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

Current Inspector: Florence Martus (804) 389-0157

Inspection Date: Oct. 22, 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.
22VAC40-191 Background Checks (22VAC40-191)

Comments:
This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia.
A renewal inspection was initiated on 10/22/20 and concluded on 10/28/20. The director was contacted by telephone to initiate the inspection. There were 8 children present with 2 staff. The inspector emailed the director a list of items required to complete the inspection. The Inspector reviewed 3 children?s records and 3 staff records submitted by the facility to ensure documentation was complete.
Information gathered during the inspection determined noncompliance with applicable standards or law and violations were documented on the violation notice issued to the facility.
The Licensing Inspector has reviewed with the provider COVID-19 Essential Guidance for Child Care programs.

Violations:
Standard #: 22VAC40-185-60-A
Description: Based on documentation provided by the director and interview, the center failed to maintain all the required information for two out of three children's records reviewed.

1. The record for child 1, start date documented at 9/7/20, did not contain the name, address and phone number of two designated people to call in an emergency if a parent cannot be reached.
2. The record for child 2, start date documented at 8/24/20, did not contain the name, address and phone number of two designated people to call in an emergency if a parent cannot be reached.
3. Both child 1 and child 2's parents put the parents information in for the the emergency contact.
4. Staff 4 stated they do not have any other emergency contacts for child 1 or child 2.

Plan of Correction: Two emergency contacts were obtained for child 1 on 10/28 and two emergency contacts were obtained for child 2 on 10/27. In the future the documentation for newly enrolled children will be reviewed to ensure the parents are not listed as the emergency contacts.

Standard #: 22VAC40-185-260-B
Description: Based on a review of documentation and interview, the center failed to provide documentation of an annual health inspection conducted.

Evidence:

1. The documentation provided for annual health inspection was dated 8/30/18.
2. The director stated they are unable to provide documentation for an inspection conducted in 2019 and are unsure if one was conducted.

Plan of Correction: In the future the center will ensure an annual health inspection will be conducted.

Standard #: 22VAC40-185-550-D
Description: Based on a review of documentation provided by the director and interview, the center failed to implement a monthly practice evacuation drill.

Evidence:

1. Documentation of the monthly evacuation drills was provided. There was documentation for a drill for the month of September 2020.
2. Staff 4 stated the center was open in September and no drill was conducted in September.

Plan of Correction: The director will ensure monthly evacuation drills will be conducted each month and documented.

Standard #: 22VAC40-191-60-C-2
Description: Based on a review of documentation provided by the director, the center failed to obtain a central registry finding within 30 days of employment.

Evidence:

1. The documentation provided for staff 3 did not contain the results of a central registry finding. Per the documentation staff 3's employment date was 9/21/20.
2. The documentation was provided to the inspector on 10/23/20. The documentation showed the forms had been mailed 9/17/20. On 10/28/20 the director stated the center had not followed-up to see the status of the findings but would.

Plan of Correction: A new central registry will be completed for staff 3. In the future a system will be put in place to ensure a central registry background check is received within 30 days after employment. The record will be documented.

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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