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: June 27, 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. 8VAC20-770 Background Checks (8VAC20-770) 22.1 Background Checks Code, Carbon Monoxide 63.2 Child Abuse & Neglect 8VAC20-790 Subsidy Regulations

Comments:

An unannounced renewal inspection was conducted on 6/27/23 from 11am-12:40pm. At the time of the inspection there were 80 school age children in care and 8 staff members. Children were observed participating in gym activities, playing on the playground and swimming. A sample size of 5 staff files and 8 children?s files were reviewed. Information gathered during the inspection determined non-compliance with applicable standards or law and documented on the violation notice issued to the facility. The violations were discussed with Staff #1 at the exit interview and the with the director by phone.

Violations:

Standard #:	8VAC20-780-160-C
Description:	Based on record review, the center did not ensure that at least every two years from the date of the initial screening or testing staff members shall obtain and submit the results of a follow-up tuberculosis (TB) screening. Evidence: The date of the most recent tuberculosis screening in the file provided for staff #4 was dated 6/9/2021, which is not within the past two years.
Plan of Correction:	Staff member will be sent to get TB screening. Upon hiring employees will have completed TB screening before onboarding
Standard #:	8VAC20-780-160-C
Description:	Based on record review, the center did not ensure that at least every two years from the date of the initial screening or testing staff members shall obtain and submit the results of a follow-up tuberculosis (TB) screening. Evidence: The date of the most recent tuberculosis screening in the file provided for staff #4 was dated 6/9/2021, which is not within the past two years.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-240-A
Description:	Based on the review of records and interview the center did not ensure that the Virginia Department of Education sponsored orientation course is completed within 90 calendar days of employment. Evidence: Staff #5 (date of hire 11/16/22) did not have a certificate of completion for the Virginia Department of Education orientation course. Staff #1 confirmed that the staff member had not completed the training.
Plan of Correction:	New Hires will be required to take all online training during onboarding. Online trainings will be completed within 30 days for current hires.
Standard #:	8VAC20-780-240-C
Description:	Based on records review and interview the center did not ensure that staff complete orientation training prior to the staff member working alone with children and no later than 7 days of the date of assuming job responsibilities. 1.Staff #5 (date of hire 11/16/22) employee record did not have documentation of orientation training. Staff #1 confirmed that documentation of orientation training was not in the record
Plan of Correction:	Upon completion of training Program Director and/or YD will ensure certification and/or documentation of training is visible and accessible in staff file.
Standard #:	8VAC20-780-270-A
Description:	Based on observation the center did not ensure that areas and equipment outside, are maintained in a clean, safe and operable condition. Evidence: 1. Two areas of plastic coating, measuring approximately 6-8 inches, were torn and pulled away from the steps of the outdoor play structure. 2.The two areas have pulled up and away from the structure frame to a height of approximately two inches, creating tripping hazards. 3.Staff #1 confirmed that the plastic coating was pulled away from the steps of the play structure.
Plan of Correction:	Work Orders have been submitted
Standard #:	8VAC20-780-280-B
Description:	Based on observation it was determined the center did not ensure that all 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. A spray bottle of Tilex cleaning solution was observed on a cabinet in the art room. The label included a warning and the precautionary statement ?hazardous to humans and animals?. 2. 7 cans of spray paint with caution labels were in an unlocked cabinet. This cabinet was accessible to children. 3. A spray bottle of Century 256 disinfectant and Tilex cleaning solution was observed in a pool closet open directly to the pool deck. These hazardous substances were accessible to the children on the pool deck.
Plan of Correction:	Program Leads and Aides will follow an opening and closing checklist to ensure areas are clean and safe. Youth Development Director will inspect area and f/u on daily checklist used by staff to ensure area is free of hazard materials and safe. All cleaning materials and hazardous materials will be put away during hours of operations and not in use.
Standard #:	8VAC20-780-350-B-5
Description:	Based on observation and interviews the center did not ensure that the staff-child-ratio of 1:18 for children school age eligible up to 9 years was maintained. Evidence: Nineteen children, ages 5-7 years old and 1 staff member were observed with Staff #7 on the playground. Staff #7 who was supervising the children on the playground stated the second staff member had taken a child to the bathroom. This left the group out of ratio. Staff #1 acknowledged that the children were out of ratio on the playground.
Plan of Correction:	The program director will ensure campers are within ratio. Program Leads will ensure ratio is kept by headcounts before and after transitioning.
Standard #:	8VAC20-780-350-B-5
Description:	Based on observation and interviews the center did not ensure that the staff-child-ratio of 1:18 for children school age eligible up to 9 years was maintained. Evidence: Nineteen children, ages 5-7 years old and 1 staff member were observed with Staff #7 on the playground. Staff #7 who was supervising the children on the playground stated the second staff member had taken a child to the bathroom. This left the group out of ratio. Staff #1 acknowledged that the children were out of ratio on the playground.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-430-K
Description:	Based on observation, the center did not ensure that a provision was made for an individual place for each child?s personal belongings. Evidence: In the Game Zone classroom children?s personal belongings including backpacks were piled on top of each other on the floor by the interior window. Staff #1 confirmed that the children did not have individual places to keep their belongings.
Plan of Correction:	Children will be provided baskets for personalized items and individualized space at all times.
Standard #:	8VAC20-780-550-D
Description:	Based on a review of the emergency evacuation drill log and interview, it was determined that the center did not ensure that monthly practice evacuation drills are conducted. Evidence: 1.There was no documentation that a practice evacuation drill was conducted in April 2023. 2.Staff #1 confirmed that an evacuation drill was not documented for April.
Plan of Correction:	YD will create calendar invites for Program Director to complete drills and document on template. Monthly check-in will be required by YD
Standard #:	8VAC20-780-550-P
Description:	Based on a review of injury records the center did not ensure that the written record of children?s serious and minor injuries included the date and time the parents were notified. Evidence: 1.Injury reports provided for Children #9 (dated 6/22/23), #10 (dated 6/22/23), #11 (dated 6/23/23), #12 (dated 6/21/23), #13 (dated 6/21/23), #14 (dated 6/21/23) did not include the times the parents were notified of the children?s injuries. 2.An injury report for Child #9 (dated 6/22/23) did not include the date the parent was notified of the child?s injury.
Plan of Correction:	The program director will create a template to use with clear instructions on completing the incident form.All directors will review and complete key areas for incident forms. (Contact information) Incident forms will be signed by a YD.