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: Sept. 19, 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 minors records 22.1 Early Childhood Care and Education 63.2 Child Abuse & Neglect

Comments:

An unannounced monitoring inspection was started in the center on September 19, 2023 from 3:15 pm until 5:00 pm and concluded on September 22, 2023. At the time of entrance, 15 children were in care with 4 staff members present. The sample size consisted of 5 children?s records and 5 staff records. Children were observed during snack, reading time and rest period. 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 contact the Licensing Inspector, Christine Mahan (757) 404-0568 with any questions.

Violations:

Standard #:	22.1-289.035-A
Description:	Repeat Based on record review and staff interviews, the licensee did not ensure all staff shall undergo a background check every five years to include a sworn statement, criminal records check (CRC) and search of the central registry check. Evidence: Staff #3's record did not include an updated sworn statement as the most recent was dated 9-26-2017.
Plan of Correction:	Staff #3 will undergo an updated sworn statement, criminal records check and central registry check
Standard #:	22.1-289.035-B-2
Description:	Repeat 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: Staff #2's record did not include documentation of obtaining a fingerprint check. Staff #2 was observed working during the inspection and confirmed they began employment in June of 2020.
Plan of Correction:	Staff #2 will undergo a fingerprint check.
Standard #:	8VAC20-770-60-B
Description:	Based on record review and staff interviews, the licensee did not ensure each staff member had a Sworn Statement completed prior to 1st day of employment. Evidence: Staff # 4?s date of hire August 3, 2023 did not have documentation of a completed Sworn Statement. Branch Executive confirmed missing information.
Plan of Correction:	A sworn statement will be completed by staff #4 and documented in staff file
Standard #:	8VAC20-770-60-C-2
Description:	Based on record review and staff interviews, the licensee did not ensure each staff member had obtained by the end of the 30th day of hire the results of the Central Registry (CPS) finding for the state of Virginia. Evidence: Staff # 4?s date of hire August 3, 2023 did not have documentation of a CPS check conducted. Staff #4 was observed working on the day of the day of the inspection. Branch Executive confirmed missing information.
Plan of Correction:	Staff #4 will obtain a Central Registry for the state of Virginia.
Standard #:	8VAC20-770-70-A
Description:	Repeat Based on observation and staff interviews, the licensee did not ensure staff records were available for review and completed with all required documentation. Evidence: The following records were missing information as listed below; 1) The records for Staff #1, #2, #3, #4 and #5 were requested for review. Staff #1, #2, #3 and #4 were observed working during the inspection. 2) The record for Staff #4 was not available for review. 3) The required information to be kept at the center related to any health problems that may interfere with fulfilling the job responsibilities was not available for review for Staff #2 and #4. 4) The references were for Staff #2 were not available for review. Branch Executive confirmed, staff records are supposed to be kept on site.
Plan of Correction:	All records will be available for review and completed with all required documentation
Standard #:	8VAC20-780-130-A
Description:	Repeat 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 record for Child #2, (first date of attendance January 2023) did not include documentation of required immunizations prior to attendance.
Plan of Correction:	Child #2's immunization will be obtained
Standard #:	8VAC20-780-140-A
Description:	Repeat 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 record for Child #2, (first date of attendance January 2023) did not include documentation of a required physical.
Plan of Correction:	The physical examination for child #2 will be obtained
Standard #:	8VAC20-780-160-A
Description:	Repeat Based on record review and staff interviews, the licensee did not ensure 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: Staff #2 did not have documentation in their record for an updated TB screening as the most recent TB screening is dated 2-2-2020.
Plan of Correction:	Staff #2 will obtain their TB screening
Standard #:	8VAC20-780-240-A
Description:	Repeat Based on a record review and staff interviews, the licensee did not ensure that staff have completed the Virginia Department of Education (VDOE)-sponsored orientation course within 90 calendar days of employment. Evidence: Staff #1?s hire date was 5-9-2023 and there was not documentation of completing the VDOE orientation.
Plan of Correction:	Each staff member will complete the VDOE sponsored orientation course
Standard #:	8VAC20-780-340-D
Description:	Based on observation, staff interviews and record reviews, the licensee did not ensure that in each grouping of children at least one staff member who meets the qualifications of a program leader or program director shall be regularly present. Such a program leader shall supervise no more than two aides. Evidence: 1) During the inspection 25 children, ages 2 to 4 were observed with 4 staff members. Staff #3 is the only staff that had documentation of meeting the program leader qualifications. Staff #1, #2 and #4 are assistants and therefore Staff #3 was supervising 3 aides/assistants. 2) Staff #2 was the only staff observed supervising Child #6 in the aquatics area. Staff #2 does not have documentation of meeting program leader qualifications.
Plan of Correction:	In each grouping of children at least 1 staff who meets the qualifications of a program director shall be regularly present and shall supervise no more than 2 aides.