VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Bedford Area Family Young Mens Christian Assoc -Thomas Jefferson
1255 Patriot Place
Thomas Jefferson Elementary School
Forest, VA 24551
(540) 586-3483

Current Inspector: Nicole Scott (804) 588-2372

Inspection Date: Aug. 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. 8VAC20-820 THE LICENSE 8VAC20-820 THE LICENSE PROCESS 8VAC20-820 HEARING PROCEDURES 8VAC20-770 BACKGROUND CHECKS 20 ACCESS TO MINOR?S RECORDS 22.1 BACKGROUND CHECKS, CODE, CARBON MONOXIDE 63.2 CHILD ABUSE AND NEGLECT

Comments:

An unannounced renewal inspection was initiate on 08/31/2023. The inspector was on site from 2:35pm until 5:00pm. There were 37 children, ages 4 to 11 years old under the supervision of 2 staff upon arrival. Two other staff members joined around 3:30pm. Children were observed during indoor play, snack time and outdoor play. Seven children's records, two medical records and five staff records were reviewed. Record review was complete on 9/5/2023. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations are documented on the violation notice issued to the program. If you have any questions about this inspection, please contact Nicole Scott, Licensing Inspector Phone-804.588.2372 Email- nicole.scott@doe.virginia.gov.

Violations:

Standard #:	22.1-289.035-B-4
Description:	REPEAT VIOLATION Based on review of five staff?s records, the center failed to ensure that all required out of state background checks were obtained. Evidence: Staff 1 had a documented employment date of 03/27/2023. Staff 1 indicated on the sworn statement that they have lived outside of the state of Virginia in the past five years. An out of state child protective service findings was not in the record.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-130-A
Description:	Based on record review and staff interviews, the center failed to obtain documentation that each child has received immunizations required by the State Board of Health the child can attend the center. Evidence: 1.Child 3, with an enrollment date of 08/14/2023 did not contain documentation of immunizations 2. Child 4, with an enrollment date of 08/21/2023 did not contain documentation of immunizations. 3. Child 6, with an enrollment date of 08/14/2023 did not contain documentation of immunizations. 4. Child 7, with an unknown enrollment date, did not contain documentation of immunizations.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-160-A
Description:	REPEAT VIOLATION Based on interview and review of staff records, the center failed to ensure that all staff had a negative tuberculosis (TB) screening at the time of employment, no more than 30 days prior to hire, and before coming in contact with children. Evidence: 1.Staff 1 started employment on 03/27/2023 and the TB test/screening was dated 4/6/2023. 2.Staff 2 started employment on 08/29/2023 and the TB test/screening was dated 4/28/2023. 3.Staff 3 started employment on 05/23/2023 and the TB test/screening was dated 6/10/2023. 4.Staff 4 started employment on 07/17/2023 and the TB test/screening was dated 6/15/2023.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-60-A
Description:	SYSTEMIC DEFICIENCY Based record review, the center failed to ensure that the separate record for each enrolled child shall contain all of the elements as required by the standards. Evidence: 1.The record for Child 1 did not contain the following information: Previously attended child day centers. 2.The record for Child 3 did not contain the following information: Proof of ID within 7 days. 3.The record for Child 4 did not contain the following information: Previously attended child day center Emergency contacts name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached. Proof of ID within 7 days. 4.The record for Child 5 did not contain the following information: Previously attended child day center Proof of ID within 7 days. 5.The record for Child 6 did not contain the following information: Previously attended child day center Proof of ID within 7 days. 6. The record for Child 7 did not contain the following information: Date of Birth/ Age First day of attendance Parents name, address, and phone number Allergy to Food Doctor?s name and number Emergency contacts name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached. Names of persons authorized to pick up the child. Written agreements between the parent and the center. Proof of ID with 7 days
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-70
Description:	SYSTEMIC DEFICIENCY Based on record review, the center failed to ensure all information for staff was maintained on the site. Evidence: 1.There was no emergency information at the center for Staff 1, Staff 2, Staff 3 or Staff 4. All staff files were kept offsite. 2. Staff # 5 had a hire date of 05/27/2023 and did one of the two required reference was completed on 6/6/2023.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-240-A
Description:	Based on review of five staff records, the center failed to ensue that all new staff had the Virginia Department of Education ? Sponsored orientation course within the 90 calendar days. Evidence: Staff # 1 had a documented employment date of 3/27/2023. There was no documentation of the 10 hour Preservice Training in the record.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-245-J
Description:	Based on interview and observation, the center failed to ensure any child with emergency medications shall always be in the care of a staff member who is MAT certified. Evidence: Child 6 and 7 has emergency medication on site. Child 6 & 7 was at the center on 8/31/2023. There was no staff member present with MAT certification on 8/31/2023.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-340-C
Description:	Based on the observation, the center failed to ensure during the hours of operation, there always shall be on the premises one staff who meets the qualifications of program leader and an immediately available staff member, volunteer or other employee wo is at least 16 years of age, with direct means for communication between the two of them if there is an emergency. Evidence: On the day of the inspection there was no teacher qualified as program leader. Staff 1 stated the previous Program Lead left about two weeks ago and no one had been appointed.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-340-F
Description:	Based on observation, the center failed to ensure that children under 10 years of age always shall be within actual sight and sound supervision of staff. Evidence: 1.Children were observed coming in from the playground to use the restroom. Children were hiding in classrooms and in cafeteria from the teacher. 2. One child was left inside in the restroom during a bathroom break. Child was escorted back outside by Inspector. 3.Children were lining up to use the bathroom and get ready for outdoor play. Both teachers were in the hallway out of sight and sound of approximately 10 children left in the cafeteria where inspector was.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-350-B-5
Description:	Based on observation, the center failed to maintain the required staff-to-children ratio for school age eligible up to 9 years old. Evidence: At approximately 2:35 pm, 37 preschool children were in care under the supervision of two staff in the cafeteria. The youngest child was 4 years old. The ratio is one staff to 18 children. Three staff would be required.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-500-A
Description:	SYSTEMIC DEFICIENCY Based on observation, the center failed to ensure children?s hands were washed with soap and running water or disposable wipe during the appropriate times. Evidence: Children were observed during snack. Children?s hands were not washed before or after the meal.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-510-L
Description:	SYSTEMIC DEFICIENCY Based on observation, the center failed to ensure that all medication shall be kept in a locked place using a safe locking method that prevents access by children. Evidence: 1.Child 6 had medication inside the first aid kit. The medication was not locked. The bag was on the table accessible to children. 2. Child 7 had medication inside the first aid kit. The medication was not locked. The bag was on the table accessible to children.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-550-G
Description:	SYSTEMIC DEFICIENCY Based on review, the center failed to maintain documentation of the emergency evacuation drills. Evidence: There was no documentation of emergency drills for review.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	8VAC20-780-560-J
Description:	Based on observation, the center failed to ensure tables shall be sanitized before and after each use for feeding. Evidence: Children were observed during snack time. Tables were not cleaned or sanitized before or after the children had snack.
Plan of Correction:	Not available online. Contact Inspector for more information.