22) 4) Child #4 (first date attendance 8-29-22) 5)Child #5 (first date attendance 1-9-23 Staff #5 confirmed missing information.
Plan of Correction:	The center director has reached out to all parents requesting updated physicals to place in children's files.
Standard #:	8VAC20-780-160-A
Description:	Based on record review and staff interview the licensee did not ensure documentation of the Tuberculosis screening shall be submitted at the time of employment and prior to coming into contact with children. Evidence: Staff #3 did not have documentation of a TB screening and the first date of employment was 9-12-22. Staff #5 confirmed missing information.
Plan of Correction:	The center director had staff #3 schedule and complete a TB test.
Standard #:	8VAC20-780-160-C
Description:	Based on record review and staff interviews, the licensee did not ensure that each staff member had obtained at least every two years from the date of the initial screening or testing, the results of a follow- up tuberculosis screening. Evidence: The staff did not have documentation in their record for an updated TB screening as listed below; 1)Staff #1 most recent TB screening dated 12-1-2020 2)Staff #3 most recent TB screening dated 2-24-2021 Staff #5 confirmed missing information.
Plan of Correction:	Staff have scheduled a TB test to be done in the next 2 weeks.
Standard #:	8VAC20-780-40-K
Description:	Based on review of center documentation and staff interviews, the licensee did not ensure the center shall develop written procedures for shaken baby syndrome or abusive head trauma, including coping with crying babies, safe sleeping practices, and sudden infant death syndrome awareness. Evidence: Staff #5 confirmed they do not have a policy available for review related to safe sleeping practices.
Plan of Correction:	The center director and executive will update written procedures to include coping with crying babies.
Standard #:	8VAC20-780-60-A
Description:	Based on review of 5 children?s records and staff interviews, the licensee did not ensure to maintain and keep at the center a separate record for each child enrolled which contained the required information. Evidence: The following information was missing from the children?s records; 1)The records for child #1 and child #5 did not have emergency contacts listed to include name, address and phone number. Staff #5 confirmed missing information. 2)The record for child #5 did not include proof of identity
Plan of Correction:	The center director met with the parents to update the emergency contact and was given proof of identity.
Standard #:	8VAC20-780-240-A
Description:	Based on record review and staff interviews, the licensee did not ensure each staff completed the Virginia Department of Education-sponsored orientation course within 90 calendar days of employment. Evidence: The record for Staff #4 (date of hire 9-12-2022) did not include documentation of completing the required orientation. Staff #5 confirmed missing information.
Plan of Correction:	The center director has ensured that all staff complete the required orientation checklist prior to starting.
Standard #:	8VAC20-780-240-C
Description:	Based on a review of 3 staff records and staff interviews, the licensee did not ensure each staff member had completed orientation training in all required facility specific topics prior to the staff member working alone with children and no later than seven days of the date of assuming job responsibilities. Evidence: The record for Staff #1 (hire date 9-12-22) did not include information indicating orientation training to include to prevention of abusive head trauma and safe sleeping practices. Staff #5 confirmed missing information.
Plan of Correction:	All staff files have been updated to include a training and orientation log.
Standard #:	8VAC20-780-245-A
Description:	Based on record review and staff interviews, the licensee did not ensure staff completed 16 hours of annual training. Evidence: The following staff did not have in their record documentation of 16 hours of annual training as listed below. 1)Staff #1 did not have any documentation of annual training. 2)Staff #2 only had 9 hours of annual training. 3)Staff #3 only had 9 hours of annual training. 4)Staff#5 did not have any documentation of annual training. Staff #5 confirmed missing information.
Plan of Correction:	The center director has updated all staff files to include updated training logs.
Standard #:	8VAC20-780-245-J-3
Description:	Based on record review and staff interviews, the licensee did not ensure that for 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 or independent contractor who meets the requirements for medication administration training/ certification. Evidence: Staff #5 confirmed child #6 arrived at approximately 7:05 am and they, Staff#5 did not arrive until approximately 8:00am. Staff #5 has obtained the required MAT training/certification and is designated staff to administer emergency medication for Child #6 if needed. Child #6 was in the center for approximately 55 minutes without a staff member who had obtained the MAT certification/ training.
Plan of Correction:	The center has assigned additional staff to become MAT certified. The training is 4/10/23.
Standard #:	8VAC20-780-280-B
Description:	Based on observation and staff interviews, the licensee did not ensure 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: The following hazardous chemicals were observed in the preschool room stored on the back shelf under the cabinets, accessible to children and in an unlocked manner (1 container of hand sanitizer, sunscreen, and disinfectant) These items are hazardous chemicals, and they were labeled "keep out of reach of children" and at least one other statement "caution", "flammable" and "warning".
Plan of Correction:	All hazardous materials have been moved to a locked cabinet. Staff check the room hourly to ensure nothing is left in the reach of children.