VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Effingham Street Family YMCA
1013 Effingham Street
Portsmouth, VA 23704
(757) 399-5511

Current Inspector: D'Nae Goodwin (757) 404-3063

Inspection Date: July 20, 2022

Complaint Related: 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. 8VAC20-770 Background Checks (8VAC20-770) 20 Access to minor?s records 22.1 Background Checks Code, Carbon Monoxide 63.2 Child Abuse & Neglect

Technical Assistance:

Technical assistance was provided in the following areas of the standards: Background checks, play areas, children's records, staff records, physical examinations, Program Leader qualifications, hand washing, nutrition, and carbon monoxide detectors.

Comments:

An unannounced monitoring inspection was conducted on 7/20/22 from 10:30am - 1:00pm. During the inspection there were 84 children ages five years old through twelve years old in care with 11 staff. Children were observed participating in various activities in the classrooms, playing outside, swimming, and eating lunch. Records were reviewed for ten children and eleven staff during the inspection. Medication, emergency procedures and emergency supplies were reviewed during the inspection. Information gathered during the inspection determined noncompliance with applicable standards or law and violations were documented on the violation notice issued to the program, and were discussed during the exit interview.

Violations:

Standard #:	8VAC20-770-60-C-2
Description:	Based on a review of eleven 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 #1 (date of hire 6/10/22) did not contain documentation of a completed search of the central registry finding. 2. The record for staff #2 (date of hire 6/7/22) did not contain documentation of a completed search of the central registry finding. 3. The record for staff #4 (date of hire 5/17/22) did not contain documentation of a completed search of the central registry finding. 4. The record for staff #5 (date of hire 6/14/22) did not contain documentation of a completed search of the central registry finding. 5. The record for staff #6 (date of hire 6/10/22) did not contain documentation of a completed search of the central registry finding. 6. The record for staff #7 (date of hire 6/10/22) did not contain documentation of a completed search of the central registry finding. 7. The record for staff #8 (date of hire 6/15/22) did not contain documentation of a completed search of the central registry finding. 8. The record for staff #9 (date of hire 6/13/22) did not contain documentation of a completed search of the central registry finding. 9. The record for staff #10 (date of hire 6/10/22) did not contain documentation of a completed search of the central registry finding. 10. Staff #p11 (Program Director) reviewed the records for the staff listed above, and confirmed that the search of the central registry finding has not been received.
Plan of Correction:	The facility responded: All staff have requested a search of the central registry, but we will check the status and forward to the Licensing Inspector when complete.
Standard #:	8VAC20-780-140-A
Description:	Based on a review of ten children's records, it was determined that the facility did not ensure that each child in attendance had a completed physical within one month of attendance. Evidence: 1. The record for child #2 did not contain a physical examination. 2. The record for child #7 did not contain a physical examination. 3. Staff #11 (Program Director) confirmed that the record for child #2 and child #7 did not contain a physical examination, and had been enrolled for more than 30 days.
Plan of Correction:	The facility responded: The parents of each child will be asked to provide the missing physical examination.
Standard #:	8VAC20-780-160-A
Description:	Based on a review of eleven staff records, it was determined that the facility did not ensure that each staff member shall submit documentation of a negative tuberculosis screening prior to employment beginning.. Evidence: 1. The record for child #2 did not contain a physical examination. 2. The record for child #7 did not contain a physical examination. 3. Staff #11 (Program Director) confirmed that the record for child #2 and child #7 did not contain a physical examination, and had been enrolled for more than 30 days.
Plan of Correction:	The facility responded: Staff will be sent to complete a TB screening. All new staff will complete a TB screening prior to employment.
Standard #:	8VAC20-780-60-A
Description:	Based on a review of ten children's records and interview, 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. The record for child #3 did not contain documentation that the proof of identity was verified. 2. The record for child #5 did not contain a complete address for the emergency contacts. 3. Staff #11 (Program Director) confirmed that the records for child #3 and child #5 did not contain all of the required information.
Plan of Correction:	The facility responded: The parents of each child will be asked to provide the missing information
Standard #:	8VAC20-780-290-A-3
Description:	Based on observation and interview, it was determined that the facility did not ensure that electrical outlets shall have protective covers that are of a size that cannot be swallowed by children. Evidence: 1. There were uncovered electrical outlets throughout the entire facility. 2. Staff #11 (Program Director) confirmed that the electrical outlets did not have protective covers.
Plan of Correction:	The facility responded: We will cover all electrical outlets with protective coverings.
Standard #:	8VAC20-780-340-D
Description:	Based on observation, a review of five staff records and interviews, it was determined that the licensee 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 #3, staff #5, and staff #8 were working with a group of School Age children outside. The records for all three staff did not contain documentation to demonstrate that any of the staff were Program Leader qualified. 2. Staff #11 (Program Director) reviewed the records for the staff listed above, and confirmed that was documentation available for viewing during the inspection that any of the staff were Program Leader qualified.
Plan of Correction:	The facility responded: All staff will not work alone with the children unless they have completed the required training to meet Program Leader qualifications.
Standard #:	8VAC20-780-530-A
Description:	Based on a review of eleven staff records and interviews, it was determined that the facility did not ensure that there shall be at least one staff in each classroom or area where children are present that has a current certification in cardiopulmonary resuscitation (CPR) and first aid as appropriate to the age of the children in care. Evidence: 1. Neither of the staff working with the grouping of nine and ten year old children had a current certification in cardiopulmonary resuscitation (CPR) and first aid as appropriate to the age of the children in care. 2. Neither of the staff working with the grouping of ten to twelve year old children (tweens) had a current certification in cardiopulmonary resuscitation (CPR) and first aid as appropriate to the age of the children in care. 3. Staff #11 (Program Director) confirmed that staff in each of these groups did not have a current certification in cardiopulmonary resuscitation (CPR) and first aid as appropriate to the age of the children in care.
Plan of Correction:	The facility responded: We will ensure that at least one staff in each grouping of children has a current certification in cardiopulmonary resuscitation (CPR) and first aid as appropriate to the age of the children in care.