VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Great Bridge/Hickory Family YMCA
633 South Battlefield Boulevard
Chesapeake, VA 23322
(757) 546-9622

Current Inspector: D'Nae Goodwin (757) 404-3063

Inspection Date: April 4, 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. 780 Special Care Provisions and Emergencies 8VAC20-780 Special Services. 8VAC20-820 THE LICENSE. 8VAC20-770 Background Checks (8VAC20-770) 20 Access to minor?s records 22 Checks Code, Carbon Monoxide.1 Background 63.2 Child Abuse & Neglect

Technical Assistance:

Standard 510 - medication / reviewed with administrative staff

Comments:

An unannounced monitoring inspection was initiated on 04/04/2024 at 9:30 am and concluded on 04/04/2024 at 11:45 am. At the time of entrance there were 29 school age children in care with 6 staff present. Children were observed during transition from the child care room to the outdoor play area where a large motor group game was implemented. The inspector reviewed a sample size of 6 children and 7 staff records. Medication and emergency supplies additionally reviewed. 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. These violations were reviewed with administrative staff at the conclusion of the inspection.

Violations:

Standard #:	22.1-289.011-F
Description:	Based on observation, the center failed to ensure that the findings of the most recent inspection were posted in a conspicuous place on the licensed premises. Evidence: 1. The findings of the most recent inspection of the licensed program, which was the 06/22/2023 renewal inspection, were not posted.
Plan of Correction:	Administrative staff stated that the current licensing inspection reports will be posted going forward.
Standard #:	22.1-289.035-B-2
Description:	Based on record review and interview, the center failed to ensure that staff obtain the results of a fingerprint criminal history record check before employment. Evidence: 1. Staff 5, hire date 06/11/2020, lacked the results of a fingerprint criminal history record check. a. Staff 5 was observed working in the licensed program during the inspection. 2. Administrative staff confirmed that the results of the fingerprint criminal history record check had not been obtained for staff 5.
Plan of Correction:	Administrative staff stated that a CRC would be obtained for staff 5.
Standard #:	8VAC20-770-60-B
Description:	Based on record review and interview, the center failed to ensure that an employee of a licensed child day program must not be employed until the agency has the person's completed sworn statement or affirmation. Evidence: 1. There was no completed sworn statement or affirmation for staff 7 who has a hire date of 07/13/2022. 2. Administrative staff confirmed that a sworn statement or affirmation was not available for staff 7.
Plan of Correction:	Staff 7 will complete a sworn statement or affirmation.
Standard #:	8VAC20-770-60-C-2
Description:	Based on record review and interview, the center failed to ensure that staff have a central registry finding within 30 days of employment. Evidence: 1. Staff 7, hire date 07/13/2022, lacks the results of a central registry finding. a. Staff 7 was observed caring for children during the inspection. 2. Administrative staff confirmed that a central registry finding was not available for staff 7.
Plan of Correction:	A central registry check will be requested for staff 7.
Standard #:	8VAC20-780-130-A
Description:	Based on record review and interview, 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: 1. Documentation of required immunizations was not available for child 1 and child 2 who were both in care during the inspection. 2. Administrative staff confirmed that immunization documentation was not available for these children.
Plan of Correction:	Administrative staff stated that immunization documentation was on file at another YMCA site and a copy would be obtained.
Standard #:	8VAC20-780-140-A
Description:	Based on record review and interview, the center failed to ensure that each child shall have a physical examination by or under the direction of a physician before attendance or within 30 days after the first day of attendance. Evidence: 1. Child 2, enrollment date 02/04/2024, lacked documentation of a physical exam. 2. Administrative staff confirmed that written documentation of a physical exam was not on file.
Plan of Correction:	Administrative staff stated that the physical exam was on file at another YMCA site and a copy would be obtained.
Standard #:	8VAC20-780-160-A
Description:	Based on record review and interview, the center failed to ensure that each staff member shall submit documentation of a negative tuberculosis screening at the time of employment. Evidence: 1. There was no documentation of a negative tuberculosis screening for staff 5 who has a hire date of 06/11/2020 and was caring for children during the inspection. 2. There was no documentation of a negative tuberculosis screening for staff 7 who has a hire date of 07/13/2022 and was caring for children during the inspection. 2. Administrative staff confirmed that a TB screening was not on file for staff 5 and staff 7.
Plan of Correction:	Administrative staff stated that both staff will obtain a TB screening.
Standard #:	8VAC20-780-40-M
Description:	Based on observation and interview, the center failed to maintain, in a way that is accessible to all staff who work with children, a current written list of all children's allergies, sensitivities, and dietary restrictions. This list shall be dated and kept confidential in each room or area where children are present. Evidence: 1. The written list of children's allergies, sensitivities and dietary restrictions was not posted in the child care classroom. 2. Administrative staff confirmed that the allergy list was not available to staff in the classroom.
Plan of Correction:	Administrative staff indicated that the allergy list would be placed in the child care room.
Standard #:	8VAC20-780-60-A
Description:	Repeat Violation: Based on record review and interview, the center failed to maintain and keep at the center a separate record for each child enrolled. Evidence: 1. There was no enrollment record available for child 1 who was in care during the inspection. 2. Administrative staff confirmed that she was not able to locate the enrollment record for child 1.
Plan of Correction:	Administrative staff stated that the record for this child was maintained at another YMCA site and a copy would be obtained.
Standard #:	8VAC20-780-70
Description:	Based on record review and interview, the center failed to ensure that staff records contain all of the required elements. Evidence: 1. Written documentation of the name, address and telephone number for a designated emergency contact was not on site for staff 1, staff, 2, staff 3, staff 4 and staff 7. a. These staff were present during the inspection. b. Administrative staff confirmed that emergency contact information was not available for these staff. 2. Written documentation was not on file to demonstrate that staff 5 possesses the education required by the job position of program director. a. Staff 5 stated she was acting as the program director for the program and her job title is listed as program director. 3. Written documentation was not on file to demonstrate that staff 4 ( hire date 02/20/2024) had completed orientation training within 7 days of employment. 4. The following required information was not on file for staff 7 who has a hire date of 07/13/2022: a. Job title; b. Two reference checks.
Plan of Correction:	Administrative staff stated that missing documents will be added to staff records.
Standard #:	8VAC20-780-80-A
Description:	Based on record review and interview, the center failed to maintain a written record of daily attendance that documents the arrival of each child in care as it occurs. Evidence: 1. When the inspector arrived at 9:30 am 5 children in care were not included on the written attendance sheet. 2. Staff verified that these 5 children had not been included on the written attendance sheet.
Plan of Correction:	Staff stated that each child had been added to the electronic attendance record which was not available therefore, staff will make sure to add each child to the written attendance record as children arrive. The written record was updated during the inspection.
Standard #:	8VAC20-780-240-A
Description:	Based on record review and interview, the center failed to ensure that staff complete the Virginia Department of Education-sponsored orientation course within 90 calendar days of employment. Evidence: 1. Staff 2, hire date 06/20/2022, lacks documentation of completion of the Virginia Department of Education sponsored orientation course. 2. Staff 6, hire date 06/08/2023, lacks documentation of completion of the Virginia Department of Education sponsored orientation course. 2. Administrative staff confirmed that there was no documentation that staff 2 and staff 6 had completed this training course.
Plan of Correction:	Administrative staff stated that staff 2 would complete this training.
Standard #:	8VAC20-780-245-A
Description:	Based on record review and interview, the center failed to ensure that staff shall complete annually a minimum of 16 hours of training appropriate to the age of children in care. Evidence: 1. There was no documentation that staff 7, hire date 07/13/2022, had completed 16 hours of annual training in 2023. Documentation provided indicated that staff 7 had completed 2 hours of training in 2023. 2. Administrative staff stated that no additional training documentation was available for staff 7.
Plan of Correction:	Administrative staff stated that if training documents can not be located - staff 7 will begin completion of annual training to ensure 16 hours are completed for 2024.
Standard #:	8VAC20-780-260-A
Description:	Based on record review and interview, the center failed to obtain an annual fire inspection report from the appropriate fire official having jurisdiction. Evidence: 1. The most recent inspection from the Chesapeake Fire Marshall's Office was conducted on 07/25/2022. 2. Administrative staff confirmed this was the most recent fire inspection on file for the facility.
Plan of Correction:	Administrative staff stated that an annual fire inspection will be requested.
Standard #:	8VAC20-780-280-B
Description:	Based on observation, the center failed to ensure that hazardous substances such as cleaning materials, shall be kept in a locked place using a safe locking method that prevents access by children. Evidence: 1. Four bottles of disinfectant cleaning agents were observed stored on the lower shelf of an unlocked cabinet in the child care classroom.
Plan of Correction:	The cabinet was locked during the inspection.
Standard #:	8VAC20-780-430-K
Description:	Based on observation, the center failed to ensure provision shall be made for an individual place for each child's personal belongings. Evidence: 1. Approximately 28 backpacks/ lunch containers and 7 coats were observed stacked on a table in the child care classroom. a. All of the children's belongings were stacked in such a way that belongings lacked any individual space as the items were placed on top of and directly beside other.
Plan of Correction:	Administrative staff stated that baskets would be put our for children's belongings.
Standard #:	8VAC20-780-510-G
Description:	Based on medication review, the center failed to ensure that medication shall be labeled with the child's name. Evidence: 1. One bottle of over-the-counter medication was not labeled with the child's name. 2. Administrative staff confirmed that this medication, for child 3, was not labeled with the child's name.
Plan of Correction:	Medication was labeled during the inspection.
Standard #:	8VAC20-780-550-H
Description:	Based on record review and interview, the center failed to maintain a record of the dates of the practice drills for one year. Evidence: 1. The emergency log for the facility lacked documentation of any fire drill for June, July and August of 2023. a. The emergency log did not indicate a second shelter-in-place practice drill for 2023. 2. Administrative staff stated they were unsure if these practice drills had been conducted in 2023.
Plan of Correction:	Administrative staff stated that emergency drills will be conducted and documented on the practice log as required.