VIRGINIA DEPARTMENT OF SOCIAL SERVICES

YMCA School Age Child Care-Cedar Road Elementary
1605 Cedar Road
Chesapeake, VA 23322
(757) 312-0366

Current Inspector: Rene Old (757) 404-1784

Inspection Date: Feb. 10, 2020 and Feb. 13, 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. 22VAC40-191 Background Checks (22VAC40-191) 63.2(17) License & Registration Procedures

Comments:

An unannounced monitoring inspection was conducted on 02/10/2020 from 3:25 pm - 5:00 pm. At the time of entrance there were 55 school age children in care with 4 staff. Children were observed doing homework in the cafeteria. Afterward children were offered the option of outdoor play or inside table games and manipulative toys. Records were reviewed for 11 children. Four staff records were reviewed on 02/13/2020 at the YMCA Greenbrier North Branch where staff records are maintained for the Chesapeake School Based programs. 16 Violations were observed in five parts of the CDC standards, general procedures and background checks. These violations are listed on the violation notice. These violations were reviewed with administrative staff at the exit interview.

Violations:

Standard #:	22VAC40-185-130-A
Description:	Based on record review and interview, the center failed to obtain 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 enrollment record for child 1 lacked documentation of current immunizations. a. Child 1 has been enrolled since September of 2019 and was in care during the inspection. 2. The program director, staff 1, verified that immunization documentation was not on file for child 1.
Plan of Correction:	Administrative staff will be sure immunization are current.
Standard #:	22VAC40-185-140-A
Description:	Based on record review and interview, the center failed to ensure that each child shall have a physical examination by or under the direction of a physician before attendance or within one month after attendance. Evidence: 1. There was no documented physical exam on file for child 1. a. Child 1 has been enrolled since September 2019 and was in care during the inspection on 02/10/2020. 2. Staff 1 verified that a current physical exam was not on file for child 1.
Plan of Correction:	Administrative staff will be sure to have updated physical.
Standard #:	22VAC40-185-160-A
Description:	Based on record review and interview, the center failed to ensure that 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 and shall have been completed within 12 months prior to or 21 days after employment. Evidence: 1. There was no TB screening on file for staff 3 who has a hire date of 09/04/2019. a. Staff 3 was present and working with the children during the inspection on 02/10/2020. 2. Administrative staff 5 confirmed that a TB screening was not available for staff 3.
Plan of Correction:	TB test have been sent.
Standard #:	22VAC40-185-160-C
Description:	Based on record review and interview, the center failed to ensure that at least every two years from the date of the first initial screening or testing, staff members shall obtain and submit the results of a follow-up tuberculosis screening. Evidence: 1. The most recent tuberculosis screening on file for staff 4 was conducted on 09/14/2017. a. Staff 4 was present and working with the children during the inspection on 02/10/2020. 2. Administrive staff 5 confirmed that a more recent TB screening was not available for staff 4.
Plan of Correction:	The center responded with the following: "TB test results for staff 4, 5"
Standard #:	22VAC40-185-40-E
Description:	Based on interview and record review, the licensee failed to ensure that the center's activities and services are maintained in compliance with these standards and the center's own policies and procedures that are required by these standards. Evidence: 1. Administrative staff 5 stated that the employment record for staff 1 could not be located. a. Staff 5 stated she had called administrative staff 6 and that staff 6 did not know the whereabouts of staff 1's record. 2. The licensee has identified a central location of the Greenbrier North YMCA for the storage of staff records for the Chesapeake School Based After School Programs. a. The record for staff 1 was located at the conclusion of the inspection at a location that was not the central location or the center as required by Standard 50.C 3. Once the record was located it was determined that staff 1 was not program director qualified and she had been assigned as the program director for the after school program.
Plan of Correction:	Will be sure to locate records in proper location and be sure to put PD who is qualified.
Standard #:	22VAC40-185-60-A
Description:	Based on record review, the center failed to ensure that children's records contain all of the required elements. Evidence: 1. The enrollment record for child 1, child 2, and child 3 lacked a work phone number for one parent. 2. The program director, staff 1, confirmed that the work phone numbers were not on file for one parent of child child 1, child 2 and child 3.
Plan of Correction:	Paperwork will be completed by.......
Standard #:	22VAC40-185-70-A
Description:	Based on record review and interview, the center failed to ensure that staff records contain all of the required elements. Evidence: 1. Emergency contact information was not on file for staff 1. a. Staff 1 verified that her emergency contact sheet was not on file at the after school site where she was observed working on 02/10/2020. 2. There was no documentation that staff 2 possesses the orientation training required by the job position. a. Administrative staff 5 confirmed that orientation training was not documented in the file of staff 2. 3. The first date of employment was not listed in the employment record for staff 2. a. Administrative staff 5 stated she could not locate an employment date for staff 2. 4. The first date of employment was not listed in the file of staff 1. a. Administrative staff 5 stated she could not located an employment date for staff 1.
Plan of Correction:	Staff 2, no longer works for GBN but will locate paperwork by 3/23/20.
Standard #:	22VAC40-185-200-A
Description:	Based on record review and interview, the center failed to have a qualified program director or qualified back-up program director who meets one of the director qualifications. Evidence: 1. There was no documentation that staff 1 possesses the education and experience required by the job position of program director. a. Staff 1 stated that she was the program director for the after school site and she was observed functioning as the program director during the 02/10/2020 inspection. Staff 2 and staff 4 additionally stated that staff 1 was the program director b. Staff 1 has a job title of aide in her employment record nevertheless, she was observed functioning in the program director position during the inspection.
Plan of Correction:	Paperwork will be updated.
Standard #:	22VAC40-185-210-A
Description:	Based on record review, the center failed to ensure that program leaders shall be meet the qualifications outlined in Standard 210.A 1 - 4. Evidence: 1. There was no documentation as to how staff 2 meets her job position of program leader. a. Administrative staff 5 confirmed that there was no documentation on file to demonstrate as to how staff 2 meets program leader qualifications. 2. There was no documentation as to how staff 3 meets her job position of program leader. a. Administrative staff 5 confirmed that there was no documentation on file to demonstrate as to how staff 3 meets program leader qualifications.
Plan of Correction:	Staff 2 is no longer employed at GBN, but will be sure to locate paperwork.
Standard #:	22VAC40-185-240-D-4
Description:	Based on record review, the center failed to ensure that any child for whom emergency medications (such as but not limited to albuterol, glucagon, and epipen) have been prescribed shall always be in the care of a staff member with current medication administration training. Evidence: 1. There were no staff on site with current medication administration training. a. There were two children in care, on 02/10/2020, for whom emergency medications have been prescribed. b. Staff 1, 2, 3 and 4 were working on the date of the inspection. 2. Administrative staff 5 confirmed that MAT Certification was not available for staff 1, 2, 3 or 4.
Plan of Correction:	Staff 1 will be at MAT IS training April 6, 2020.
Standard #:	22VAC40-185-340-D
Description:	Based on observation and record review, the center failed to ensure that In each grouping of children at least one staff member who meets the qualifications of a program leader or program director shall be regularly present. Such a program leader shall supervise no more than two aides. Evidence: 1. There was no qualified program leader in the group of children observed in the cafeteria, with staff 1 and staff 2, from approximately 4:00 pm - 5:00 pm on 02/10/2020. a. The documentation on file for staff 1 and staff 2, during the staff record review on 02/13/2020, did not demonstrate that these staff meet program leader qualifications. 2. When the inspector arrived at 3:25 pm, on 02/10/2020, there was only one staff present, staff 4, who meets program leader qualifications. a. There were a total of four staff present with the entire group however, a program leader can supervise no more than three aides
Plan of Correction:	Staff qualifications will be re-evaluated.
Standard #:	22VAC40-185-510-E
Description:	Based on observation, the center failed to ensure that medication shall be labeled with the child's name. Evidence: 1. One over-the-counter medication, for child 1, lacked a name label.
Plan of Correction:	Training for medication will happen.
Standard #:	22VAC40-185-540-E
Description:	Based on observation, the center failed to ensure that there shall be a working battery operated radio and flashlight in each building used by children. Evidence: 1. The battery operated flashlight and radio were not working during the inspection. a. Staff 1 stated that she could not get the radio & flashlight to work.
Plan of Correction:	Flashlight will be fixed or replaced.
Standard #:	22VAC40-191-60-C-2
Description:	Based on record review and interview, the center failed to ensure that staff have a central registry finding within 30 days of employment. Evidence: 1. There was no central registry finding on file for staff 2. a. Staff 2 has been employed since September of 2019 and was observed working in the licensed program on 02/10/2020. 2. Administrative staff 5 confirmed that a central registry finding was not available for staff 2.
Plan of Correction:	Staff 2 CPS has been sent.
Standard #:	22VAC40-80-120-E-2
Description:	Based on observation, the center failed to ensure that the findings of the most recent inspection shall be posted. Evidence: 1. The findings of the most recent inspection, conducted on 11/13/2019, were not posted.
Plan of Correction:	It will be posted
Standard #:	63.2(17)-1720.1-B-3
Description:	Based on record review and interview, the center failed to obtain to obtain a copy of the results of a search of the central registry maintained by any other state in which the individual has resided in the preceding five years for any founded complaint of child abuse or neglect against him. Evidence: 1. The results of a central registry check from the State of California and the State of Washington were not available for staff 3. a. Staff 3 indicated on her sworn statement or affirmation she had resided in California and Washington within the past five years. b. Staff 3 has a hire date of 09/04/2019 and was observed working in the program on 02/10/2020. 2. Administrative staff 5 confirmed that these central registry checks were not on file for staff 3.
Plan of Correction:	This has been sent 3/6/2020.