VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Young Men's Christian Association of Greater Richmond-Northside
4207 Old Brook Road
Richmond, VA 23227
(804) 474-4405

Current Inspector: Lynn Powers (804) 840-8260

Inspection Date: May 31, 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 8VAC20-770 Background Checks 20 Access to minor's records 22.1 Early Childhood Care and Education 32.1 Report by person other than physician 63.2 Child Abuse & Neglect

Technical Assistance:

n/a

Comments:

An unannounced monitoring inspection was initiated on Wednesday, May 31, 2023, to determine the center's compliance with licensing standards. The inspection was concluded on Tuesday, June 6, 2023. On May 31, the inspector was on site from 4:00pm to approximately 5:15pm. There was a total of 43 children in care in the direct care of five staff members. The center?s program director assisted the inspector throughout the inspection. Upon the inspector's arrival, the children were observed in their designated groups finishing up a snack. The children and staff were engaged in various activities. They were later observed transitioning to the gym and the playground. The center is equipped with age-appropriate materials and equipment for the children's use. Staff were engaged with the children and offered guidance when needed. The areas where children receive care were inspected and found in compliance. The required postings were observed. Medication is administered when needed and medications were reviewed. During the inspection, five children's records and six staff records were reviewed. Additional documentation was submitted electronically on June 1 and June 6, 2023. 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-A
Description:	Based on a review of six staff records, the center did not ensure one staff completed a required background check every five years. Evidence: The most recent sworn statement in the record of Staff #1 (DOE: 02/22/18) was completed on 02/28/23. The previous sworn statement in the record was completed on 02/16/18. A new sworn statement should have been completed no later than 02/16/23.
Plan of Correction:	Per the Center: "We will ensure timely background checks are done/completed."
Standard #:	8VAC20-770-60-B
Description:	Based on a review of six staff records and interview, the center did not ensure one staff had a complete sworn statement or affirmation prior to employment. Evidence: The sworn statement in the record of Staff #5 (DOE: 06/12/22) was completed on 11/04/22. The center was unable to locate a sworn statement that was completed prior to the staff beginning employment.
Plan of Correction:	Per the Center: "We have fixed this issue moving forward."
Standard #:	8VAC20-780-140-A
Description:	Based on a review of five children's records and interview, the center did not ensure one child had a physical examination by or under the direction of a physician before the child's attendance; or within 30 days after the first day of attendance. Evidence: 1) The record of Child #5 (DOA: 09/15/22) did not contain documentation of a physical examination. 2) During interview, a member of management confirmed a physical examination was not on file for Child #5.
Plan of Correction:	Per the Center: "We will fix this immediately and the process has been fixed."
Standard #:	8VAC20-780-160-C
Description:	Based on a review of six staff records, the center did not ensure three staff obtained and submitted the results of a follow-up tuberculosis (TB) screening at least every two years. Evidence: 1) The most recent TB screening in the record of Staff #3 (DOE: 05/12/21) was completed on 05/24/23. The previous TB screening was completed on 05/10/21. A new TB screening should have been obtained no later than 05/10/23. 2) The most recent TB screening in the record of Staff #4 (DOE: 05/12/21) was completed on 05/24/23. The previous TB screening was completed on 04/26/21. A new TB screening should have been obtained no later than 04/26/23. 3) The most recent TB screening in the record of Staff #6 (DOE: 04/21/21) was completed on 06/05/23. The previous TB screening was completed on 04/15/21. A new TB screening should have been obtained no later than 04/15/23.
Plan of Correction:	Per the Center: "We will ensure timely background/TB screens and checks."
Standard #:	8VAC20-780-60-A-8
Description:	Based on a review of five children's records and interview, the center did not obtain a written care plan for one child with a diagnosed food allergy. Evidence: 1) The record of Child #2 (DOA: 09/06/22) indicated the child has a diagnosed food allergy, but the record did not contain a written care plan, 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. 2) During interview, a member of management confirmed a written care plan has not been obtained for Child #2.
Plan of Correction:	Per the Center: "We will obtain all required allergy plans."
Standard #:	8VAC20-780-90--A
Description:	Based on a review of five children's records and interview, the center did not obtain the required written agreements between the parent and the center for one child. Evidence: 1) The record of Child #3 (DOA: 09/06/22) did not contain a written agreement between the parent and the center by the child's first day of attendance that included: An authorization for emergency medical care should an emergency occur when the parent cannot be located immediately unless the parent states in writing an objection to the provision of such care on religious or other grounds; a statement that the center will notify the parent when the child becomes ill and that the parent will arrange to have the child picked up as soon as possible if so requested by the center; and a statement that the parent will inform the center within 24 hours or the next business day after his child or any member of the immediate household has developed any reportable communicable disease, as defined by the State Board of Health, except for life threatening diseases which must be reported immediately. 2) During interview, a member of management acknowledged the child's record did not contain the required agreements between the parent and the center.
Plan of Correction:	Per the Center: "We will make sure all required signatures are collected before children begin."
Standard #:	8VAC20-780-240-A
Description:	Based on a review of six staff records, the center did not ensure one staff complete within 90 calendar days of employment the Virginia Department of Education-sponsored orientation course. Evidence: The Virginia Department of Education-sponsored orientation course in the record of Staff #5 (DOE: 06/12/22) was completed on 01/12/23; exceeding 90 calendar days of employment.
Plan of Correction:	Per the Center: "We will make sure staff complete all required trainings."
Standard #:	8VAC20-780-245-A
Description:	Based on a review of six staff records and interview, the center did not ensure two staff completed annually a minimum of 16 hours of training appropriate to the age of children in care. Evidence: 1) The record of Staff #3 (DOE: 05/12/21) contained a total of 8 hours of annual training from 05/2022 - 05/2023. 2) The record of Staff #6 (DOE: 04/21/21) contained a total of 7 hours of annual training from 04/2022 - 04/2023. 3) During interview, a member of management confirmed the staff members did not have 16 hours of annual training on file.
Plan of Correction:	Per the Center: "We are working on better standard to provide better reporting for trainings."
Standard #:	8VAC20-780-270-A
Description:	Based on observations of the playground area, the center did not ensure areas and equipment of the center, inside and outside, shall be maintained in a clean, safe and operable condition. Evidence: 1) The inspector observed three plastic boards around the playground that were cracked. Children were observed playing in this area. 2) During interview, a member of management acknowledged the cracks and indicated maintenance has been made of aware that they need to be fixed. Unsafe conditions shall include, but not be limited to, splintered, cracked or otherwise deteriorating wood; chipped or peeling paint; visible cracks, bending or warping, rusting or breakage of any equipment; head entrapment hazards; and protruding nails, bolts or other components that could entangle clothing or snag skin.
Plan of Correction:	Per the Center: "We have taken out all plastic boards from playground."