Translation Disclaimer

Agencies | Governor
Search Virginia.Gov
staff of hermes icon

Access the Virginia Department of Social Services' dedicated page for guidance and resources related to COVID-19.

Click Here»

Click Here for Additional Resources
Search for Child Day Care
|Return to Search Results | New Search |

Boys & Girls Clubs - Suffolk Unit
2325 E. Washington Street
Suffolk, VA 23434
(757) 934-0349

Current Inspector: Melinda Popkin (757) 802-5281

Inspection Date: Aug. 17, 2015

Complaint Related: No

Areas Reviewed:
22VAC40-185 ADMINISTRATION.
22VAC40-185 STAFF QUALIFICATIONS AND TRAINING.
22VAC40-185 PHYSICAL PLANT.
22VAC40-185 STAFFING AND SUPERVISION.
22VAC40-185 PROGRAMS.
22VAC40-185 SPECIAL CARE PROVISIONS AND EMERGENCIES.
22VAC40-185 SPECIAL SERVICES.
63.2 Licensure and Registration Procedures
63.2 Facilities and Programs..
22VAC40-191 Background Checks (22VAC40-191)

Comments:
An unannounced monitoring inspection was conducted on 08/17/2014 from 11:30am - 1:30pm. During the inspection there were 95 children ages six to twelve years old in care with eight staff. A tour of the facility was conducted and children were observed playing games, watching a movie, playing in the gym and eating lunch. Records were reviewed for seven children and 5 staff at the facility. Records were reviewed for an addition four staff at the central records location. Medication was reviewed along with emergency procedures and emergency supplies. Areas of non-compliance are identified on the violation notice, and were discussed during the exit interview. 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 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word ?corrected? is not acceptable. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).

Violations:
Standard #: 22VAC40-185-130-A
Description: Based on a review of seven children's records, it was determined that the facility did not ensure that there was documentation that each child has received the immunizations required by the State Board of Health before the child can attend the center. Evidence: 1. There was no record of immunization for child #5, who was present during the inspection. 2. Staff #10 (Program Director) confirmed that the record of immunization was not available for viewing during the inspection.

Plan of Correction: Files will be reviewed by Front Desk Supervisor to ensure that all files are completed. Parents of children without immunizations will be contacted by facility and informed that members may not return until immunization files are turned in. At the end of each month, Front desk supervisor will walk through to check that all new membership files are intact and signed off after review by Service Director by the 28th of each month. Person responsible for implementation - Service Director and Front Desk Supervisor.

Standard #: 22VAC40-185-160-A
Description: Based on a review of nine staff records, it was determined that the facility did not ensure that each staff member has documentation of a negative tuberculosis screening within 21 days after beginning employment. Evidence: 1. The record for staff #6 (date of hire 6/29/15) did not contain documentation of a negative tuberculosis screening. Staff #6 was present during the inspection and working with children. 2. The record for staff #7 (date of hire 6/18/15) did not contain documentation of a negative tuberculosis screening. Staff #7 was present during the inspection and working with children. 3. The record for staff #9 (date of hire 6/22/15) did not contain documentation of a negative tuberculosis screening. Staff #9 was present during the inspection and working with children.

Plan of Correction: Staff members that did not have proper documentation were given 10 days to obtain TB screenings. Any future employees will not be allowed to work until TB screenings are completed and are in files on site and at the Administrative Office. No staff will be allowed to start until a completed employee checklist is turned into the Director of Operations. Person responsible for implementation - Service Director and Director of Operations.

Standard #: 22VAC40-185-160-C
Description: Based on a review of nine staff records, it was determined that the facility did not ensure that staff resubmit updated TB results every 2 years. Evidence: 1. The record for staff #1 had documentation of a TB screening dated 7/20/12. 2. The record for staff #2 had documentation of a TB screening dated 3/11/13. 3. Staff #10 (Program Director) confirmed that an updated TB screening had not been received for staff #1, or staff #2.

Plan of Correction: Staff members were given 10 days to obtain updated TB screenings. Staff will not be allowed to return to work until current TB screenings are in staff files on site and at the Administrative Office. A spreadsheet will be created that contains all staff members? hire dates, documentation renewal dates and TB expiration dates and kept on site and at Administrative Office. Staff records will be checked semi-annually to ensure that expiration dates are not reached on documentation renewals. Person responsible for implementation - Service Director and Director of Operations.

Standard #: 22VAC40-185-60-A
Description: Based on a review of seven children's records, it was determined that the facility did not ensure that they maintain and keep at the center a complete record for each child enrolled that contains all required information. Evidence: 1. Staff #10 (Program Director) was unable to locate a record for child #7 during the inspection.

Plan of Correction: Training will be held with all Front Desk qualified personnel the procedure for registering new members, including obtaining the proper documentation, acceptable application completion, and the proper place to store records. At the end of each month, Front desk supervisor will walk through to check that all new membership files are intact and signed off after review by Service Director by the 28th of each month. Person responsible for implementation - Service Director, Front Desk Supervisor, and Senior Program Leader.

Standard #: 22VAC40-185-70-A
Description: Based a review of nine staff records, it was determined that the facility did not ensure that they maintain and keep at the center a complete record for each staff that contains all required information. Evidence: 1. Staff #10 (Program Director) was unable to provide the records for staff #6, staff #7, staff #8, and staff #9 during the inspection, and therefore was unable to provide documentation of a person to be notified in an emergency was kept at the facility. The Licensing Inspector went to the central office location and reviewed the records for staff #6, staff #7, staff #8, and staff #9. 2. The record for staff #6 (date of hire 6/29/15), present during the inspection and working with children, did not have documentation that two or more references as to character and reputation as well as competency were checked before employment, and did not have documentation of orientation training. 3. The record for staff #7 (date of hire 6/18/15), present during the inspection and working with children, did not have documentation that two or more references as to character and reputation as well as competency were checked before employment. 4. The record for staff #8 (date of hire 7/28/15), present during the inspection and working with children, did not have documentation that two or more references as to character and reputation as well as competency were checked before employment. 5. The record for staff #9 (date of hire 6/22/15), present during the inspection and working with children, did not have documentation that two or more references as to character and reputation as well as competency were checked before employment, and did not have documentation of orientation training.

Plan of Correction: New staff members will have reference letters in employment files on site as well as at Administrative Office. The complete new employee checklist will be enforced for all staff members upon hiring and if proper documentation is not obtained, personnel will not be hired. Service Director and Director of Operations will have to verify employee checklist before staff is allowed to work on site with children. A spreadsheet will be created that contains all staff members? hire dates, documentation renewal dates and TB expiration dates and kept on site and at Administrative Office. Staff records will be checked semi-annually to ensure that expiration dates are not reached on documentation renewals. Person responsible for implementation - Service Director, and Director of Operations.

Standard #: 22VAC40-185-340-D
Description: Based on interviews and a review of documentation provided by the facility, it was determined that the facility did not ensure that in each grouping of children at least one staff member who meets the qualifications of a program leader or program director shall be regularly present. Evidence: 1. Staff #8 and staff #9 were working with 22 children, ages 6 to 7 years old, in the cafeteria area playing games. A review of the records for staff #8 and staff #9 did not have any documentation that either staff was qualified as a program leader. 2. Staff #6 and staff #7 were working with 20 children, ages 8 to 10 years old, in the gym. A review of the records for staff #6 and staff #7 did not have any documentation that either staff was qualified as a program leader. 3. Staff #10 (Program Director) confirmed that there was no documentation to demonstrate that staff #6, staff #7, staff #8, and staff #9 met the qualifications for program leader.

Plan of Correction: The complete new employee checklist will be enforced for all staff members upon hiring and if proper documentation is not obtained, personnel will not be hired. Service Director and Director of Operations will have to verify employee checklist before staff is allowed to work on site with children. A spreadsheet will be created that contains all staff members? hire dates, documentation renewal dates and TB expiration dates and kept on site and at Administrative Office. Staff records will be checked semi-annually to ensure that expiration dates are not reached on documentation renewals. Person responsible for implementation - Service Director and Director of Operations.

Standard #: 22VAC40-185-340-F
Description: Based on observation, it was determine that the facility did not ensure that children under 10 years of age always shall be within actual sight and sound supervision of staff. Evidence: 1. The Licensing Inspector observed child #4 (date of birth 10/5/05) and child #5 (date of birth 3/22/07) enter the cafeteria of the facility without staff supervision. Child #4 and child #5 spoke with staff #8, and then proceeded to leave the cafeteria and walk down the hallway to another part of the facility without staff maintaining sight and sound supervision. 2. Licensing Inspector exited the cafeteria and proceeded down the hallway along the same route as child #4 and child #5. Child #4 and child #5 were observed going through a door at the end of the hallway. The door leads to an outdoor walkway which connects to another part of the facility. Child #4 and child #5 entered the door and proceeded to go down a hallway in that part of the building and enter another door that leads to the gym. The Licensing Inspector observed child #4 and child #5 in the gym with staff #6 and staff #7. The 20 children present in the gym were 8, 9, and 10 years of age.

Plan of Correction: There will be a training held for the staff to reemphasize the procedures for sight and sound supervision, which includes walkie-talkie communication, available staff/volunteer to monitor hallways and bathrooms, and the physical pass off of a child from one area to another. Will incorporate this training into our annual training week of shutdown between afterschool and summer programming. Person responsible for implementation - Service Director and Senior Program Leader.

Standard #: 22VAC40-185-510-J
Description: Based on observations and interviews, it was determined that facility did not ensure that medication, except for those prescriptions designated otherwise by written physician's orders, including refrigerated medication and staff's personal medication, shall be kept in a locked place using a safe locking method that prevents access by children. Evidence: 1. There was an Albuterol inhaler for child #6 lying on a table on the gym. 2. Licensing Inspector and staff #10 (Program Director) observed child #6 come over to the table and pick up the medication and place it in her pocket. 3. The record for child #6 was reviewed, and there was no written physician's orders for the medication to be kept unlocked. 4. Staff #10 (Program Director) stated he was unaware that child #6 had brought the Albuterol inhaler to the facility.

Plan of Correction: Staff will ensure that parents are aware of the policies pertaining to medication on site and where it is to be stored. Files will be reviewed for members that require medicine (albuterol) and parents will be asked if their child needs to have their medication on site. If confirmed that they do, the proper medication storage procedures as per M.A.T certifications state will be used. Medicine logged in M.A.T. logbook and medicine kept in safe in facility office. Signs will be posted at Front Desk for parents and members to state that no members are allowed to have any type of medication in their possession. Person responsible for implementation - Service Director and Front Desk Supervisor.

Standard #: 22VAC40-191-60-C-1
Description: Based on a review of nine staff records, it was determined that the facility did not deny continued employment of a staff who did not have an original criminal history record report within 30 days of employment. Evidence: 1. The record for staff #6 (date of hire 6/29/15) did not have documentation of a completed original criminal history record report. Staff #6 was present during the inspection and working with children. 2. The record for staff #7 (date of hire 6/18/15) did not have documentation of a completed original criminal history record report. Staff #7 was present during the inspection and working with children. 3.The record for staff #9 (date of hire 6/22/15) did not have documentation of a completed original criminal history record report. Staff #9 was present during the inspection and working with children. 4. Staff #11 reviewed the records for staff #6, staff #7, and staff #9, and confirmed that she had not received an original criminal history record report for any of the staff.

Plan of Correction: Staff #7 no longer works for the organization. For remaining staff without completed records, they were given 10 days to turn in completed forms to the Director of Operations. The complete new employee checklist will be enforced for all staff members upon hiring and if proper documentation is not obtained, personnel will not be hired. Service Director and Director of Operations will have to verify employee checklist before staff is allowed to work on site with children. A spreadsheet will be created that contains all staff members? hire dates, documentation renewal dates and TB expiration dates and kept on site and at Administrative Office. Staff records will be checked semi-annually to ensure that expiration dates are not reached on documentation renewals. Person responsible for implementation - Service Director and Director of Operations.

Standard #: 22VAC40-191-60-C-2
Description: Based on a review of nine staff records, it was determined that the facility did not deny continued employment of a staff who did not have a search of the central registry finding within 30 days of employment. Evidence: 1. The record for staff #6 (date of hire 6/29/15) did not have documentation of a completed search of the central registry finding. Staff #6 was present during the inspection and working with children. 2. The record for staff #staff #7 (date of hire 6/18/15) did not have documentation of a completed search of the central registry finding. Staff #7 was present during the inspection and working with children. 3.The record for staff #staff #9 (date of hire 6/22/15) did not have documentation of a completed search of the central registry finding. Staff #9 was present during the inspection and working with children. 4. Staff #11 reviewed the records for staff #6, staff #7, and staff #9, and confirmed that she had not received a completed search of the central registry finding for any of the staff.

Plan of Correction: Staff #7 no longer works for the organization. For remaining staff without completed records, they were given 10 days to turn in completed forms to the Director of Operations. The complete new employee checklist will be enforced for all staff members upon hiring and if proper documentation is not obtained, personnel will not be hired. Service Director and Director of Operations will have to verify employee checklist before staff is allowed to work on site with children. A spreadsheet will be created that contains all staff members? hire dates, documentation renewal dates and TB expiration dates and kept on site and at Administrative Office. Staff records will be checked semi-annually to ensure that expiration dates are not reached on documentation renewals. Person responsible for implementation - Service Director and Director of Operations.

Standard #: 63.2-1720-F
Description: Based on a review of nine records, the provider did not ensure that any employee who does not have a completed criminal record check is not allowed to work, unless such person works under the direct supervision of another employee for whom a criminal record check has been completed. Evidence 1. The Licensing Inspector observed staff #6 and staff #7 supervising a group of 20 children ages 8 to 10 years old in the gym. 2. The record for staff #6 (date of hire 6/29/15) did not have documentation for a completed criminal record check available for viewing during the inspection. 3. The record for staff #7 (date of hire 6/18/15) did not have documentation for a completed criminal record check available for viewing during the inspection.

Plan of Correction: Staff #7 no longer works for the organization. For remaining staff without completed records, they were given 10 days to turn in completed forms to the Director of Operations. The complete new employee checklist will be enforced for all staff members upon hiring and if proper documentation is not obtained, personnel will not be hired. Service Director and Director of Operations will have to verify employee checklist before staff is allowed to work on site with children. A spreadsheet will be created that contains all staff members? hire dates, documentation renewal dates and TB expiration dates and kept on site and at Administrative Office. Staff records will be checked semi-annually to ensure that expiration dates are not reached on documentation renewals. Person responsible for implementation - Service Director and Director of Operations.

Disclaimer:

A compliance history is in no way a rating for a facility.

The online compliance history includes only information after July 1, 2003. In addition, the online compliance history includes information regarding adverse actions that may be the subject of a pending appeal. An adverse action is not final until a provider has exhausted or waived all due process rights. For compliance history prior to July 1, 2003, or information regarding the status of pending adverse actions, please contact the Licensing Inspector listed in the facility's information. The Virginia Department of Social Services (VDSS) is not responsible for any errors in or omissions from the compliance history information.

Virginia Quality is a voluntary quality rating and improvement system for early care and education facilities serving children ages birth through pre-K. Eligible child care facilities must be fully licensed, licensed exempt and a VDSS subsidy vendor, or a voluntary registered day home and a VDSS subsidy vendor. Only programs enrolled in Virginia Quality will display a rating. Virginia Quality contact information for your region is available at the following link Regional Contacts.

Top

Thank you for visiting.
How was your experience?
X