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The YMCA of South Hampton Roads - Western Branch Primary School

Inspection · 2022-02-11

Date
2022-02-11
Complaint Related
No
Licensing Inspector
Trisha Brown
(757) 404-2601
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.
8VAC20-790 SUBSIDY REGULATIONS.
8VAC20-770 Background Checks (22VAC40-191)
22.1 Early Childhood Care and Education

Inspector Notes

This inspection was conducted by licensing staff using an alternate remote protocol, including telephone contacts, documents review, and a virtual tour of the program.
The in-charge person was contacted by video call to conduct the inspection. There were 36 children present and two staff. The inspector emailed the provider a list of items required to complete the inspection. The Inspector reviewed four children?s records and two staff records, along with any requested program records submitted by the facility to determine if required documentation was complete.
Information gathered during the inspection determined non-compliance(s) with applicable standards or law and violations were documented on the violation notice issued to the program.

Violations

5
Standard 8VAC20-770-60-B
Based on review of two staff records, it was determined that the facility did not ensure that all staff members had a completed search of the central registry on file within 30 days of employment.

Evidence:
Staff #1 (9/21/21) and staff #2 (10/1/19), both of whom were on duty at the time of the inspection, neither had a completed search of the central registry on file.
Plan of Correction: Facility will ensure that all background checks are completed in a timely manner and checked on as required.
Standard 8VAC20-780-160-A-1
Based on review of two staff records, it was determined that the facility did not ensure that all staff had a tuberculosis (Tb) screening prior to coming in contact with the children.

Evidence:
Staff #2, who was on duty at the time of the inspection, had a hire date of 10/1/19. However, her Tb screening was dated 1/21/22.
Plan of Correction: Facility will ensure that all staff obtain and provide a Tb screening prior to coming into contact with the children.
Standard 8VAC20-780-350-B
Based on review of center documents, it was determined that the facility did not ensure that all staff to child ratios were maintained,

Evidence:
On the Preliminary Request for Information, the facility stated and attendance sheets verified, that there were 42 children in care with only two staff. An additional staff member would have been needed.
Plan of Correction: Facility management will ensure that there are always adequate staff on site.
Standard 8VAC20-780-550-G
Based on review of the emergency evacuation, shelter-in-place and lockdown drills log submitted by the facility, it was determined that the facility did not ensure that drills were practiced as required and that all information regarding the drills was documneted.

Evidence:
1. There was no indication that emergency evacuation drills were practiced in either November or December of 2021.
2. The log indicates that a lockdown drill was held on December 9, 2021. However, it was missing the name of the person conducting the drill, the time of the drill, notification method, number of participating staff, number of participating children, special conditions, problems encountered and weather
Plan of Correction: Facility will ensure that going forward all drills will be conducted in a timely manner and that all required information is clearly documented.
Standard 8VAC20-780-60-A
Based on review of four children's records, it was determined that the facility did not ensure that each child had a record available on site.

Evidence:
The record for child #4 was at the central office for the organization as a meeting was being held with the parent.
Plan of Correction: Facility will ensure that all children's records are maintained at the site.
View original record on Virginia Department of Social Services