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Caroline Family YMCA
17422 Library Boulevard
Ruther glen, VA 22546
(804) 448-9622

Current Inspector: Jaime Harris (804) 807-3278

Inspection Date: May 15, 2024

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.
8VAC20-820 THE LICENSE.
8VAC20-820 THE LICENSING PROCESS.
8VAC20-820 HEARINGS PROCEDURES.
8VAC20-770 Background Checks
20 Access to minor?s records
22.1 Early Childhood Care and Education
63.2 Child Abuse & Neglect

Technical Assistance:
Effective January 1, 2025, the VDOE will begin determining compliance with ? 22.1-289.057 of the Code of Virginia, which is legislation passed by the General Assembly in 2020. The law requires all licensed child day programs, religious exempt child day centers that serve preschool age children, and certified preschools to test potable drinking water. The law requires that programs submit their plans and test results to the Virginia Department of Health Office of Drinking Water (VDH ODW) and the Superintendent. If the results of the testing indicate elevated lead levels, the program shall remediate, retest, and resubmit results to VDH ODW and the Superintendent. There is an additional alternative bottled water option that comes with additional requirements. The statutory requirement can be found online at https://law.lis.virginia.gov/vacode/title22.1/chapter14.1/section22.1-289.057/.

Resources are now available for providers on the "What's New" webpage on the ChildCareVA website at https://www.childcare.virginia.gov/providers/what-s-new.

Comments:
An unannounced monitoring inspection was initiated on Wednesday, May 15, 2024 and concluded on May 16, 2024. On May 15, the inspector was on site from10:25am to approximately 12:50pm. There were a total of eight children in care in the direct care of two staff members. During the inspection, the children and staff were observed participating in a variety of activities. Staff were observed having positive interactions with the children. All areas of the facility used by the children were inspected. The center is equipped with toys and supplies and items were available to the children. The required postings were reviewed and found to be in compliance. Medication is administered, but there are no medications on-site at this time. During the inspection, five children's records and two staff records were reviewed. Additional documentation was reviewed virtually on May 16, 2024.

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

Violations:
Standard #: 22.1-289.035-B-2
Description: (Repeat Violation) Based on a review of two staff records and interviews, the center did not ensure one staff had the satisfactory results of the fingerprint-based national criminal background check prior to employment.

Evidence: The record of Staff #2, employed on 04/10/24, did not contain the results of the fingerprint-based national criminal background check.

During interview, a member of management reported the background check for Staff #2 was requested, but the results could not be located.

Plan of Correction: The information will be obtained. In the future, the center will complete all required background checks within the required timeframes.

Standard #: 8VAC20-770-40-D-6
Description: Based on a review of two staff records and interviews, the center did not ensure a required central registry finding for one staff member required to obtain background checks that was dated more than 90 days prior to the date of employment was not accepted.

Evidence: The central registry finding in the record of Staff #2, employed on 04/10/24, was completed on 04/10/22.

During interview, a member of management stated the central registry finding for Staff #2 was obtained for a position outside of the licensed center and a new one was not obtained within 30 days of Staff #2's employment with the licensed center.

Plan of Correction: The information will be obtained. In the future, the center will complete all required background checks within the required timeframes.

Standard #: 8VAC20-770-60-B
Description: (Repeat Violation) Based on a review of two staff records and interviews, the center did not ensure one staff had a completed sworn statement or affirmation prior to employment.

Evidence: The record of Staff #2, employed on 04/10/24, did not contain a completed sworn statement.

During interview, a member of management confirmed a sworn statement could not be located for Staff #2.

Plan of Correction: The information will be obtained. In the future, the center will complete all required background checks within the required timeframes.

Standard #: 8VAC20-780-160-A
Description: (Repeat Violation) Based on a review of two staff records and interviews, the center did not ensure one staff member submitted documentation of a negative tuberculosis (TB) screening within the required timeframe.

Evidence: The most recent tuberculosis (TB) screening in the record of Staff #2, employed on 04/10/24, was dated 03/09/22 and expired on 03/09/24.

During interview, a member of management confirmed the center does not have a current negative TB screening on file for Staff #2.

Documentation of the screening shall be submitted at the time of employment and prior to coming into contact with children; and 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.

Plan of Correction: A current negative TB screening will be obtained.

Standard #: 8VAC20-780-60-A
Description: Based on a review of five children's records and interview, the center did not ensure one child's record contained the required information.

Evidence: The record of Child #4, enrolled on 02/05/24, did not contain a second emergency contact. During interview, a member of management confirmed the center did not have two complete emergency contacts on file for Child #4.

Each child record shall contain the name, address, and phone number of two designated
people to call in an emergency if a parent cannot be reached.

Plan of Correction: The missing emergency contact was obtained. In the future, staff reviewing submitted paperwork will ensure all emergency contacts contain the required information.

Standard #: 8VAC20-780-70
Description: (Repeat Violation) Based on a review of two staff records and interviews, the center did not ensure one staff record contained the required information.

Evidence: The record of Staff #2, employed on 04/10/24, was missing a second reference.

During interview, a member of management reported a second reference could not be located for Staff #2.

Each staff record should contain documentation that two or more references as to character and reputation as well as competency were checked before employment or volunteering.

Plan of Correction: The information will be obtained. In the future, the center obtain references prior to employment.

Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.


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