VIRGINIA DEPARTMENT OF SOCIAL SERVICES

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

Current Inspector: Florence Martus (804) 389-0157

Inspection Date: March 30, 2023

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. 8VAC20-820 HEARINGS PROCEDURES. 8VAC20-770 Background Checks 20 Access to minor's records 22.1 Early Childhood Care and Education 63.2 Child Abuse & Neglect

Technical Assistance:

n/a

Comments:

An unannounced monitoring inspection was conducted on Thursday, March 30, 2023 to determine the center's compliance with licensing standards. The inspector was on site from10:45am to approximately 1:40pm. There were a total of three children in care in the direct care of two staff members. During the inspection, the children and staff were observed participating in a variety of activities. Staff were observed having positive interactions with the children. All areas of the facility used by the children were inspected. The center is equipped with toys and supplies and items were available to the children. The required postings were reviewed and found to be in compliance. Medication is administered, but there are no medications on-site at this time. During the inspection, five children's records and two staff records were reviewed. Information gathered during the inspections determined non-compliance with applicable standards or law and violations were documented on the violation notice issued to the program.

Violations:

Standard #:	22.1-289.035-B-2
Description:	Based on a review of two staff records and interview, the center did not ensure two staff had the satisfactory results of the fingerprint-based national criminal background check prior to employment. Evidence: 1) The fingerprint-based national criminal background check in the record of Staff #1, employed on 01/04/23, was dated 02/27/23. 2) The record of Staff #2, employed on 02/01/23, did not contain the results of the fingerprint-based national criminal background check. 3) During interview, a member of management confirmed the fingerprint results for Staff #1 were obtained after employment and the fingerprint results for Staff #2 have not been received to date.
Plan of Correction:	In the future, fingerprint results will be required at the time of employment.
Standard #:	8VAC20-770-60-B
Description:	Based on a review of two staff records, the center did not ensure two staff had a completed sworn statement or affirmation prior to employment. Evidence: 1) The sworn statement in the record of Staff #1, employed on 01/04/23, was completed on 09/24/19. 2) During interview, a member of management stated the sworn statement was completed for a position outside of the licensed center and a new one was not obtained. A sworn statement is required to be obtained no more than 90 days prior to employment. 3) The record of Staff #2, employed on 02/01/23, did not contain a completed sworn statement. 4) During interview, a member of management confirmed a sworn statement could not be located for Staff #2.
Plan of Correction:	In the future, staff will be required to complete a sworn disclosure statement at the time of employment.
Standard #:	8VAC20-770-60-C-2
Description:	Based on a review of two staff records and interview, the center did not ensure two staff members had a central registry finding within 30 days of employment. Evidence: 1) The record of Staff #1, employed on 01/04/23, did not have a central registry finding. 2) The central registry finding in the record of Staff #2, employed on 02/01/23, was dated 03/20/23. 3) During interview, a member of management confirmed the results of the central registry have not been received for Staff #1 and the results of the central registry for Staff #2 were received more than 30 days after employment. The record did not contain documentation of any further contact with the Office of Background Investigations, and the staff member had been continuously employed.
Plan of Correction:	In the future, documentation of contact with OBI will be maintained if results are not received within 30 days of employment. The request of the search of the central registry for Staff #1 was sent on 03/08/23.
Standard #:	8VAC20-780-160-A
Description:	Based on a review of two staff records and interview, the center did not ensure two staff members submitted documentation of a negative tuberculosis screening within the required timeframe. Evidence: 1) The most recent tuberculosis (TB) screening in the record of Staff #1, employed on 01/04/23, was dated 03/06/23. The staff had a prior TB screening that expired on 10/18/21. 2) The most recent TB screening in the record of Staff #2, employed on 02/01/23, was dated 05/03/22. 3) During interview, a member of management confirmed Staff #1 and Staff #2 did not submit documentation of a negative tuberculosis screening within the required timeframe. Documentation of the screening shall be submitted at the time of employment and prior to coming into contact with children; and the documentation shall have been completed within the last 30 calendar days of the date of employment and be signed by a physician, physician's designee, or an official of the local health department.
Plan of Correction:	Moving forward, TB screenings will be obtained prior to employment and will not be dated more than 30 days prior to employment.
Standard #:	8VAC20-780-70
Description:	Based on a review of two staff records, the center did not ensure two staff records contained the required information. Evidence: 1) The references in the record of Staff #1, employed on 01/04/23, were obtained on 03/03/23 and on 02/21/23. 2) The references in the record of Staff #2, employed on 02/01/23, were obtained on 02/20/23. Each staff record should contain documentation that two or more references as to character and reputation as well as competency were checked before employment or volunteering.
Plan of Correction:	In the future, references will be obtained prior to employment.
Standard #:	8VAC20-780-560-G
Description:	Based on observation and interview, the center did not meet the requirements when food is brought from home. Evidence: 1) The lunch boxes observed at the center on 03/30/23 were not clearly dated. There were three children present during the inspection. 2) During interview, staff and management confirmed not all lunch boxes were dated. When food is brought from home, the food container shall be sealed and clearly dated and labeled in a way that identifies the owner.
Plan of Correction:	Moving forward, the center will have a system to ensure all food brought from home is clearly dated and labeled to identify the owner.