VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Young Men's Christian Association of Greater Richmond - S.P.E.
4301 Fort McHenry Parkway
Glen allen, VA 23060
(804) 474-4405

Current Inspector: Jennifer Moore (540) 430-0384

Inspection Date: Nov. 2, 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. 8VAC20-820 THE LICENSE. 8VAC20-820 THE LICENSING PROCESS. 8VAC20-770 Background Checks (8VAC20-770) 20 Access to minors records 22.1 Background Checks Code, Carbon Monoxide 22.1 Early Childhood Care and Education

Comments:

An unannounced monitoring inspection was initiated on 11/2/2022 and concluded on 11/3/2022. The inspector was on site on 11/2/2022 from approximately 3:20 pm-4:45 pm. There were 42 children present, ranging in ages from five (5) to 10 years, with three (3) staff supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies, nutrition and background checks. A total of 5 child records and 5 staff records were reviewed. Information gathered during the inspection determined non-compliance with applicable standards or law and violations were documented on the violation notice issued to the program. Please complete the plan of correction and date to be corrected for each violation cited on the violation notice and return it to me within 5 business days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word corrected is not acceptable. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measures. Please do not use staff names; list staff by positions only.

Violations:

Standard #:	8VAC20-770-60-C-2
Description:	Based on a review of five (5) staff records and interview, the center did not ensure that one (1) staff had a central registry finding within 30 days of employment as required. Evidence: 1. The record of staff # 5 (date of employment: 10/3/2022) did not contain a central registry finding. 2. Administration acknowledged that the finding had not been obtained.
Plan of Correction:	we are working on our processes with DSS, but have followed up to try and obtain the results. we will be resending if DSS doesn?t have results back
Standard #:	8VAC20-780-60-A
Description:	Based on a review of five (5) children's records and interview, the center did not ensure that one (1) child had a record that contained the required information. Evidence: 1. The record of child #4 was missing one (1) emergency contact. The records are required to have the name address, and phone number of two (2) designated people to call in an emergency if a parent could not be reached. 2. Administration acknowledged that the record was incomplete.
Plan of Correction:	we will continue to work on correcting all child files
Standard #:	8VAC20-780-60-A-8
Description:	Based on a review of five (5) children's records and interview, the center did not ensure to have a written care plan for one (1) child with a diagnosed food allergy, to include instructions from a physician regarding the food to which the child is allergic and the steps to be taken in the event of a suspected or confirmed allergic reaction. Evidence: 1. The record of child #1 (date of attendance: 10/27/2021) did not contain an allergy care plan. The child had a diagnosed food allergy. 2. Administration acknowledged that the allergy care plan had not been obtained.
Plan of Correction:	we will work with parents to retrieve the correct allergy plans
Standard #:	8VAC20-780-70
Description:	Based on a review of five (5) staff records and interview, the center did not ensure to keep a complete record for three (3) staff as required. Evidence: 1. The record of staff #1 (date of employment: 10/10/2022) did not contain documentation that the employee possessed the orientation and training required by the job position. The record of staff #3 (date of employment: 7/12/2022) did not contain documentation to demonstrate the individual possessed the education and training required by the job position. The record of staff #4 (date of employment: 5/20/2022) did not contain documentation that the individual possessed the orientation required by the job position. 2. Administration acknowledged that the documentation was missing from each record.
Plan of Correction:	we will make sure all staff have completed documentation in their files, along with a better process for trainings
Standard #:	8VAC20-780-240-A
Description:	Based on a review of five (5) staff records and interview, the center did not ensure that one (1) staff completed the Virginia Department of Education-sponsored orientation within 90 calendar days of employment as required. Evidence: 1. The record of staff #3 (date of employment: 7/12/2022) did not contain documentation of the department sponsored course. 2. Administration acknowledged that it had not been completed.
Plan of Correction:	we are working with the staff person to finish the preservice training
Standard #:	8VAC20-780-550-D
Description:	Based on review of documentation and interview, the center did not ensure to implement a monthly practice evacuation drill. Evidence: 1. A drill was not documented in October of 2022. 2. Administration acknowledged that the evacuation drill was not completed.
Plan of Correction:	we will make sure all drills are done consistently