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Young Men's Christian Association of the Virginia Peninsulas

Inspection · 2024-09-05

Date
2024-09-05
Complaint Related
No
Licensing Inspector
Heather Dapper
(804) 625-2304
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.
8VAC20-770 Background Checks (8VAC20-770)
22.1 Background Checks Code, Carbon Monoxide
63.2 Child Abuse & Neglect

Inspector Notes

An unannounced, on-site renewal inspection was initiated on September 5, 2024 and completed on September 10, 2024, as a part of the provisional licensure period. The on-site inspection began at 3:45 PM and ended at 5:20 PM. The inspector reviewed compliance in the areas listed above. There were 14 children present and two staff. The inspector reviewed five children?s records on site and three staff records electronically on September 10, 2024. This inspection included document review, tour of the facility, interviews, and observations.

Information gathered during the inspection determined non-compliance with applicable standards or law, and violations are documented on the violation notice issued to the program.

Please complete the plan of correction (POC) and date to be corrected sections for each violation cited on the violation notice. Specify how the deficient practice will be or has been corrected. Submit your POC within five (5) business days from today, which will be the close of business on October 8, 2024. A POC submitted after this date will not appear on the public website.

The inspection report was amended on 11/12/2024 and 11/25/2024.

Violations

9
Standard 22.1-289.011-F
Repeat Violation, Systemic Deficiency
Based on observation and interviews, it was determined that the facility did not ensure the last inspection report and any other documents required by the Superintendent shall be posted in a conspicuous place on the licensed premises.

Evidence:
The most recent inspection summary (8/20/2024) was not posted.
Plan of Correction: Last inspection report will be kept onsite and posted
Standard 8VAC20-780-130-A
Repeat Violation, Systemic Deficiency
Based on a review of children's records and interview, the center did not ensure that each child's record contained documentation of immunizations required by the State Board of Health before the child can attend the center.

Evidence:
1. The records for child #1, child #2, child #3, child #4, and child #5 did not have documentation of immunizations.
2. Staff #1 stated that the immunizations records for child #1, child #2, child #3, child #4, and child #5 were not at the center. During the inspection, staff #2 stated that the iPad was not working.
Plan of Correction: Student files will be kept on site.
Standard 8VAC20-780-160-A
Based on review of records and interview, the center did not ensure that each staff member shall submit documentation of a negative tuberculosis screening (TB) at the time of employment. The documentation shall have been completed within the last 30 calendar days of the date of employment and be signed by a physician, physician's designee, or an official of the local health department.

Evidence:
The record for staff #3 (employed 6/10/24) had documentation of a TB screening on 4/20/24.
Plan of Correction: Employees will obtain within 30 days of start date
Standard 8VAC20-780-190-A
Based on review of staff records and interview, the center did not ensure the assigned program director met program director qualifications.

Evidence:
The record of staff #2, identified as the center?s program director, contained documentation of completing 22 semester hours of the required 48 hours of college credit from a college or university. Staff #2 stated she did not have the required 48 semester hours of college credit.
Plan of Correction: Copies of qualification will be added to file
Standard 8VAC20-780-540-C
Repeat Violation, Systemic Violation
Based on observation and interview, the first aid kit did not contain the minimum required supplies.
Evidence:
The first aid kit did not contain first aid manual or tweezers.
Plan of Correction: Tweezers were added to the first aid kit
Standard 8VAC20-780-550-B
Based on record review, it was determined the center did not ensure that the emergency preparedness plan was reviewed and updated, if applicable, annually.

Evidence:
1. The emergency preparedness plan did not have documentation of an update.
2. The emergency preparedness plan did not have the correct Program Director name, telephone contact number, or facility address.
Plan of Correction: We will update emergency preparedness plan
Standard 8VAC20-780-550-D
Based on record review, the center did not ensure a monthly practice of evacuation drill was implemented.

Evidence:
There was not any documentation that emergency evacuation drills were practiced during the months of February or March 2024.
Plan of Correction: The center will implement monthly drills.
Standard 8VAC20-780-60-A
Repeat Violation, Systemic Deficiency
Based on a review of children's records and interview, the center did not ensure that each record contains all required information.

Evidence: 1. The record for child #4 did not have one of the two designated people to call in an emergency. 2. The record for child #5 did not have two of the two designated people to call in an emergency.
Plan of Correction: All records will have at least two emergency contacts
Standard 8VAC20-780-90-A
Repeat Violation, Systemic Deficiency
Based on a review of children's record, the center did not obtain a written agreement between the parent and the center by the first day of the child's attendance that was signed by the parent.

Evidence:
1. The records for child #1, child #2, child #3, child #4, and child $5 did not have documentation of written parental agreements.
Plan of Correction: Student files will be kept on site
View original record on Virginia Department of Social Services