VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Piedmont Family YMCA Early Learning Center
233 Fourth Street, NW
Suite Y
Charlottesville, VA 22903
(434) 974-9622

Current Inspector: Beth Orebaugh (540) 847-9173

Inspection Date: Nov. 21, 2019 , Dec. 5, 2019 , Dec. 17, 2019 , Jan. 10, 2020 , Feb. 3, 2020 and Feb. 14, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-185 ADMINISTRATION. 22VAC40-185 STAFF QUALIFICATIONS AND TRAINING. 22VAC40-185 PHYSICAL PLANT. 22VAC40-185 STAFFING AND SUPERVISION. 22VAC40-185 PROGRAMS. 22VAC40-191 Background Checks (22VAC40-191)

Technical Assistance:

A supplemental page was provided.

Comments:

An unannounced complaint inspection was conducted on November 21, 2019, December 5, 2019, December 17, 2019, January 10, 2020, February 3, 2020, and February 14, 2020. The on-site portion of the inspection was conducted on November 21, 2019 from approximately 7:00 a.m. to 10:40 a.m. On that date there were 70 children present and in the care of 13 staff members. There were 75 children enrolled in the center. The inspection was in response to a complaint that was received in the Valley Licensing Office on November 12, 2019, and was regarding the Staffing and Supervision part of the licensing standards. There were eleven staff members interviewed and the records of five staff members were reviewed. The preponderance of the evidence gathered during the investigation did support the allegations and the complaint disposition was, therefore, "valid." The violations resulting from the inspection were noted on the violation notice and the risk ratings for the violations were discussed. An exit phone interview was conducted on March 13, 2020. Please complete the columns for ?Plan of Correction? and "Date To Be Corrected" for each violation cited on the violation notice and return it to the Valley Licensing Office within five business days. Please contact your licensing inspector, Diann Reed, at (540) 280-0742, if you have any questions.

Violations:

Standard #:	22VAC40-185-40-E
Complaint related:	Yes
Description:	Based on review of policies and procedures and staff interviews, the licensee failed to ensure operational responsibilities when the center?s policy for identifying where children are at all times was not followed. Evidence: 1. Under the ?Supervision Standards? section of the center?s ?New Hire Orientation Document? it states, ?It is the program?s strict policy that no child is ever left alone.? 2. On 10/30/2019, Child A (16 months) was left alone and unsupervised for approximately two to three minutes when Staff #3 and Staff #9 took the rest of the classroom outside to play. 3. Staff #4 stated she left Classroom A while Staff #3 and Staff #9 were in the classroom with the rest of the children. Approximately three minutes later she returned to Classroom A and saw Child A asleep and alone. 4. Staff #3 reported that she and Staff #9 were playing outside with the children from Classroom A. After no more than two minutes, Staff #7 informed her that Child A had been left alone in the classroom. 5. On 10/31/2019, Child B (4 years) was left alone and unsupervised for approximately 1 to 15 minutes while Staff #1 and Staff #8 took the rest of the group outside to play. 6. Staff #1 reported that after arriving to the field to play she counted the children and realized one was missing. She went back to Classroom B and found Child B alone in the bathroom. Staff #1 stated the child was away from the group for one to two minutes. 7. Staff #8 reported that after being outside 10 to 15 minutes, Staff #1 realized Child B was missing. Staff #1 went back inside to Classroom B and found Child B unsupervised in the bathroom.
Plan of Correction:	The following revised process was implemented immediately: Children are to be counted upon crossing of every threshold and doorway and again when arriving at final destination if in transition. During transitions, one teacher will remain at the front of the line for their classroom and one teacher must remain and the back of the line. Both teachers will count children when lining up, crossing a threshold, and arriving at final destination. The teachers must communicate the count to each other during all of these times before the class can proceed any further. The Early Learning Center launched BrightWheel app that streamlines the check-in, ratio, and head count process. Each classroom was provided a tablet loaded with all of the children?s information and must be signed in and out daily. The Directors can view headcounts and ratios at any time by classroom on the app. Director and Assistant Director are now conducting unannounced daily classrooms checks and requiring teachers to provide head counts immediately when asked. Lead teachers responsible are no longer employed by the YMCA.
Standard #:	22VAC40-185-340-A
Complaint related:	Yes
Description:	Based on interviews with staff members, the center failed to ensure the care and protection of two children on two separate occasions when the children were left unsupervised in their classrooms. Evidence: 1. On 10/30/2019, Staff #3, Staff #4, and Staff #9 were supervising 11 children in Classroom A. Staff #4 took one child out of the classroom, leaving 10 children with the two remaining staff members. Staff #3 and Staff #9 did not ensure the care and protection of Child A (16 months) when they left the child unsupervised in the classroom and walked the rest of the children outside to play. Neither Staff #3 nor Staff #9 realized Child A had been left behind for approximately two to three minutes. 2. Staff #4 reported that she left Classroom A with one child and upon her return, approximately three minutes later, she found Child A alone and asleep on pillows on the floor. 3. Staff #3 stated that after Staff #4 left that classroom with one child, she and Staff #9 walked the rest of the children outside through the classroom door. After no more than two minutes, they were told by Staff #7 that Child A had been left inside. 4. Staff #9 reported that they had 11 children that day and Staff #4 stated she was taking two children out of the room. Staff #9 stated she counted the children at the door before going outside and again when they arrived outside. She counted nine children. After a while Staff #7 opened the classroom door and said they had left Child A in the room. 5. On 10/31/2019, Staff #1 and Staff #8 were supervising 11 children in Classroom B. They walked the group of children out of the classroom, through two hallways of the center, out the main door of the center into the building and out a side building door to the field to play. Staff #1 and Staff #8 did not ensure the care and protection of Child B (4 years) when he was found unsupervised in the bathroom of Classroom B. 6. Staff #1 reported that she counted the children at the classroom door and again at the end of the first hallway in the center and both times there were 11 children. Once the group was outside on the field, she counted 10 children. She realized Child B was not present. Staff #1 went inside to the classroom and found Child B in the bathroom. She reported Child B was gone for approximately one or two minutes. 7. Staff #8 stated the teachers counted the children one time, at the classroom door. Once outside, after 10 to 15 minutes, Staff #1 realized that Child B was not with the group.
Plan of Correction:	The following revised process was implemented immediately: Children are to be counted upon crossing of every threshold and doorway and again when arriving at final destination if in transition. During transitions, one teacher will remain at the front of the line for their classroom and one teacher must remain and the back of the line. Both teachers will count children when lining up, crossing a threshold, and arriving at final destination. The teachers must communicate the count to each other during all of these times before the class can proceed any further. The Early Learning Center launched BrightWheel app that streamlines the check-in, ratio, and head count process. Each classroom was provided a tablet loaded with all of the children?s information and must be signed in and out daily. The Directors can view headcounts and ratios at any time by classroom on the app. Director and Assistant Director are now conducting unannounced daily classrooms checks and requiring teachers to provide head counts immediately when asked. Lead teachers responsible are no longer employed by the YMCA.
Standard #:	22VAC40-185-340-F
Complaint related:	Yes
Description:	Based on interviews with staff members, the center failed to ensure on two different dates that children under 10 years of age shall always be in actual sight and sound supervision of staff. Evidence: 1. On 10/30/2019, Staff #3, Staff #4, and Staff #9 were supervising 11 children in Classroom A. Child A (16 months) was not in sight and sound supervision of staff for approximately two to three minutes when Staff #4 took one child and left the classroom to go into another classroom, and Staff #3 and Staff #9 took 9 children outside to play. Staff #4 found Child A unattended and asleep in the classroom. 2. Staff #4 reported she took one child with her as she left Classroom A. When Staff #4 returned to Classroom A after approximately three minutes, she found Child A alone and asleep on the pillows in the classroom. 3. Staff #3 reported that on this date, she heard Staff #4 say she was leaving the classroom and taking a child with her so they would be in ratio. She stated that after Staff #4 left, she and Staff #9 took the rest of the children outside. Staff #3 reported that after no more than two minutes, Staff #7 opened the classroom door and asked how many children they had because they had left Child A inside. 4. Staff #9 stated 11 children were present when Staff #4 said out loud that she was leaving the room with Child A and another child. Staff #9 did not see how many children Staff #4 actually took with her. Staff #9 and Staff #3 counted 9 children at the classroom door then preceded directly outside. After some time, Staff #7 told both staff that Child A had been left behind in the classroom. 5. On 10/31/2019, Staff #1 and Staff #8 were supervising 11 children in Classroom B. Child B (4 years) was out of sight and sound supervision of staff when left alone in the classroom during transition of the group outside. Staff #1 and Staff #8 were not aware that Child B was missing until after the group was on the field outside. Staff #1 entered the center and found Child B unsupervised in the bathroom of the classroom. 6. Staff #1 reported she counted all 11 children at the classroom door before heading outside. She stopped the class at the end of the hallway before turning toward the entrance of the center and counted 11 children again. She stated when the class arrived outside on the field, she realized Child B was not with them. She went back inside and found Child B alone in the bathroom of the classroom. She stated he could not have been gone more than a minute or two. 7. Staff #8 reported that both staff had counted the children at the classroom door before leaving the room to go outside. Staff #8 reported they did not stop to count the children after the initial time. The group of children had been outside between 10 to 15 minutes when Staff #1 noticed Child B was not present and went inside to find him in the bathroom of the classroom.
Plan of Correction:	The following revised process was implemented immediately: Children are to be counted upon crossing of every threshold and doorway and again when arriving at final destination if in transition. During transitions, one teacher will remain at the front of the line for their classroom and one teacher must remain and the back of the line. Both teachers will count children when lining up, crossing a threshold, and arriving at final destination. The teachers must communicate the count to each other during all of these times before the class can proceed any further. The Early Learning Center launched BrightWheel app that streamlines the check-in, ratio, and head count process. Each classroom was provided a tablet loaded with all of the children?s information and must be signed in and out daily. The Directors can view headcounts and ratios at any time by classroom on the app. Director and Assistant Director are now conducting unannounced daily classrooms checks and requiring teachers to provide head counts immediately when asked. Lead teachers responsible are no longer employed by the YMCA.
Standard #:	22VAC40-185-350-E-1
Complaint related:	Yes
Description:	Based on review of parent sign-in sheets, clock-in times for staff, and interviews with three staff members, the center failed to maintain the required ratio of one staff to every four infants on two separate dates. Evidence: 1. On the morning of 11/14/2019, there were over eight children, four of which were infants, together in one group in Classroom A in the care of two staff members for approximately 10 minutes. The required ratio of one staff for every four children was not met. 2. The parent sign-in sheets for 11/14/2019 showed that the eighth, ninth, tenth, and eleventh child arrived at 7:20 a.m. and the 12th child arrived at 7:25 a.m. Four of the 12 children in care between 7:20 a.m. and 7:30 a.m. were infants. 3. The clock-in times for staff showed that there were two staff members present at the center from 6:30 a.m. to 7:30 a.m. At 7:30 a.m., two more staff members arrived. 4. Staff #10 reported that every morning all of the children that arrive early are brought to Classroom A with two staff until enough staff arrive to take the children to their regular classrooms. 5. On the morning of 11/20/2019, the required ratio of one staff for every four infants was not met when Staff #6 was the only staff member caring for five infants in Classroom C for approximately 19 minutes. 6. Staff #6 reported that she had four infants in Classroom C on the morning of 11/20/2019 when the fifth child, Child C, arrived. She was alone with the five infants until Staff #5 came in to help her. 7. The parent of Child C (5 months) documented the arrival time on the sign-in sheet as 8:11 a.m. 8. Staff #5 stated that on 11/20/2019 she walked into Classroom C at 8:30 a.m. and found Staff #6 caring for five infants.
Plan of Correction:	The Early Learning Center launched BrightWheel app that streamlines the check-in, ratio, and head count process. Each classroom was provided a tablet loaded with all of the children?s information and must be signed in and out daily. The Directors can view headcounts and ratios at any time by classroom on the app. Staff schedules were immediately adjusted on 2/15/2020 to better accommodate the increase of early morning arrivals. Additional training to staff: If a parent arrives with a child that will put them over ratio, they are to ask the parent to wait briefly while they radio for additional teacher to come to classroom. All classrooms (in addition to Kitchen Manager and Front Desk) are provided a hand held radio to communicate at any time. If bathroom relief, transition, or other reason requires additional help for a class, they will use radio to call for assistance.