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Patrick Henry Elementary Boys & Girls Clubs Afterschool Program
146 East Main Street
Martinsville, VA 24112
(276) 656-1171

Current Inspector: Rebecca Forestier (540) 309-2835

Inspection Date: Oct. 24, 2017 and Oct. 27, 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.
22VAC40-80 THE LICENSE.
63.2 Child Abuse and Neglect
63.2 Licensure and Registration Procedures
63.2 Facilities and Programs..
22VAC40-191 Background Checks (22VAC40-191)

Comments:
Today's visit was a routine monitoring inspection. The inspection began at 2:30pm and concluded at 4:40pm. There were fifty-seven children present with five staff members. During the inspection arrival of the children was observed, snack time was observed, hand washing was observed, homework time was observed, seven out of sixty children's records were reviewed, three out of five staff records were reviewed, emergency supplies were reviewed, and some policies and procedures were reviewed. A second inspection day took place on 10/27/17 at the agency's main location in order to review staff records. Discussion took place regarding background check violations. Please provide evidence to the Licensing Inspector regarding follow-up concerning the background check violation within ten days of today's inspection and documentation once the results of the background check have been received by your agency. Thank you for your time, please call me at (540)309-2051 if you have any questions.

Violations:
Standard #: 22VAC40-185-140-A
Description: Based on the inspector's review of seven out of sixty children's records, the center failed to ensure a portion of the sample documentation of physical exams within thirty days of the child's first day of attendance. Evidence #1: The record for child #1 did not have a physical exam and the child's first date of attendance was documented as 6/5/17. Evidence #2: The record for child #6 did not have a physical exam and the child's first date of attendance was documented as 5/15/17.

Plan of Correction: The site PD will obtain copies of the children's physicals and audit additional records for completeness.

Standard #: 22VAC40-185-60-A
Description: Based on the inspector's review of seven out of sixty children's records, the center failed to ensure a portion of the sample contained all of the required information. Evidence #1: The record for child #4 does not have the physical address for one out of two required emergency contacts. Evidence #2: The record for child #7 does not have the physical address for one out of two required emergency contacts.

Plan of Correction: The site PD will obtain the missing information and add it to the files. Additional records will be audited for completeness.

Standard #: 22VAC40-185-70-A
Description: Based on the inspector's review of three out of five staff records, the center failed to ensure a portion of the records were complete. Evidence: The records for staff member #2 with a hire date of 9/15/17 does not have the results of two out of two required references.

Plan of Correction: References will be checked and documentation will be added to the staff member's record.

Standard #: 22VAC40-185-200-A
Description: Based on the inspector's review of the designated Program Director's record, the center failed to document PD qualifications for the staff member's documented position. Evidence: The record staff #3 indicates the position title of Program Director for the site. The staff member's record does not include documentation to substantiate PD qualifications.

Plan of Correction: The Administrator dor the program will review and add documentation to the staff member's record for PD qualifications.

Standard #: 22VAC40-185-340-D
Description: Based on the review of a sample of three out of five staff records and inspector's observations, the record for a staff member, with a program lead title and acting as a program lead during the time of the inspection, failed to have documentation to substantiate PL qualifications. Evidence: The record for staff member #2 did not include documentation to substantiate PL qualifications. The title in the staff member's record and role as observed during the time of inspection were Program Lead.

Plan of Correction: The Administrator for the program will obtain and document PL qualifications in the staff member's record.

Standard #: 22VAC40-185-540-E
Description: Based on the inspector's review of required nonmedical emergency supplies, the center failed to ensure to have an operable radio Evidence: The available radio was not operable during the time of the inspection.

Plan of Correction: The site PD will get additional batteries for the radio and the radio will be checked weekly to ensure it is fully operational.

Standard #: 22VAC40-185-550-D
Description: Based on the inspector's request to review the site's shelter in place drills for the past school year, the center failed to have documentation of conducting two shelter in place drills during the annual year as required by this standard. Evidence: Documentation for the shelter in place drills conducted during the program's year was not available during the time of the inspection.

Plan of Correction: The site PD will ensure shelter in place drills are conducted and documented twice this school year.

Standard #: 22VAC40-185-560-F
Description: Based on the inspector's observations, the center failed to post the current week's menu for the program as required when food is provided by the center.. Evidence: The posted menu was for the month of September.

Plan of Correction: The current monthly menu will be posted at the start of each month.

Standard #: 22VAC40-191-60-C-2
Description: Based on the inspector's review of three out of five staff records, the center failed to ensure a recently hired staff member had the results of the central registry within thirty days of employment. Evidence: The record for staff member #2 had a documented date of hire indicated as 9/15/17. There were no results for the search of the central registry or documentation of follow-up with the agency responsible for processing the request when the background check was not returned within thirty days.

Plan of Correction: The program's Administrator will conduct follow and make an additional request if necessary. The Licensing Inspector will be notified within ten days of today's inspection regarding the results of the contact.

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.

Virginia Quality is a voluntary quality rating and improvement system for early care and education facilities serving children ages birth through pre-K. Eligible child care facilities must be fully licensed, licensed exempt and a VDSS subsidy vendor, or a voluntary registered day home and a VDSS subsidy vendor. Only programs enrolled in Virginia Quality will display a rating. Virginia Quality contact information for your region is available at the following link Regional Contacts.

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