VIRGINIA DEPARTMENT OF SOCIAL SERVICES

YMCA of the Virginia Peninsulas-Carrollton Elementary School
14440 New Town Haven Lane
Carrollton, VA 23314
(757) 570-1335

Current Inspector: Melinda Popkin (757) 802-5281

Inspection Date: Jan. 17, 2024

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:

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 five (5) business days from today. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction should contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person or person(s) responsible for implementation.

Comments:

A Renewal Inspection was initiated and concluded on 1/17/2023. There were 58 children present with 4 staff supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies and nutrition. Children were observed arriving to the multipurpose room, washing hands, having an afternoon snack (brought from home), completing homework assignments, engaged in table top activities and playing a gross motor game in the gymnasium. Staff and children's records were not on site during he inspection. An electronic review of the record sample was conducted on 1/19/2024 and 1/23/2024. A total of 5 child records, 4 staff records and 1 Board Member records were reviewed. The on site inspection on 1/17/2024 started at 3:50 pm and concluded at 5:55 pm. 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.

Violations:

Standard #:	8VAC20-780-150-B
Description:	Based on a review of children?s records, the licensee did not ensure that documentation of each child?s physical examination and immunizations are always signed by a physician, his designee, or an official of a local health department. Evidence: Five children?s records were reviewed digitally following the site inspection. The documentation of physical examination and immunizations for child #1 and child #4 were not signed or stamped by a physician, his designee, or an official of a local health department.
Plan of Correction:	The licensee will submit a plan of correction within 5 days of receipt of this notice dated 1/25/2024.
Standard #:	8VAC20-780-60-A
Description:	Based on interview and observation, the licensee did not always maintain and keep at the center a separate record for each child enrolled which contained the required information. Evidence: When asked to provide 5 specific children?s records for review, the site director was unable to locate the file box containing all of the enrolled the children?s records. After placing a phone call, the site director confirmed that the children?s records had not been returned to the center from another site where care was offered to families two days prior. A binder with partial information for 25 of the 70 enrolled children was located on site. Five children?s records were reviewed electronically following the inspection. The record for child #1 `and child #2 contained only one of the two required emergency contacts? name address and phone number
Plan of Correction:	The licensee will submit a plan of correction within 5 days of receipt of this notice dated 1/25/2024.
Standard #:	8VAC20-780-70
Description:	Based on observation and interview, the name, address, and telephone number of a person to be notified in an emergency was not always kept for each staff person at the center. Evidence: When asked to review the records for staff #1, staff #2, staff #3 and staff #4 who were present during the site inspection, the site supervisor was unable to locate any of the staff records. The site director stated that the staff records had not been returned to the center from the site where care was offered to families two days prior. When asked if emergency contact information was available on site for staff, the site director stated that she did not have this information on site because it was located in the staff records.
Plan of Correction:	The licensee will submit a plan of correction within 5 days of receipt of this notice dated 1/25/2024.
Standard #:	8VAC20-780-340-A
Description:	Based on observations and interview, staff did not always ensure the care and protection of children in their care. Evidence: According to a documented list of children with allergies and/or requiring medication, there were 3 enrolled children (child #6, child #7 and child #8) who required Emergency Medication to be kept available on site. When asked to view the medications, the site director discovered that the medication box had not been returned to the current location, after it had been taken to another childcare site where families were offered care for children on the school holiday 2 days prior. Child #7 and child #8 each had an albuterol inhaler prescribed for emergency use which were not located on site. Child #8 had an Auvi-Q Epinephrine auto-injector and Benadryl, prescribed for severe allergic reaction to peanuts. These medications were also not on site at the time of inspection. During the inspection, staff removed a child from the main childcare area when it was discovered that the child had packed peanut butter crackers for snack that day and was preparing to eat them in the cafeteria where child #8 was present. Not having the required emergency medication available compromised the care and protection of the child #6, child #7 and child #8 who may have required their medication.
Plan of Correction:	The licensee will submit a plan of correction within 5 days of receipt of this notice dated 1/25/2024.
Standard #:	8VAC20-780-540-E
Description:	Based on observation and interview, the program did not have a working, battery-operated radio available. Evidence: When the program?s first aid supplies were inspected, the site director was asked to present the emergency batter operated radio. The site director stated that at the time that she was promoted and relocated to this site in December, the battery-operated radio was observed to be corroded and was thrown out. She stated that a new battery-operated radio had not yet been obtained.
Plan of Correction:	The licensee will submit a plan of correction within 5 days of receipt of this notice dated 1/25/2024.
Standard #:	8VAC20-780-550-D
Description:	Based upon a review of documentation and interview, the licensee did not ensure that the center implements a monthly practice evacuation drill. Evidence: The last documented evacuation drill was documented on the program?s drill log was for October 2023. The program director who was on site during the inspection stated that she was promoted to Site Director in November and had not been instructed or trained to conduct monthly drills so they had not been conducted for November or December 2023.
Plan of Correction:	The licensee will submit a plan of correction within 5 days of receipt of this notice dated 1/25/2024.