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YMCA Loudoun County Program at Frederick Douglass Elem School
510 Principal Drummond Way SE
Leesburg, VA 20175
(703) 777-9622

Current Inspector: Lisa Hudson (571) 389-2459

Inspection Date: Jan. 28, 2020

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.
22VAC40-80 THE LICENSING PROCESS.

Technical Assistance:
A meeting will be scheduled to further discuss the non-compliance issues found during the inspection today as well as the the inspection in December.

Comments:
An unannounced Renewal inspection was conducted today. A total of 13 children with 1 staff present at the beginning of the inspection. According to staff, one staff who was scheduled to work was not present. Child records and medication were inaccessible during the inspection. Due to the number of violations and the inability to substantiate a majority of compliance, the exit interview for the Renewal inspection will be scheduled in person at our licensing office at which time appropriate corrective actions for each violation will be discussed. Please email me at: lisa.hudson@dss.virginia.gov with any questions.

Violations:
Standard #: 22VAC40-185-50-B
Description: Based on observation and staff interview, both children and staff records were not accessible.
Evidence:
1. Staff #1 stated that both staff and child records were located in a cabinet which was not accessible to them or to the Licensing Inspector during the inspection.

Plan of Correction: All staff will be informed of where all site materials including Participant Registration Binder, Medication/First Aid Kit are located; as well on how to access these items. They will also be informed on how and where to display required information. All of these items will remain in one set permanent location. Information on how to find the site materials has been loaded into the Google Keep system and has been shared with staff to ensure staff are able to find materials quickly and site set up and done before children arrive into the program setting.

Standard #: 22VAC40-185-80-A
Description: Based on documentation review and staff interview, the written record of attendance did not include all children in attendance.
Evidence: Staff #1 stated that there were a total of 12 children in care. 12 children were recorded on the attendance record. A total of 13 children were counted and confirmed.

Plan of Correction: The written attendance record kept at the site will be updated weekly to ensure that the information on each child is up to date and that staff are able to account for all program members. Communication via direct email and phone to staff members will be made if a change is made to the attendance of a member before the set attendance record pick up is made. Side Director will pick up updated attendance records weekly to ensure an accurate account of the children in the program.

Standard #: 22VAC40-185-180-B
Description: Based on observation and staff interview, one staff was not capable of carrying out assigned responsibilities.
Evidence:
1. Staff #1 was in a substitute capacity at the Center.
2. According to Staff #1, the assigned staff had called out and Staff #1 was unaware of why the assigned assistant staff was not present.
3. Staff #1 was the only staff on duty with 13 children and was unable to leave the programming area to locate the records, first aid kit and medications.
4. Staff #1 was unable to access the children's records with health information, emergency contacts for children and medication.
5. When Staff #2 arrived, they stated that the location of the records was moved and Staff #1 was unaware of where the records were.

Plan of Correction: All substitute staff will be informed of where all site materials including Licensing board, Admin Binder, Participant Registration Binder, Medication/First Aid Kit are located; as well on how to access these items. They will also be informed on how and where to display required information. All of these items will remain in one set permanent location. This information has been loaded into the Google Keep system and has been shared with staff to ensure staff are able to find materials quickly and site set up and done before children arrive into the program setting.

Standard #: 22VAC40-185-240-D-5
Description: Based on review of staff certifications, at least one staff with Daily Health Observation training was not present.
Evidence: On 01/28/2020, Staff #1 was the only staff present. No verification that Staff #1 had Daily Health Observation training was found.

Plan of Correction: Staff scheduled at site do have this training completed. New Site Director DHO training schedule in progress. All staff certifications will be located on the Licensing board.

Standard #: 22VAC40-185-340-C
Description: Based on observation, the center did not have in addition to the program leader, an additional staff member on the premises who was immediately available.
Evidence:
At the start of the inspection at approximately 2:45pm, there were 13 children in care with 1 staff member. An additional staff member did not arrive until approximately 3:25pm.

Plan of Correction: Staffing will be reviewed daily to ensure that the site is properly staffed in accordance to licensing standards and requirements. Management will be hiring a third staff member to provide additional support for this program. The site location has a Site director assigned for the school year.

Standard #: 22VAC40-185-340-F
Description: Based on observation, children under 10 years of age were not within actual sight and sound supervision of staff.
Evidence:
1. Staff #1 left the children in the hallway alone while they began to set up a screen presentation in the cafeteria for approximately 5 minutes until Staff #2 realized the children were unattended.

2. All 13 children in care were found running in the hallway and both bathrooms outside of the cafeteria while Staff #1 and #2 were in the cafeteria.

Plan of Correction: Staff will be properly trained to ensure that children are not left unattended while in the program setting. Staff training regarding communication will conducted to ensure that they communicate to one another to avoid this situation in the future. Staff coaching and training was done to ensure that communication is always done between members to ensure a safe environment for the children and staff present.

Standard #: 22VAC40-185-340-I
Description: Based on observation, staff did not greet each child upon arrival.
Evidence:
Staff #1 stated that a total of 12 children were present and was unaware that an additional child had arrived.

Plan of Correction: Staff members will be reminded to welcome/acknowledge all members in program upon member arrival. Staff will also take attendance of all members in a timely matter to ensure that all members are accounted for. Attendance counts will be conducted periodically throughout the duration of the program to ensure all participants are accounted for. In doing this it will allow the staff to conduct a head count before attendance and after/during the program.

Standard #: 22VAC40-185-510-D
Description: Based on observation and staff statement, one medication authorization was not available to staff.
Evidence: Staff #1 stated that one child enrolled has a medication. The medication authorization was not available to staff on 01/28/2020.

Plan of Correction: All staff will be informed of where all site materials including Participant Registration Binder, Medication/First Aid Kit are located; as well on how to access these items. They will also be informed on how and where to display required information. All of these items will remain in one set permanent location. This information on how to find the medication and materials has been loaded into the Google Keep system and has been shared with staff to ensure staff are able to find materials quickly and site set up and done before children arrive into the program setting. All staff members assigned to this location have been scheduled for the DHO training who do not have it complete or need to update it. This training will take place the last week of February.

Standard #: 22VAC40-185-540-A
Description: Based on observation and staff statement, a first aid kit was not accessible when there were children in care.
Evidence: According to Staff #1, the first aid kit was not accessible on 01/28/2020.

Plan of Correction: All staff will be informed of where all site materials including Medication/First Aid Kit are located; as well on how to access these items. They will also be informed on how and where to display required information. All of these items will remain in one set permanent location. This information on how to find the medication and materials has been loaded into the Google Keep system and has been shared with staff to ensure staff are able to find materials quickly and site set up and done before children arrive into the program setting.

Standard #: 22VAC40-80-120-E-2
Description: Based on observation, the most recent inspection was not found posted on the premises.
Evidence: The findings from the 12/12/19 licensing inspection was not found.

Plan of Correction: A copy of the most Recent Inspection will be displayed on Licensing Board.

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. To find programs participating in Virginia Quality, click here.

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