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Eastern Shore Family YMCA
26164 Lankford Highway
Onley, VA 23418
(757) 787-5601

Current Inspector: Nanette Roberts (757) 404-2322

Inspection Date: June 21, 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.
8VAC20-770 Background Checks (8VAC20-770)
20 Access to minor?s records
22.1 Background Checks Code, Carbon Monoxide
63.2 Child Abuse & Neglect

Technical Assistance:
Technical assistance was provided in the following areas of the standards: Background checks, staff records, child records, required training, Program Leader qualifications, supervision, emergency drills, transportation, attendance, CPR/First aid certification, carbon monoxide detectors, and allergies.

Comments:
An unannounced monitoring inspection was conducted on 6/21/22 from 10:15am - 12:30pm. During the inspection there were 15 school age children in care with five staff. Children were observed participating in various activities in the classrooms, playing outside, swimming, and eating lunch. Records were reviewed for five children and six staff during the inspection. Medication, emergency procedures, emergency supplies and transportation procedures were also reviewed during the inspection. Information gathered during the inspection determined non-compliance(s) with applicable standards or law and violations were documented on the violation notice issued to the program,
and were discussed during the exit interview.

Violations:
Standard #: 22.1-289.035-B-2
Description: Based on a review of six staff records, it was determined that the facility did not ensure that an employee is allowed to begin employment without a completed national criminal history record check (finger printing).

Evidence:
1. The record for staff #4, working during the inspection did not contain documentation of a completed national criminal history record check (finger printing).
2. The record for staff #6, working during the inspection did not contain documentation of a completed national criminal history record check (finger printing).
3. Staff #7 (Program Director) reviewed the record for the staff #5 and confirmed that he had not received the results of the national criminal record check (finger printing) before either staff began employment.

Plan of Correction: The facility responded: Staff #4 and staff #6 will complete a national criminal record check (finger printing). All new staff will not be allowed to begin employment without completing a national criminal record check (finger printing).

Standard #: 8VAC20-770-60-B
Description: Based on a review of six staff records, it was determined that the facility did not ensure that the facility did not ensure that an employee must not be employed until a sworn statement or affirmation has been completed.

Evidence:
1. The record for staff #6, working during the inspection, did not contain a sworn statement or affirmation.
2. Staff #7 (Program Director) reviewed the record for staff #6, and confirmed the sworn statement or affirmation was not completed prior to employment.

Plan of Correction: The facility responded: Staff #6 will complete a sworn statement or affirmation. All new staff will not be allowed to begin employment without completing a sworn statement or affirmation.

Standard #: 8VAC20-780-160-A
Description: Based on a review of six staff records, it was determined that the facility did not 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 employing.

Evidence:
1. The record for staff #4, working during the inspection, did not contain documentation of a negative tuberculosis screening.
2. The record for staff #6, working during the inspection, did not contain documentation of a negative tuberculosis screening.
3. Staff #7 (Program Director) reviewed the record for staff #4 and staff #6, and confirmed that the documentation of a negative tuberculosis screening had not been received prior to employment.

Plan of Correction: The facility responded: Staff #4 and staff #6 will be sent to complete a TB screening. All new staff will complete a TB screening prior to employment.

Standard #: 8VAC20-780-510-I
Description: Based on a review of the medication being stored at the facility, it was determined that the facility did not ensure that in order to administer prescription medication, the center has obtained written authorization from a parent or guardian.

Evidence:
1.The written authorization for the medication (Benadryl) for child #6 was not signed by the parent.
2. Staff #7 (Program Director) confirmed that there was medication that did not have written authorization from the parent to be administered.

Plan of Correction: The facility responded: The parents of child #6 will be asked to sign the medication authorization. We will make sure a medication authorization is signed by a parent or guardian prior to accepting any medication.

Standard #: 8VAC20-780-550-C
Description: Based on a review of documentation and interview, it was determined that the facility did not ensure that the emergency evacuation and shelter-in-place procedures/maps shall be posted in a location conspicuous to staff and children on each floor of each building.

Evidence:
1. The maps and procedures for emergency evacuation and shelter-in-place were not posted in the facility.
2. Staff #7 (Program Director) confirmed that the maps and procedures for emergency evacuation and shelter-in-place were not posted anywhere in the facility.

Plan of Correction: The facility responded: The evacuation maps and procedures have been posted in the facility.

Standard #: 8VAC20-780-560-G
Description: Based on interviews, it was determined that the licensee did not ensure that when food is brought from home it is labeled with the child's name and date.

Evidence:
1. None of the lunch boxes for the children present at the facility were labeled with their name or the date
2. Staff #7 (Program Director) acknowledged that the lunch boxes brought by the children were not labeled with their name or the date.

Plan of Correction: The facility responded: All lunch boxes for the children will be labeled with the child's name and the date.

Standard #: 8VAC20-820-120-E-2
Description: Based on observation and interview, it was determined that the facility did not ensure that the findings of the most recent inspection of the facility were posted on the premises.

Evidence:
1. The results from the most recent inspection (4/13/22) was not posted anywhere in the facility.
2. Staff #7 (Program Director) confirmed that the findings of the most recent inspection were not posted in the facility.

Plan of Correction: The facility responded: Corrected during the inspection. Going forward we will ensure that the findings of the most recent inspection are posted.

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.

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