Inspection · 2023-06-01
Date
2023-06-01
Complaint Related
No
Licensing Inspector
Nanette Roberts
(757) 404-2322
(757) 404-2322
SHSIA monitoring inspection of an approved subsidy vendor to determine compliance with current subsidy requirements regarding the health and safety of children and to promote quality standards for the children in their care.
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 THE LICENSE.
8VAC20-820 THE LICENSING PROCESS.
8VAC20-820 HEARINGS PROCEDURES.
8VAC20-770 Background Checks (8VAC20-770)
20 Access to minor?s records
22.1 Background Checks Code, Carbon Monoxide
63.2 Child Abuse & Neglect
Inspector Notes
A renewal inspection was conducted on 06/01/2023. There were 12 school age children present with 2 staff supervising. The inspector reviewed compliance in the areas of administration, physical plant, staffing and supervision, programming, medication, special care and emergencies and nutrition. A total of 5 child records and 3 staff records were 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 and discussed with staff 1 during the exit interview.
Violations
13Standard 22.1-289.011-F
Based upon observation and staff interview, the facility has not ensured that the most recent inspection of the facility is posted in a conspicuous place on the licensed premises.
Evidence:
1. Documentation of the most recent inspection was not posted.
2. Staff 1 acknowledged that the parent information board with the most recent inspection was not set up.
Evidence:
1. Documentation of the most recent inspection was not posted.
2. Staff 1 acknowledged that the parent information board with the most recent inspection was not set up.
Plan of Correction: The facility responded with the following:
The inspection summary will be posted on the licensing board. Childcare staff on site will be provided with a template to ensure all documents and postings are visible and accessible on site. YD will ensure checks and balances.
The inspection summary will be posted on the licensing board. Childcare staff on site will be provided with a template to ensure all documents and postings are visible and accessible on site. YD will ensure checks and balances.
Standard 8VAC20-780-130-A
Based upon review of children's records, the facility has not ensured that they have obtained documentation that each child has received the required immunizations.
Evidence:
The five children's records reviewed did not include documentation of immunizations.
Evidence:
The five children's records reviewed did not include documentation of immunizations.
Plan of Correction: The facility responded with the following:
Children files will be upload into the YMCA account and review by childcare admin team, PD and Youth Development Director. Files not received prior to care will be contacted prior to their arrival. PD will provide notifications if needed to parents on-site.
Children files will be upload into the YMCA account and review by childcare admin team, PD and Youth Development Director. Files not received prior to care will be contacted prior to their arrival. PD will provide notifications if needed to parents on-site.
Standard 8VAC20-780-140-A
Based upon review of children's records, the facility has not ensured that each child's record includes documentation that the child has had a physical examination by or under the direction of a physician.
Evidence:
None of the five children's records reviewed included documentation of physical examinations.
Evidence:
None of the five children's records reviewed included documentation of physical examinations.
Plan of Correction: The facility responded with the following:
Children files will be upload into the YMCA account and review by childcare admin team, PD and Youth Development Director. Files not received prior to care will be contacted prior to their arrival. PD will provide notifications if needed to parent on-site.
Children files will be upload into the YMCA account and review by childcare admin team, PD and Youth Development Director. Files not received prior to care will be contacted prior to their arrival. PD will provide notifications if needed to parent on-site.
Standard 8VAC20-780-245-L
Based upon review of the records for the two staff on duty during the inspection, the facility has not ensured that there is always at least one staff member on duty who has obtained within the last three years, instruction on performing the daily health observation of children.
Evidence:
Neither of the records for staff 1 and staff 2, on duty during the inspection, included documentation that either staff obtained training in daily health observation of children.
Evidence:
Neither of the records for staff 1 and staff 2, on duty during the inspection, included documentation that either staff obtained training in daily health observation of children.
Plan of Correction: The facility responded with the following:
Daily Health Observation will be required upon hiring. Employees will be removed from floor in the event all training has not been completed. DHO will be completed by current staff within 15 days.
Daily Health Observation will be required upon hiring. Employees will be removed from floor in the event all training has not been completed. DHO will be completed by current staff within 15 days.
Standard 8VAC20-780-280-B
Based upon observation, the facility has not ensured that hazardous substances are kept in locked places using safe locking methods that prevent access by children.
Evidence:
1. There were 2 spray bottles of germicidal agent on a counter by the kitchen and 3 containers of hand sanitizer on the tables throughout the cafeteria area. All containers included warning labels.
Evidence:
1. There were 2 spray bottles of germicidal agent on a counter by the kitchen and 3 containers of hand sanitizer on the tables throughout the cafeteria area. All containers included warning labels.
Plan of Correction: The facility responded with the following:
Hazardous materials will be locked up. PD will work with school facility to remove any materials not used in care.
Hazardous materials will be locked up. PD will work with school facility to remove any materials not used in care.
Standard 8VAC20-780-40-D
Based upon observation and staff interview, the facility has not ensured that the license is posted in a place conspicuous to the public.
Evidence:
1. The facility's license was not posted.
2. Staff 1 acknowledged that the parent board that included the facility license was not set up.
Evidence:
1. The facility's license was not posted.
2. Staff 1 acknowledged that the parent board that included the facility license was not set up.
Plan of Correction: The facility responded with the following:
The inspection summary will be posted on the licensing board. Childcare staff on site will be provided with a template to ensure all documents and postings are visible and accessible on site. YD will ensure checks and balances.
The inspection summary will be posted on the licensing board. Childcare staff on site will be provided with a template to ensure all documents and postings are visible and accessible on site. YD will ensure checks and balances.
Standard 8VAC20-780-540-C
Based upon review of the first aid kit, the facility has not ensured that the first aid kit includes all required supplies.
Evidence:
The first aid kit did not include adhesive tape.
Evidence:
The first aid kit did not include adhesive tape.
Plan of Correction: The facility responded with the following:
First Aid will be inventory every 30 days.
Adhesive tape will be replenish by YD.
First Aid will be inventory every 30 days.
Adhesive tape will be replenish by YD.
Standard 8VAC20-780-550-D
Based upon review of records and staff interview, the facility has not ensured that monthly practice evacuation drills are implemented.
Evidence:
1. There were no evacuation drills documented for March, April and May of 2023.
2. Staff 1 acknowledged that no drills were conducted in the listed months.
Evidence:
1. There were no evacuation drills documented for March, April and May of 2023.
2. Staff 1 acknowledged that no drills were conducted in the listed months.
Plan of Correction: The facility responded with the following:
YD will ensure drills are conducted within a timely manor using checklist and calendar. PD will conduct drills with team and children in care. Drill log will be accessible and view on licensing board.
YD will ensure drills are conducted within a timely manor using checklist and calendar. PD will conduct drills with team and children in care. Drill log will be accessible and view on licensing board.
Standard 8VAC20-780-550-E
Based upon review of records and staff interview, the facility has not ensured that shelter-in-place drills are practiced twice per year.
Evidence:
1. There were no shelter-in-place drills documented for the past year.
2. Staff 1 acknowledged that there was no record of shelter-in-place drills during the past year.
Evidence:
1. There were no shelter-in-place drills documented for the past year.
2. Staff 1 acknowledged that there was no record of shelter-in-place drills during the past year.
Plan of Correction: The facility responded with the following:
YD will ensure drills are conducted within a timely manner using checklist and calendar. PD will conduct drills with team and children in care. Drill log will accessible and view on licensing board.
YD will ensure drills are conducted within a timely manner using checklist and calendar. PD will conduct drills with team and children in care. Drill log will accessible and view on licensing board.
Standard 8VAC20-780-550-F
Based upon review of records and staff interview, the facility has not ensured that lockdown drills are practiced at least annually.
Evidence:
1. There was no lockdown drill documented during the past year.
2. Staff 1 acknowledged that there was no lockdown drill documented in the past year.
Evidence:
1. There was no lockdown drill documented during the past year.
2. Staff 1 acknowledged that there was no lockdown drill documented in the past year.
Plan of Correction: The facility responded with the following:
YD will ensure drills are conducted within a timely manner using checklist and calendar. PD will conduct drills with team and children in care. Drill log will accessible and view on licensing board.
YD will ensure drills are conducted within a timely manner using checklist and calendar. PD will conduct drills with team and children in care. Drill log will accessible and view on licensing board.
Standard 8VAC20-780-560-F
Based upon observation and staff interview, the facility has not ensured that there is a menu posted for the current week.
Evidence:
1. There was no menu posted.
2. Staff 1 acknowledged that they did not have a menu for the current week, thus it was no posted.
Evidence:
1. There was no menu posted.
2. Staff 1 acknowledged that they did not have a menu for the current week, thus it was no posted.
Plan of Correction: The facility responded with the following:
Program Director will communicate with Cafeteria manager to ensure menu is provided.
Program Director will communicate with Cafeteria manager to ensure menu is provided.
Standard 8VAC20-780-60-A
Based upon review of children's records, the facility has not ensured that the record for each enrolled child contains the required information.
Evidence:
1. The records for child 2, child 3, child 4 and child 5 do not include the names, addresses and telephone numbers for two persons to be contacted in an emergency when the parents cannot be reached.
2. The record for child 5 does not include the required parent agreements.
Evidence:
1. The records for child 2, child 3, child 4 and child 5 do not include the names, addresses and telephone numbers for two persons to be contacted in an emergency when the parents cannot be reached.
2. The record for child 5 does not include the required parent agreements.
Plan of Correction: The facility responded with the following:
Children's information will be uploaded into YMCA account upon registration. Child information will be reviewed by childcare admin team and YD.
Children's information will be uploaded into YMCA account upon registration. Child information will be reviewed by childcare admin team and YD.
Standard 8VAC20-780-70
Based upon review of records, the facility has not ensured that staff records include documentation of how the staff person meets the requirement of the position.
Evidence:
The documentation of program director qualifications for staff 1 does not substantiate program director qualifications in that the transcripts did not include the required semester hours nor was there documentation of a management course or management training.
Evidence:
The documentation of program director qualifications for staff 1 does not substantiate program director qualifications in that the transcripts did not include the required semester hours nor was there documentation of a management course or management training.
Plan of Correction: The facility responded with the following:
Program Director qualifications will be printed and easily accessible upon review of staff files.
Program Director qualifications will be printed and easily accessible upon review of staff files.