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Danville Family YMCA
215 Riverside Drive
Danville, VA 24540
(434) 792-0621

Current Inspector: Rebecca Forestier (540) 309-2835

Inspection Date: May 31, 2016

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.
22VAC40-80 THE LICENSE.
22VAC40-191 Background Checks (22VAC40-191)

Comments:
An unannounced non mandated monitoring inspection was conducted 5/31/2016 . There were 20 children in care with three staff present. The inspector and licensing administrator arrived at 2:40 P.M. and departed the program at 5:10 P.M. Observed the children during: free play, snack time, gym time and movie time. Discussion with the site director: maintaining records, medication requirements and review all medications authorizations for dates, DHO training requirements, director attending Phase 2 in the licensing office, and provisional license process.

Violations:
Standard #: 22VAC40-185-140-A
Description: Based on review of eight children's records, the center failed to ensure that all physical examination were obtained within 30 days of enrollment. Evidence: 1. The inspector found that child # 6 did not have a physical examination in the record. The start date for child # 6 was 8/10/2015.

Plan of Correction: Per the director: All children have now had a physical. No child will be allowed in the program without a physical.

Standard #: 22VAC40-185-140-B
Description: Based on review of eight children's records, the center failed to ensure that a physical exam was with in the time period required. Evidence: 1. The inspector found that child # 1 started the program on 5/23/2016 and the physical exam was conducted 4/20/2015. The child's DOB is 12/26/2011. The requirement for this age is for the physical exam to be conducted within 12 months of entrance into a program.

Plan of Correction: Per the director: Child will have a new physical before returning to childcare.

Standard #: 22VAC40-185-160-A
Description: Based on four review of staff's records, the center failed to ensure that the TB screenings were obtained within 21 days of hire or completed within 12 months prior to hire. Evidence: 1. The inspector found that staff # 2 was hired on 1/7/2016 and the TB screening was completed on 6/20/2014.

Plan of Correction: Per the director: New TB test has been done. All TB test screenings will be done within 21 days of hire.

Standard #: 22VAC40-185-40-E
Description: Based on review of records and observation, the center failed to ensure that all terms of the license were met. Evidence: 1. The licensee failed to ensure compliance with standards that are required to maintain a license

Plan of Correction: A plan of correction was not received for this violation from the director.

Standard #: 22VAC40-185-60-A
Description: Based on review of three children's records, the center failed to ensure that all records were complete. Evidence: 1. The inspector found that children # 2 and 8 had one of the two required emergency contacts with complete addresses.

Plan of Correction: Per the director: no child will be allowed to enter the child care without all information filled out. Child # 2, and 8 has been fixed.

Standard #: 22VAC40-185-70-A
Description: Based on review of four staff's records, the center failed to ensure that all records were complete. Evidence: 1. The inspector found that staff's # 3 and 4 did not have the required references. Staff # 3 had one of the two required references with the start date of 4/2015. Staff # 4 did not have the two required references wtih the start date of 2/8/2016.

Plan of Correction: Per the director: the references will be done for all staff prior to hiring going forward. Staff # 3 and 4 will have references by 6/15/2016.

Standard #: 22VAC40-185-240-B
Description: Based on review and interviews with staff, the center failed to ensure that staff received in all policies and procedures in writing. Evidence: 1. The inspector found that the following policies were missing from the staff handbook: procedure for supervising a child arrives after a scheduled class or activity, procedure to confirm absence of a child when the child is scheduled to arrive from another program, procedures for identifying where attending children are at all time, and procedures for ensure that all children are accounted before leaving for a field trip.

Plan of Correction: Per the director: handbooks will be rewritten and sent to the LI for approval.

Standard #: 22VAC40-185-510-A
Description: Based on review of authorizations, the center failed to ensure that all medications had an authorization. Evidence: 1. Child #4 did not have authorization for the medication. Child # 4 started the program 5/23/2016. 2. Child # 5 epi pen expired 10/2015.

Plan of Correction: Per the director: MAT form is now completed. The medication that was expired was replaced with a updated epipen.

Standard #: 22VAC40-185-510-E
Description: Based on review of medications, the center failed to ensure that all medications had a prescription label. Evidence: 1. Child #4's medication did not have a prescription label, or labeled with the child's name, dosage amount and times to be given. Child # 4 started the program 5/23/2016.

Plan of Correction: Per the director: new epipen with labels are at the center. All medications must be labeled properly before entering program.

Standard #: 22VAC40-185-510-N
Description: Based on observation and review of authorizations, the center failed to ensure that all parents were notified that the medication needs to be picked up within 14 days. Evidence: 1. The inspector found that child # 8 had medications and the child is no longer in care as of 5/10/2016.

Plan of Correction: Per the director: no medication will stay with the center after a child leaves. All children with medication will be called and take the medication with them upon leaving the center.

Standard #: 22VAC40-185-550-C
Description: Based on observation the procedures/maps, the center failed to ensure that all items and procedures required were on the map. Evidence: 1. The inspector found that the evacuation map did not have the shelter in place and the procedures to follow during an evacuation.

Plan of Correction: Per the director: a new map will be done.

Standard #: 22VAC40-185-550-D
Description: Based on review of the evacuation log and interviews with the site director, a monthly fire drill has not occurred. Evidence: 1. The inspector found that a drill has not completed for April 2016.

Plan of Correction: Per the director: Drill has been done for may and will continue each month going forward.

Standard #: 22VAC40-185-550-H
Description: Based on interviews with the site director and review of the documents, the center failed to ensure that a document containing emergency information was maintained on the vehicles. Evidence: 1. The inspector found that the route to the hospital was not with the documents on the bus.

Plan of Correction: Per the director: Hospital Routes have been placed on the buses and corrected.

Standard #: 22VAC40-191-60-B
Description: Based on review of four staff's records, the center failed to ensure that all sworn disclosures were completed by the staff prior to starting their position. Evidence: 1. The inspector found that staff # 4 completed the sworn disclosure on 3/14/2016 and the documented start date was 2/8/2016.

Plan of Correction: Per the director: Sworn Disclosure will be signed on the day of hire for all new employee's.

Standard #: 22VAC40-191-60-C-1
Description: Based on review of four staff's records, the center failed to ensure that all background checks were completed within the 30 days of hire. Evidence: 1. Staff #4 documented start date was 2/8/2016 and the CRC was returned on 4/28/2016.

Plan of Correction: Per the director: all CRC going forward will be completed within 30 days of hire.

Standard #: 22VAC40-191-60-C-2
Description: Based on review of four staff's records, the center failed to ensure that all background checks were completed within the 30 days of hire. Evidence: 1. Staff #4 documented start date was 2/8/2016 and the CPS was returned on 4/6/2016.

Plan of Correction: Per the director: all CPS will be complete with in 30 days.

Standard #: 22VAC40-80-120-E-2
Description: Based on observations, the center failed to ensure that the most recent findings of the most recent inspection was posted. Evidence: 1. The inspector found that the findings from the most recent inspection was not posted. The findings that was posted was from 3/31/2015.

Plan of Correction: Per the director: most recent inspection will be posted at all times.

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.

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