VIRGINIA DEPARTMENT OF SOCIAL SERVICES

YMCA SACC at Bowling Green Elementary
17502 New Baltimore Road
Milford, VA 22514
(804) 448-9622

Current Inspector: Florence Martus (804) 389-0157

Inspection Date: Feb. 27, 2024

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) 20 Access to minor's records 22.1 Background Checks Code, Carbon Monoxide 63.2 Child Abuse & Neglect

Technical Assistance:

n/a

Comments:

A renewal inspection was initiated on Tuesday, February 27, 2024, and concluded on Wednesday, March 6, 2024. The licensing inspector conducted an announced inspection on March 6, 2024, at the administrative office to review two staff records from 9:10am to approximately 10:30am. The licensing inspector conducted an unannounced renewal inspection on-site on Tuesday, February 27, 2024, from 4:15pm to approximately 5:25pm. There were four children present in the direct care of two staff. Upon the inspectors' arrival, the children were observed coloring in a teacher-led activity. Later, they were observed during free-play. The center is equipped with age-appropriate materials and equipment for the children's use. Staff were engaged with the children and offering guidance when needed. The areas where children receive care were inspected and found to be in compliance. The center had the following posted: license, daily schedule, emergency numbers, evacuation maps, and various parent information. The center's first aid kit and non-emergency supplies were inspected and found complete. During the inspection, five children's records and two staff records were reviewed. The center administers medications when needed, but medications were not reported on site at this time. 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.

Violations:

Standard #:	22.1-289.035-B-2
Description:	(Repeat Violation) Based on a review of two staff records and interview, the center did not ensure one staff obtained a fingerprint-based national criminal background check prior to employment. Evidence: The results of the fingerprint-based national criminal background check in the record of Staff #2, employed on 06/08/23, were completed on 06/15/23. During interview, a member of management acknowledged the fingerprints for Staff #2 were received after Staff #2 received orientation training, for which she was compensated for on 06/08/23.
Plan of Correction:	Corrected. In the future, staff will obtain fingerprints prior to employment.
Standard #:	8VAC20-770-60-B
Description:	Based on a review of two staff records and interviews, the center did not ensure one staff had a completed sworn statement or affirmation prior to employment. Evidence: The record of Staff #2, employed on 06/08/23, did not contain documentation of a completed sworn statement. During interview, a member of management acknowledged that a completed sworn statement was not on file for Staff #2.
Plan of Correction:	The staff will complete a new sworn statement. In the future, staff will have completed sworn statement prior to employment.
Standard #:	8VAC20-770-60-C-2
Description:	Based on a review of two staff record and interviews, the center did not ensure one staff had a central registry finding within 30 days of employment. Evidence: The record of Staff #2, employed on 06/08/23, did not contain the results of the central registry finding. During interview, a member of management reported the results of the central registry finding for Staff #2 could not be located.
Plan of Correction:	A new central registry was requested for the staff.
Standard #:	8VAC20-780-160-A
Description:	Based on a review of two staff records and interviews, the center did not ensure one staff member submitted documentation of a negative tuberculosis (TB) screening within the required timeframe. Evidence: The record of Staff #2, employed on 06/08/23, did not contain documentation of a negative TB screening. During interview, a member of management reported documentation of a negative TB screening could not be located for Staff #2.
Plan of Correction:	The staff will obtain a new TB as soon as possible.
Standard #:	8VAC20-780-160-C
Description:	Based on a review of two staff records and interviews, the center did not obtain documentation that one staff had a follow-up tuberculosis (TB) screening at least every two years from the date of the first initial screening or testing. Evidence: The most recent TB screening in the record of Staff #1, employed on 06/14/21, was dated 09/03/21. During interview, a member of management reported an updated TB screening was not on file for Staff #1. An updated TB screening should have been obtained no later than 09/03/23.
Plan of Correction:	The staff will obtain an updated TB as soon as possible.
Standard #:	8VAC20-780-60-A
Description:	(Repeat Violation) Based on a review of five children's records and interviews, the center did not ensure one child's record contained the required information. Evidence: The record of Child #1 (DOA: 05/28/19) did not contain documentation of child updates and confirmation of up-to-date information in the child's record as required by 8VAC20-780-420-E.3. During interview, a member of management acknowledged the record did not contain confirmation of up-to-date information.
Plan of Correction:	The center will create a method to ensure parents provide and confirm updates when needed.
Standard #:	8VAC20-780-70
Description:	(Repeat Violation) Based on observations and a review of documentation on 02/27/24, the center did not ensure that the required information for each staff was kept at the center. Evidence: During the inspection on 02/27/24, Staff #1 and Staff #2 were observed at the center. The emergency contact information and information about any health problems which may interfere with fulfilling the job responsibilities were not observed at the center for the staff. The center should maintain at the center the name, address and telephone number of a person to be notified in an emergency and information about any health problems which may interfere with fulfilling the job responsibilities for each staff member.
Plan of Correction:	Corrected. The missing information was taken to the center and will remain there for each staff member.