VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Effingham Street Family YMCA
1013 Effingham Street
Portsmouth, VA 23704
(757) 399-5511

Current Inspector: Nanette Roberts (757) 404-2322

Inspection Date: Jan. 22, 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 HEARINGS PROCEDURES. 8VAC20-770 Background Checks (8VAC20-770) 22.1 Background Checks Code, Carbon Monoxide

Comments:

An unannounced monitoring inspection was conducted on 1/22/2024 from 4:00pm to 6:30pm. At the time of the inspection there were 40 children in care and 5 staff members. Children were observed participating in various activities including group choice, snack and homework time. Records were reviewed for 5 children and 6 staff members. Medication, evacuation drills, emergency supplies and other required records and postings were also reviewed. The information gathered during the inspection determined non-compliance with applicable standards or law and violations were documented on the violation notice and discussed during the exit interview.

Violations:

Standard #:	22.1-289.035-B-4
Description:	Based on a review of six staff records, it was determined that the facility did not ensure that all staff who had lived out of state within the past five years had a sex offender registry check, and a child abuse and neglect registry check on file from the state the staff member had lived. Evidence: Staff #5 indicated on her sworn statement that she had lived out of state in the past five years. The state participates in the National Fingerprint File however, there was no documentation in the record that the required out of state sex offender registry check, or a search of the child abuse and neglect registry had been completed.
Plan of Correction:	Plan of correction will include all out of state staff to be processed through their state central registry. Also to complete the central registry for current staff member out of state.
Standard #:	8VAC20-780-160-A
Description:	Repeat violation Based on a review of six staff records, it was determined the center did not ensure that each staff member submit documentation of a negative tuberculosis screening at the time of employment, prior to coming into contact with children and be completed within the last 30 calendar days of employment. Evidence: 1.The TB screening for staff #2 (date of hire 9/21/2023) was dated 1/24/2024, this was after the staff member began working at the center and after coming into contact with children. 2.The TB screening for staff #6 (date of hire 12/11/2023) was dated 1/24/2024 this was after beginning work and coming into contact with children. 3.The TB screening for staff #5 was dated 3/6/2023 which was more than 30 days prior to her start date of 10/25/2023. The TB screening was dated 7 months prior to the staff member's date of hire.
Plan of Correction:	Plan of correction will include supervisor to make sure that a TB screenings/test are within 30 days of hire or receive a doctor's note from new hire that physician will not rescreen or test.
Standard #:	8VAC20-780-60-A
Description:	Based on review of five children?s records and interviews, it was determined that the center did not ensure that each child?s record contains all required information. Evidence: 1.The record for child #2 did not include parent contact information, physicians name and phone number and two emergency contacts. 2.The record for child #3 did not contain two emergency contacts. 3.The record for child #4 did not contain documentation of the child?s physician and phone number. 4.The record s for child #4 and child #5 did not include documentation of immunizations or physicals. 5. Staff #1 confirmed the information was not in the children's records.
Plan of Correction:	Plan of correction will be to audit the childcare documents to ensure all signatures are present.
Standard #:	8VAC20-780-80-A
Description:	Based on observation and record review it was determined the facility did not ensure that a written daily record of children?s daily attendance, including arrival and departure times, was maintained. Evidence: 1. Staff had a list of children and the schools they arrive from; however, this list did not include written documentation of children?s daily arrival and departure times. 2. Staff #1 confirmed the checklist used did not document arrival and departure times.
Plan of Correction:	Plan of correction will include staff using paper sign in sheets with the tablet to document arrival and departure times.
Standard #:	8VAC20-780-90--A
Description:	Based on record review and interviews, it was determined the center did not ensure that the required signed, written agreements between the parents and the center were in the child?s record by the first day of the child?s attendance. Evidence: 1.The record for child #2, child #4 and child #5 did not include signed agreements for authorization of emergency medical care, the statement that the center will notify the parent when the child becomes ill, and the statement that the parent will notify the center within 24 hours if the child or a household member has developed a communicable disease.
Plan of Correction:	Plan of correction will be to audit the childcare documents to ensure all information is present.
Standard #:	8VAC20-780-240-A
Description:	Based on the review of records and interview, it was determined the center did not ensure that the Virginia Department of Education sponsored orientation course is completed within 90 calendar days of employment. 1.The record for staff #4 (hire date of 9/8/2023) did not contain documentation that the VDOE orientation had been completed.
Plan of Correction:	Plan of correction will include new hires completed orientation within 90 days of hire.
Standard #:	8VAC20-780-270-A
Description:	Based on observation and interviews, it was determined that the facility did not ensure all areas and equipment of the center shall be maintained in a safe and operable condition. Evidence: 1.There were exposed roots approximately 16? from the exit chute of the green slide that posed a tripping hazard. 2. Staff #1 confirmed the roots were exposed.
Plan of Correction:	Plan of correction for this violation will is staff will do a monthly check of the playground area to ensure that no roots are growing under playground equipment and mulch remains at 6 inches. An order to have mulch redone and roots pulled up has been put in.
Standard #:	8VAC20-780-330-B
Description:	Based on observation, it was determined that the center did not ensure that where playground equipment is provided, resilient surfacing shall comply with minimum safety standards when tested in accordance with the procedures described in the American Society for Testing and Materials F1292-99 (Compressed Loose Fill Synthetic Materials Depth Chart) and shall be under equipment with moving parts or climbing apparatus to create a fall zone free of hazardous obstacles. Evidence: 1.The resilient surface (mulch) under the swings and at the end of both slides, measured 3? which was less than the required minimum depth of 6?. 2.Staff #1 confirmed the mulch was not 6? in depth.
Plan of Correction:	The plan of correction for this violation,staff will do a monthly check of the playground area to ensure that no roots are growing under playground equipment and mulch remains at 6 inches. An order for mulch has been put in to have the mulch redone and the roots pulled up.
Standard #:	8VAC20-780-550-D
Description:	Repeat violation Based on record reviews and interviews, it was determined the facility did not ensure that the center shall implement a monthly practice evacuation drill. Evidence: 1.There was no documentation of a practice evacuation drill for January 2023. 2.The Director confirmed the January evacuation drill was not documented.
Plan of Correction:	Plan of correction will be to make sure all drills are documented properly.