VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Family YMCA, Inc. Mt. Olivet
255 Lancer Lane
Martinsville, VA 24112
(276) 632-6455

Current Inspector: Tara K Martin (804) 588-2371

Inspection Date: Jan. 10, 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 8VAC20-770 BACKGROUND CHECKS 22.1 BACKGROUND CHECKS, CODE, CARBON MONOXIDE

Comments:

An unannounced on-site renewal inspection was conducted on 01/10/2024 and a staff record and policy/procedures review was conducted at the administrative office on 01/18/2024. There were 12 children, ages 5 years-9 years, and a total of 4 staff members present during the inspection. The inspector reviewed compliance in the areas of administration, staff qualifications and trainings, staffing and supervision, programs, emergencies and nutrition. The children were observed in free choice activities and during departure. A total of 5 children?s records, 4 staff records, 5 applicant records, and 2 medications were reviewed. The inspector arrived to the center for the onsite inspection at 4:20 pm and departed at 5:45 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 provider.

Violations:

Standard #:	8VAC20-780-130-A
Description:	REPEAT VIOLATION/SYSTEMIC VIOLATION Based on record review and staff interviews, the center failed to obtain documentation that each child has received the immunizations required by the State Board of Health before the child can attend the center. Evidence: The records for Child 1, 2, 3, 4, and 5 did not contain immunization records. Staff 4 confirmed that they did not have the immunization records for Child 1, 2, 3, 4, and 5.
Plan of Correction:	Will locate the complete child's record.
Standard #:	8VAC20-780-140-A
Description:	REPEAT VIOLATION/SYSTEMIC VIOLATION Based on staff interviews, the center failed to obtain a copy of the child?s physical examination before the child?s attendance or within 30 days after the first day of attendance. Evidence: The records for Child 1, 2, 3, 4, and 5 did not contain documentation of the child?s physical exam; the documented first date of attendance for Child 1, 2, 3, and 4 was 08/16/2023. Staff 4 confirmed that they did not have documentation of physical exams for Child 1, 2, 3, 4, and 5.
Plan of Correction:	Will locate the compete record.
Standard #:	8VAC20-780-40-M
Description:	SYSTEMIC VIOLATION Based on document review and staff interviews, the center failed to maintain in a way that is accessible to all staff who work with children, a written list of all children?s allergies, sensitivities, and dietary restrictions documented in the allergy plan. Evidence: The record for Child 2 contained a written allergy care plan that documented the child?s diagnosed food allergies. The written list of all children?s allergies, sensitivities and dietary for the center did not include Child 2?s diagnosed food allergies. Staff 2 stated that they were informed that Child 2 had an environmental allergy. Interviews with Staff 1, 2 and 4 confirmed that they were unaware that Child 2 had documented food allergies.
Plan of Correction:	Will write the allergies on the list.
Standard #:	8VAC20-780-60-A
Description:	SYSTEMIC VIOLATION Based on record review, the center failed to ensure that the separate record for each enrolled child contains all of the elements as required by the standards. Evidence: 1. The record for Child 1 did not contain the following information: written agreements between the parent and the center as required by the standards; and documentation of viewing proof of the child?s identity and age. 2. The record for Child 2 did not contain the following information: written agreements between the parent and the center as required by the standards; and documentation of viewing proof of the child?s identity and age. 3. The record for Child 3 did not contain the following information: written agreements between the parent and the center as required by the standards; and documentation of viewing proof of the child?s identity and age. 4. The record for Child 5 did not contain the following information: written agreements between the parent and the center as required by the standards; documentation of viewing proof of the child?s identity and age; and first date of attendance.
Plan of Correction:	Will locate the complete children's records.
Standard #:	8VAC20-780-80-A
Description:	SYSTEMIC VIOLATION Based on observation and staff interviews, the center failed to ensure that for each group of children, the center shall maintain a written record of daily attendance that documents the arrival and departure of each child in care as it occurs. Evidence: The written record of daily attendance did not document the departure of each child as it occurred.
Plan of Correction:	Will address with the staff.
Standard #:	8VAC20-780-540-C
Description:	Based on observations, the center failed to ensure that the required first aid kits shall contain all of the required elements as required by the standards. Evidence: The first aid kit did not contain an antiseptic cleaning solution.
Plan of Correction:	Will address with staff and purchase the items.