VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Caroline Family YMCA
17422 Library Boulevard
Ruther glen, VA 22546
(804) 448-9622

Current Inspector: Florence Martus (804) 389-0157

Inspection Date: March 15, 2019

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. 22VAC40-191 Background Checks (22VAC40-191) 63.2(17) License & Registration Procedures

Technical Assistance:

n/a

Comments:

An unannounced monitoring inspection was conducted on Friday, March 15, 2019 to determine the center's compliance with licensing standards. The inspector arrived at 10:10am and concluded the inspection at 12:45pm. The center's director assisted the inspector throughout this inspection. The census for today's inspection consisted of five children in the direct care of 2 staff and one administrator. Upon the inspector's arrival, the children were engaged in a variety of activities. They were observed taking bathroom breaks, washing hands, and eating a morning snack. The children were observed interacting with peer and staff. During snack, the children and staff discussed the differences between fruits and vegetables. The staff were observed having positive interactions with the children. After snack, the children were observed cleaning up and going outside. The playground was inspected and found to be in compliance. The classroom used by the children is decorated with the children's artwork and is equipped with age and stage appropriate materials. 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. There are various staff with CPR/FA certification and daily health observation training. Five children's records and three staff's records were reviewed during today's inspection. Last Health Inspection: 08/30/2018 Last Fire Inspection: 08/03/2018 The last documented evacuation drill was held on 01/24/2019 (see violation notice) The last documented shelter-in-place drill was held on 09/11/2018 The center is reminded that a second shelter-in-place drill must be held before the end of the school year. If you have any questions about this inspection, please contact the licensing inspector, Florence Martus, at (804) 662-9772.

Violations:

Standard #:	22VAC40-185-160-A
Description:	Based on a review of three staff records on 03/15/2019, the center did not ensure that two staff submitted documentation of a negative tuberculosis (TB) screening no later than 21 days after employment. Evidence: 1) The record for Staff #2 (DOH: 08/25/2016) did not contain documentation of a negative TB screening. 2) The record for Staff #3 (DOH: 10/02/2018) did not contain documentation of a negative TB screening. 3) During interview, a member of management stated the TB screenings for Staff #2 and Staff #3 were completed, but were not available for review on the day of the inspection.
Plan of Correction:	Per the Center: TB's will be redone. In the future, they will be done within 21 days.
Standard #:	22VAC40-185-280-B
Description:	Based on observation at the center on 03/15/2019, the center did not ensure to keep all hazardous substances in a locked place using a safe locking method that prevents access by children. Evidence: 1) During an inspection of the classroom, the licensing inspector observed a bottle of cleaning solution on top of a cabinet that was accessible to the children in care.
Plan of Correction:	Per the Center: Cleaning supplies are not usually kept in the classrooms. The bottle was removed from the classroom while the inspector was on site.
Standard #:	22VAC40-185-550-D
Description:	Based on a review of documentation on 03/15/2019, the center did not implement practice evacuation drills monthly. Evidence: 1) The last documented evacuation drill was dated 01/24/2019. A practice evacuation drill was not documented for February, 2019. The center shall implement a monthly practice evacuation drill and a a minimum of two shelter-in-place practice drills per year for the most likely to occur scenarios.
Plan of Correction:	Per the Center: Will be updated and completed as required.
Standard #:	22VAC40-191-60-C-2
Description:	Based on a review of three staff records and interview on 03/15/2019, the center did not obtain a central registry clearance for one staff member within 30 days of employment. Evidence: 1) The record for Staff #3, hired on 10/02/2018, did not contain the results of a central registry finding. 2) During interview, a member of management stated the central registry findings for Staff #3 were obtained, but were not available for review on the day of this inspection.
Plan of Correction:	Per the Center: Management will work on locating the results for existing staff and will forward them to the licensing inspector.
Standard #:	63.2(17)-1720.1-B-2
Description:	Based on a review of three staff records and interview on 03/15/2019, the center did not obtain results of a national fingerprint-based criminal history record check for two staff members within the required timeframes. Evidence: 1) The record for Staff #2, hired on 08/25/2016, did not contain the results of a national fingerprint-based criminal history record check. 2) The record for Staff #3, hired on 10/02/2018, did not contain the results of a national fingerprint-based criminal history record check. As of 01/22/2018, a statement of eligibility based on a national fingerprint-based criminal history record check is required to be obtained prior to employment. For staff employed prior to 01/22/2018, a statement of eligibility based on a national fingerprint-based criminal history check was required to be obtained prior to 09/30/2018. 3) During interview, a member of management stated the fingerprint-based background checks were completed for Staff #2 and Staff #3, but were not available for review on the date of this inspection.
Plan of Correction:	Per the Center: Management will work on locating the results for existing staff and will forward them to the licensing inspector.