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Boys & Girls Clubs - Suffolk Unit
2325 E. Washington Street
Suffolk, VA 23434
(757) 934-0349

Current Inspector: Melinda Popkin (757) 802-5281

Inspection Date: Aug. 7, 2017 and Aug. 8, 2017

Complaint Related: No

Areas Reviewed:
22VAC40-185 ADMINISTRATION.
22VAC40-185 STAFF QUALIFICATIONS AND TRAINING.
22VAC40-185 PHYSICAL PLANT.
22VAC40-185 STAFFING AND SUPERVISION.
22VAC40-185 PROGRAMS.
22VAC40-185 SPECIAL CARE PROVISIONS AND EMERGENCIES.
22VAC40-185 SPECIAL SERVICES.
63.2 Facilities and Programs..
22VAC40-191 Background Checks (22VAC40-191)

Comments:
An unannounced monitoring inspection was conducted on 8/7/2014 from 10:22am - 12:35pm. During the inspection there were 94 children ages six years old to twelve years old in care with twelve staff. A tour of the facility was conducted and children were observed in a variety of activities in the classrooms, playing in the gym, and eating lunch. Records were reviewed for nine children while at the facility. The records for nine staff were reviewed on 8/8/17 at the central office. There is no medication being stored at the facility currently. Emergency procedures, emergency supplies and transportation were reviewed. Areas of non-compliance are identified on the violation notice.

Violations:
Standard #: 22VAC40-185-130-A
Description: Based on a review of nine children's records, it was determined that the facility did not ensure that each child in attendance had documentation that each child has received the immunizations required by the State Board of Health before the child can attend the center.

Evidence:
1. The record for child #4 (date of enrollment 2/21/17) did not contain documentation of an immunization record.
2. The record for child #9 (no date of enrollment ) did not contain documentation of an immunization record.
3. Staff #1 (Program Director) reviewed the record for child #4 and child #9, and confirmed neither record contained an immunization record.

Plan of Correction: The facility responded: The parents of the children listed above will be asked to provide a copy of the immunization record.

Standard #: 22VAC40-185-140-A
Description: Based on a review of nine children's records, it was determined that the facility did not ensure that each child in attendance had a completed physical within one month of attendance. Evidence: 1. The record for child #4 (date of enrollment 2/21/17) did not contain documentation of a physical examination. 2. The record for child #9 (no date of enrollment ) did not contain documentation of a physical examination. 3. Staff #1 (Program Director) reviewed the record for child #4 and child #9, and confirmed neither record contained a physical.

Plan of Correction: The facility responded: The parents of the children listed above will be asked to provide a copy of the physical.

Standard #: 22VAC40-185-160-A
Description: Based on a review of nine staff records, it was determined that the facility did not ensure each staff member shall submit documentation of a negative tuberculosis screening. Documentation of the screening shall be submitted no later than 21 days after employment or volunteering and shall have been completed within 12 months prior to or 21 days after employing or volunteering. Evidence: 1. The record for staff #3 (date of hire 6/12/17) contained a TB screening that was dated 8/31/15. 2. Staff #10 (Director of Operations) confirmed that the TB screening in the record for staff #3 was completed more than 12 months prior to employment.

Plan of Correction: The facility responded: Staff #3 will get a new TB screening prior to returning from college.

Standard #: 22VAC40-185-60-A
Description: Basedon a review of nine children's records, it was determined that the facility did not ensure that they maintain and keep at the center a complete record for each child enrolled that contains all required information. Evidence: 1. The record for child #1 did not contain the address for the second emergency contact. 2. The record for child #3 did not contain any information about the father, and did not have documentation to show the annual update was completed by the parent. 3. The record for child #6 did not contain any documentation to indicate whether or not the child previously attended child care. 4. The record for child #7 did not contain the phone numbers for the parents. 5. The record for child #8 did not contain the phone number for the second emergency contact. 6. The record for child #9 did not contain contact information for the child's physician, the written agreements between the parents and the center, documentation for viewing the child's proof if identity,

Plan of Correction: The facility responded: The parents of the children listed above will be asked to provide all of the missing information.

Standard #: 22VAC40-185-550-E
Description: Based on a review of the emergency drill log and interviews, it was determined that the facility did not ensure that it maintained a record of the dates of the practice drills for one year. Evidence: 1. There was no written documentation on the emergency drill log for the month of July 2017. 2. Multiple staff stated that several emergency evacuation drills were completed in July because a problem with the fire alarm going off when the program was operating. 3. Administrative staff stated that she forgot to document the emergency evacuation drill for July 2017.

Plan of Correction: The facility responded: The emergency evacuation drill for July 2017 will be recorded on the emergency drill log. All future emergency evacuation will be entered on the emergency evacuation drill log once the drill is completed.

Standard #: 22VAC40-185-550-M
Description: Based on a review of 18 injury/accident reports, the facility did not ensure that the written record of children's serious and minor injuries included all required items. Evidence: 1. Twelve of the injury reports reviewed did not contain the date the parents were notified about the injury, the time at which the parents were notified about the injury, or the the method for how the parents were notified about the injury. 2. Eighteen of the injury reports reviewed did not contain two signatures. 3. Eight of the injury reports did not include the future action to prevent recurrence of the injury 4. Staff #1 (Program Director) confirmed that all of the injury reports reviewed did not contain all of the required information.

Plan of Correction: The facility responded: Staff will be retrained on how to complete injury reports to ensure the injury reports contain all of the required information.

Disclaimer:
A compliance history is in no way a rating for a facility.

The online compliance history includes only information after July 1, 2003. In addition, the online compliance history includes information regarding adverse actions that may be the subject of a pending appeal. An adverse action is not final until a provider has exhausted or waived all due process rights. For compliance history prior to July 1, 2003, or information regarding the status of pending adverse actions, please contact the Licensing Inspector listed in the facility's information. The Virginia Department of Social Services (VDSS) is not responsible for any errors in or omissions from the compliance history information.

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