VIRGINIA DEPARTMENT OF SOCIAL SERVICES

West End Center For Youth
1226 Patterson Avenue, S.W.
Roanoke, VA 24016
(540) 342-0902

Current Inspector: Rebecca Forestier (540) 309-2835

Inspection Date: April 5, 2022

Complaint Related: No

Areas Reviewed:

8VAC20-780 ADMINISTRATION. 8VAC20-780 STAFF QUALIFICATIONS AND TRAINING. 8VAC20-780 PHYSICAL PLANT 8VAC20-780 STAFFING AND SUPERVISION. 8VAC20-780 PROGRAMS. 8VAC20-780 SPECIAL CARE PROVISIONS AND EMERGENCIES 8VAC20-780 SPECIAL SERVICES. 22.1 EARLYCHILDHOOD CARE AND EDUCATION

Comments:

A renewal inspection was conducted onsite on 04/05/2022 and concluded with a virtual record review inspection on 04/06/2022. There were 75 children, ages 5 years-11 years, 6 staff providing direct care and supervision, and various support staff and volunteers present during the inspection. The inspector reviewed compliance in the areas of administration, staff qualifications and trainings, physical plant, staffing and supervision, programs, emergencies and nutrition. A total of 7 children?s records, 6 staff records, and 5 applicant/agent records were reviewed during the inspection. Information gathered during the inspection determined non-compliance with applicable standards or law and violations were documented on the violation notice issued to the provider.

Violations:

Standard #:	22.1-289.035-B-2
Description:	Based on record review and discussion with staff, the center failed to ensure that all applicants submit to fingerprinting. Evidence: 1. There were no fingerprint results available for Agent 1 during the 04/06/2022 inspection. Agent 4 verified that Agent 1 took office in 03/2020. 2. There were no fingerprint results available for Agent 2 during the 04/06/2022 inspection. Agent 4 verified that Agent 1 took office in 03/2020.
Plan of Correction:	Will get them done.
Standard #:	22.1-289.035-B-2
Description:	Based on record review and discussion with staff, the center failed to ensure that no person shall be hired for compensated employment prior to the facility obtaining an employment eligibility letter upon the completion of a fingerprint background check as required by the Code of Virginia. Evidence: 1. The record for Staff 1 contained a documented hire date of 07/20/2020. There was not an employment eligibility letter available for review. 2. The record for Staff 4 contained a documented hire date of 09/03/2020. There was not an employment eligibility letter available for review. 3. The hire date for Staff 6 was 10/04/2021 as verified by Agent 5. There was not an employment eligibility letter available for review.
Plan of Correction:	Will get them done.
Standard #:	22.1-289.035-B-2
Description:	Based on record review and discussion with staff, the center failed to ensure that no person shall be hired for compensated employment prior to the facility obtaining an employment eligibility letter upon the completion of a fingerprint background check as required by the Code of Virginia. Evidence: 1. The record for Staff 1 contained a documented hire date of 07/20/2020. There was not an employment eligibility letter available for review. 2. The record for Staff 4 contained a documented hire date of 09/03/2020. There was not an employment eligibility letter available for review. 3. The hire date for Staff 6 was 10/04/2021 as verified by Agent 5. There was not an employment eligibility letter available for review.
Plan of Correction:	Will get them done.
Standard #:	22.1-289.036-A
Description:	Based on record review and discussion with staff, the center failed to ensure that every applicant for licensure as a child day center shall undergo a background check in accordance with the Code of Virginia prior to issuance of a license and every five years thereafter. Evidence: The record for Agent 3 contained the following: a sworn statement dated 04/07/2016; a search of the central registry dated 04/12/2016; and a criminal record dated 06/02/2016. There were no repeat background check documents obtained in 2021.
Plan of Correction:	Will get them done.
Standard #:	8VAC20-770-40-D-1-a
Description:	Based on record review and discussion with staff, the center failed to obtain the required sworn statements and findings from a search of the central registry for all applicants and agents. Evidence: 1. There was not a sworn statement or findings from a search of the central registry available for Agent 1. Agent 4 verified that Agent 1 took office in 03/2020. 2. There was not a sworn statement or findings from a search of the central registry available for Agent 2. Agent 4 verified that Agent 2 took office in 03/2020. 3. There was not findings from a search of the central registry available for Agent 4. Agent 4 took their position on 11/08/2021.
Plan of Correction:	Will get them done.
Standard #:	8VAC20-770-60-C-2
Description:	Based on record review and discussion with staff, the center failed to obtain the finding from a search of the central registry within 30 days of employment. Evidence: 1. The record for Staff 3 contained a documented hire date of 09/11/2020. There were no finding from a search of the central registry available for review. 2. The hire date for Staff 6 was 10/04/2021 as verified by Agent 5. The findings from a search of the central registry were dated 12/12/2021.
Plan of Correction:	Will get them done.
Standard #:	8VAC20-780-160-C
Description:	Based on record review and discussion with staff, the center failed to ensure that at least every two years from the date of the initial screening or testing, staff member shall obtain and submit the results of a follow-up tuberculosis screening. Evidence: 1. The most recent tuberculosis test/screening for Staff 2 was dated 11/27/2018; there was not a follow-up test/screening for 2020 available for review. 2. The most recent tuberculosis test/screening for Staff 6 was dated 11/20/2018; there was not a follow-up test/screening for 2020 available for review.
Plan of Correction:	Will get the missing information.
Standard #:	8VAC20-780-60-A
Description:	Based on record review and discussion with staff, the center failed to ensure that the separate record for each child enrolled contains all of the elements as required by the standards. Evidence: 1. The record for Child 1 did not contain the following information: the name and phone number of the child?s physician; documentation of viewing proof of the child?s identity and age; and documentation of health information as required. 2. The record for Child 2 did not contain the following information: name, address and phone number of two designated people to call in an emergency if a parent cannot be reached (the addresses for both designated people were incomplete). 3. The record for Child 3 did not contain the following information: name, address and phone number of two designated people to call in an emergency if a parent cannot be reached (the addresses for both designated people were incomplete) 4. The record for Child 4 did not contain the following information: work phone number of each parent (an employer was listed but the record did not contain a work phone number); phone number of child?s physician; name, address and phone number of two designated people to call in an emergency if a parent cannot be reached (the addresses for both designated people were incomplete); and documentation of health information as required. 5. The record for Child 6 did not contain the following information: allergies and intolerance to medication or any other substances, and actions to take in an emergency; name, address and phone number of two designated people to call in an emergency if a parent cannot be reached (no addresses were provided); and documentation of health information as required by 8VAC20-780-130. 6. The record for Child 7 did not contain the following information: name, address and phone number of two designated people to call in an emergency if a parent cannot be reached (the addresses for both designated people were incomplete).
Plan of Correction:	Will use the model form for all new and returning students. All paperwork will be due by the first date of attendance.
Standard #:	8VAC20-780-70
Description:	Based on record review and discussion with staff, the center failed to ensure that staff records contain all of the elements as required by the standards. Evidence: 1. The record for Staff 3 did not contain the following information: name, address and telephone number of a person to be notified in an emergency. 2. The record for Staff 4 did not contain the following information: documentation that two or more references as to character and reputation as well as competency were checked before employment. 3. The record for Staff 6 did not contain the following information: documentation that two or more references as to character and reputation as well as competency were checked before employment; and health information as required.
Plan of Correction:	Will get the missing information.
Standard #:	8VAC20-780-80-A
Description:	Based on document review and discussion with staff, the center failed to ensure that for each group of children, the center shall maintain a written record of daily attendance that documents the arrival and departure of each child in care as it occurs. Evidence: The written record of daily attendance did not document the departure of each child.
Plan of Correction:	Will begin to document the departure.
Standard #:	8VAC20-780-340-F
Description:	Based on observation and discussion with staff, the center failed to ensure that children shall always be within actual sight and sound supervision of staff. Evidence: Four children were observed in an office space participating in an activity with a volunteer from an outside partner agency. There was not a staff member present in the office space. The children were not within the sight and sound supervision of a staff member during this time.
Plan of Correction:	Will ensure that staff will always be with a volunteer and will hold an orientation for all volunteers.
Standard #:	8VAC20-780-500-A
Description:	Based on observation and discussion with staff, the center failed to ensure that children?s hands shall be washed with soap and running water or disposable wipes before and after eating meals and snacks. Evidence: Children were observed arriving to the program and immediately eating their afternoon snack without washing hands before or after eating the snack.
Plan of Correction:	Will make sure that children was their hands.
Standard #:	8VAC20-780-530-C
Description:	Based on record review and discussion with staff, the center failed to ensure that there shall be at least two people who are currently certified in CPR and First Aid on the premises during the center?s hours of operation, on fieldtrips, and wherever children are in care. Evidence: Staff 1 was the only staff on the premises with a current certification in CPR and First Aid during the 04/05/2022 inspection.
Plan of Correction:	All group leaders will be certified.
Standard #:	8VAC20-780-560-J
Description:	Based on observation and discussion with staff, the center failed to ensure that tables shall be sanitized before and after each use for feeding. Evidence: Various groups of children were observed eating their afternoon snack at various times using the same tables. The tables were not sanitized between each use by the various groups of children.
Plan of Correction:	Tables will be marked to indicate sanitized once they are sanitized so that children and staff know which tables are sanitized and open for use.