Caroline Family YMCA

8VAC20-790-600-F

“Based on a review of two staff records and interview, the vendor did not ensure one staff member who works directly with children completed the department's health and safety update course annually. Evidence: The record of Staff #2, employed on 01/04/2023, did not contain the department's health and safety update course for 2023. During interview, a member of management confirmed Staff #2 has not completed the updated training to date.”

22.1-289.035-B-4

“Based on a review of two staff records and interview, the center did not obtain the required out-of-state background checks from any state in which one staff member had resided in the preceding five years within the required timeframe. Evidence: The record of Staff #1, employed on 02/01/23, indicated the staff had resided in another state outside of Virginia within the last five years. The record did not contain a copy of the results of a criminal history record information check or a sex offender registry check. The child abuse and neglect registry search was requested on 05/08/23, but the results were not in the record. During interview, a member of management confirmed the out-of-state background checks for Staff #1 were not obtained within the required timeframe. The out-of-state criminal history record information check and the sex offender registry check are required to be obtained prior to employment. The out-of-state search for founded complaints of child abuse or neglect is required to be requested within the first 30 days of employment.”

8VAC20-780-245-A

“Based on a review of two staff records and interview, the center did not ensure one staff completed annually a minimum of 16 hours of training appropriate to the age of children in care. Evidence: Staff #2, employed on 01/04/23, completed four hours of annual training from 01/05/2023-01/04/2024. During interview, a member of management confirmed Staff #2 had not completed a minimum of 16 hours of training annually.”

8VAC20-780-70

“Based on a review of two staff records, the center did not ensure two staff records contained the required information. Evidence: 1) The references in the record of Staff #1, employed on 01/04/23, were obtained on 03/03/23 and on 02/21/23. 2) The references in the record of Staff #2, employed on 02/01/23, were obtained on 02/20/23. 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.”

8VAC20-780-160-A

“Based on a review of two staff records and interview, the center did not ensure two staff members submitted documentation of a negative tuberculosis screening within the required timeframe. Evidence: 1) The most recent tuberculosis (TB) screening in the record of Staff #1, employed on 01/04/23, was dated 03/06/23. The staff had a prior TB screening that expired on 10/18/21. 2) The most recent TB screening in the record of Staff #2, employed on 02/01/23, was dated 05/03/22. 3) During interview, a member of management confirmed Staff #1 and Staff #2 did not submit documentation of a negative tuberculosis screening within the required timeframe. 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.”

8VAC20-780-560-G

“Based on observation and interview, the center did not meet the requirements when food is brought from home. Evidence: 1) The lunch boxes observed at the center on 03/30/23 were not clearly dated. There were three children present during the inspection. 2) During interview, staff and management confirmed not all lunch boxes were dated. When food is brought from home, the food container shall be sealed and clearly dated and labeled in a way that identifies the owner.”

8VAC20-770-60-B

“Based on a review of two staff records, the center did not ensure two staff had a completed sworn statement or affirmation prior to employment. Evidence: 1) The sworn statement in the record of Staff #1, employed on 01/04/23, was completed on 09/24/19. 2) During interview, a member of management stated the sworn statement was completed for a position outside of the licensed center and a new one was not obtained. A sworn statement is required to be obtained no more than 90 days prior to employment. 3) The record of Staff #2, employed on 02/01/23, did not contain a completed sworn statement. 4) During interview, a member of management confirmed a sworn statement could not be located for Staff #2.”

22.1-289.035-B-2

“Based on a review of two staff records and interview, the center did not ensure two staff had the satisfactory results of the fingerprint-based national criminal background check prior to employment. Evidence: 1) The fingerprint-based national criminal background check in the record of Staff #1, employed on 01/04/23, was dated 02/27/23. 2) The record of Staff #2, employed on 02/01/23, did not contain the results of the fingerprint-based national criminal background check. 3) During interview, a member of management confirmed the fingerprint results for Staff #1 were obtained after employment and the fingerprint results for Staff #2 have not been received to date.”

8VAC20-770-60-C-2

“Based on a review of two staff records and interview, the center did not ensure two staff members had a central registry finding within 30 days of employment. Evidence: 1) The record of Staff #1, employed on 01/04/23, did not have a central registry finding. 2) The central registry finding in the record of Staff #2, employed on 02/01/23, was dated 03/20/23. 3) During interview, a member of management confirmed the results of the central registry have not been received for Staff #1 and the results of the central registry for Staff #2 were received more than 30 days after employment. The record did not contain documentation of any further contact with the Office of Background Investigations, and the staff member had been continuously employed.”

8VAC20-780-70

“Based on a review of two staff records, the center did not ensure two staff records contained the required information. Evidence: 1) The references in the record of Staff #1, employed on 01/04/23, were obtained on 03/03/23 and on 02/21/23. 2) The references in the record of Staff #2, employed on 02/01/23, were obtained on 02/20/23. 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.”

8VAC20-780-160-A

“Based on a review of two staff records and interview, the center did not ensure two staff members submitted documentation of a negative tuberculosis screening within the required timeframe. Evidence: 1) The most recent tuberculosis (TB) screening in the record of Staff #1, employed on 01/04/23, was dated 03/06/23. The staff had a prior TB screening that expired on 10/18/21. 2) The most recent TB screening in the record of Staff #2, employed on 02/01/23, was dated 05/03/22. 3) During interview, a member of management confirmed Staff #1 and Staff #2 did not submit documentation of a negative tuberculosis screening within the required timeframe. 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.”

8VAC20-780-560-G

“Based on observation and interview, the center did not meet the requirements when food is brought from home. Evidence: 1) The lunch boxes observed at the center on 03/30/23 were not clearly dated. There were three children present during the inspection. 2) During interview, staff and management confirmed not all lunch boxes were dated. When food is brought from home, the food container shall be sealed and clearly dated and labeled in a way that identifies the owner.”

8VAC20-770-60-B

“Based on a review of two staff records, the center did not ensure two staff had a completed sworn statement or affirmation prior to employment. Evidence: 1) The sworn statement in the record of Staff #1, employed on 01/04/23, was completed on 09/24/19. 2) During interview, a member of management stated the sworn statement was completed for a position outside of the licensed center and a new one was not obtained. A sworn statement is required to be obtained no more than 90 days prior to employment. 3) The record of Staff #2, employed on 02/01/23, did not contain a completed sworn statement. 4) During interview, a member of management confirmed a sworn statement could not be located for Staff #2.”

22.1-289.035-B-2

“Based on a review of two staff records and interview, the center did not ensure two staff had the satisfactory results of the fingerprint-based national criminal background check prior to employment. Evidence: 1) The fingerprint-based national criminal background check in the record of Staff #1, employed on 01/04/23, was dated 02/27/23. 2) The record of Staff #2, employed on 02/01/23, did not contain the results of the fingerprint-based national criminal background check. 3) During interview, a member of management confirmed the fingerprint results for Staff #1 were obtained after employment and the fingerprint results for Staff #2 have not been received to date.”

8VAC20-770-60-C-2

“Based on a review of two staff records and interview, the center did not ensure two staff members had a central registry finding within 30 days of employment. Evidence: 1) The record of Staff #1, employed on 01/04/23, did not have a central registry finding. 2) The central registry finding in the record of Staff #2, employed on 02/01/23, was dated 03/20/23. 3) During interview, a member of management confirmed the results of the central registry have not been received for Staff #1 and the results of the central registry for Staff #2 were received more than 30 days after employment. The record did not contain documentation of any further contact with the Office of Background Investigations, and the staff member had been continuously employed.”

8VAC20-780-270-A

“Based on observation and interview, the center did not ensure areas and equipment of the center, inside and outside, were maintained in a clean, safe and operable condition. Evidence: 1) During the inspection of the playground equipment on 10/14/22, the inspector observed a crack at the bottom of one of the slides. The crack created a pinching hazard, could entangle clothing or snag skin. 2) During interview, management reported the children use this slide.”

8VAC20-780-560-G

“Based on observation and interview, the center did not meet the requirements when food is brought from home. Evidence: 1) The lunch boxes observed at the center on 10/14/2022 were not clearly dated or labeled in a way that identified the owner. There were 19 children present during the inspection. 2) During interview, staff and management confirmed not all lunch boxes are dated or labeled to identify the owner.”

8VAC20-780-540-C

“Based on an inspection of the first aid kit and interview, the center did not ensure all required items were supplied in the kit. Evidence: 1) The first aid kit did not contain at least two triangular bandages. 2) During interview, management reported the center did not have triangular bandages on site.”

8VAC20-780-280-B

“Based on observation and interview, the center did not maintain hazardous substances such as cleaning materials in a locked placed using a safe locking method that prevents access by children. Evidence: 1) During the inspection of the vehicles used for transportation, the inspector observed a bucket with various bottles of cleaning supplies that were accessible to children. 2) During interview, management reported the cleaning supplies are not locked during transportation and the bus is used for transporting children.”

8VAC20-780-270-A

“Based on observation and interview, the center did not ensure areas and equipment of the center, inside and outside, were maintained in a clean, safe and operable condition. Evidence: 1) During the inspection of the playground equipment on 10/14/22, the inspector observed a crack at the bottom of one of the slides. The crack created a pinching hazard, could entangle clothing or snag skin. 2) During interview, management reported the children use this slide.”

8VAC20-780-560-G

“Based on observation and interview, the center did not meet the requirements when food is brought from home. Evidence: 1) The lunch boxes observed at the center on 10/14/2022 were not clearly dated or labeled in a way that identified the owner. There were 19 children present during the inspection. 2) During interview, staff and management confirmed not all lunch boxes are dated or labeled to identify the owner.”

8VAC20-780-540-C

“Based on an inspection of the first aid kit and interview, the center did not ensure all required items were supplied in the kit. Evidence: 1) The first aid kit did not contain at least two triangular bandages. 2) During interview, management reported the center did not have triangular bandages on site.”

8VAC20-780-280-B

“Based on observation and interview, the center did not maintain hazardous substances such as cleaning materials in a locked placed using a safe locking method that prevents access by children. Evidence: 1) During the inspection of the vehicles used for transportation, the inspector observed a bucket with various bottles of cleaning supplies that were accessible to children. 2) During interview, management reported the cleaning supplies are not locked during transportation and the bus is used for transporting children.”

8VAC20-780-70

“Based on a review of five staff records and interviews, the center did not ensure that one record contained the required information. Evidence: 1) The record for Staff #4, hired on 02/20/22, did not contain documentation that two or more references as to character and reputation as well as competency were checked before employment or volunteering. One reference was checked on 12/17/21 and a second reference was checked on 05/18/22. 2) During interviews, a member of management acknowledged one of the references was checked after hire.”

8VAC20-780-240-A

“Based on a review of five staff records and interviews, the center did not ensure one staff had completed the Virginia Department of Education-sponsored orientation course within 90 calendar days of employment. Evidence: 1) The Virginia Department of Education-sponsored orientation course in the record for Staff #3, hired on 01/17/22, was dated 05/11/22. 2) During interviews, a member of management reported Staff #3 did not complete the course within 90 calendar days of employment.”

8VAC20-770-60-C-2

“Based on a review of five staff records and interviews, the center did not ensure that one staff member had a central registry finding within 30 days of employment. Evidence: 1) The central registry finding in record for Staff #4, hired on 02/20/22, did not contain the results of a central registry finding. 2) During interviews, a member of management confirmed the results of the central finding for Staff #4 were not received within 30 days of employment. The records did not contain documentation of any further contact and the staff member had been continuously employed.”

22.1-289.035-B-2

“Based on a review of five staff records and interviews, the center did not ensure one staff obtained fingerprint results prior to hire. Evidence: 1) The fingerprint results in the record for Staff #4, hired on 02/20/22, were dated 02/23/2022. 2) During interview, a member of management confirmed the fingerprint results were not obtained prior to hire for Staff #4.”

8VAC20-780-160-A

“Based on a review of five staff records and interviews, the center did not ensure one staff member had documentation of a negative tuberculosis (TB) screening at the time of employment and prior to coming into contact with children. Evidence: 1) The most recent TB screening in the record for Staff #4, hired on 02/20/22, was dated 03/27/22. 2) During interviews, a member of management reported the documentation of a negative TB screening for Staff #4 was not obtained at the time of employment and prior to coming into contact with children.”

8VAC20-780-70

“Based on a review of five staff records and interviews, the center did not ensure that one record contained the required information. Evidence: 1) The record for Staff #4, hired on 02/20/22, did not contain documentation that two or more references as to character and reputation as well as competency were checked before employment or volunteering. One reference was checked on 12/17/21 and a second reference was checked on 05/18/22. 2) During interviews, a member of management acknowledged one of the references was checked after hire.”

8VAC20-780-240-A

“Based on a review of five staff records and interviews, the center did not ensure one staff had completed the Virginia Department of Education-sponsored orientation course within 90 calendar days of employment. Evidence: 1) The Virginia Department of Education-sponsored orientation course in the record for Staff #3, hired on 01/17/22, was dated 05/11/22. 2) During interviews, a member of management reported Staff #3 did not complete the course within 90 calendar days of employment.”

8VAC20-770-60-C-2

“Based on a review of five staff records and interviews, the center did not ensure that one staff member had a central registry finding within 30 days of employment. Evidence: 1) The central registry finding in record for Staff #4, hired on 02/20/22, did not contain the results of a central registry finding. 2) During interviews, a member of management confirmed the results of the central finding for Staff #4 were not received within 30 days of employment. The records did not contain documentation of any further contact and the staff member had been continuously employed.”

22.1-289.035-B-2

“Based on a review of five staff records and interviews, the center did not ensure one staff obtained fingerprint results prior to hire. Evidence: 1) The fingerprint results in the record for Staff #4, hired on 02/20/22, were dated 02/23/2022. 2) During interview, a member of management confirmed the fingerprint results were not obtained prior to hire for Staff #4.”

8VAC20-780-160-A

“Based on a review of five staff records and interviews, the center did not ensure one staff member had documentation of a negative tuberculosis (TB) screening at the time of employment and prior to coming into contact with children. Evidence: 1) The most recent TB screening in the record for Staff #4, hired on 02/20/22, was dated 03/27/22. 2) During interviews, a member of management reported the documentation of a negative TB screening for Staff #4 was not obtained at the time of employment and prior to coming into contact with children.”

8VAC20-780-160-C

“Based on a review of two staff records and interviews, the center did not ensure that one staff resubmit tuberculosis (TB) test results at least every two years from the date of the first initial screening or testing. Evidence: 1) The most recent TB screening in the record for Staff #1, hired on 04/02/19, was dated 05/28/19. The TB screening expired on 05/28/21. 2) During interview, a member of management reported the TB screening for Staff #1 expired on 05/28/21 and a new one has not been obtained.”

8VAC20-770-60-C-2

“Based on a review of two staff records and interviews, the center did not ensure that one staff member had a central registry finding within 30 days of employment. Evidence: 1) The central registry finding in record for Staff #1, hired on 04/02/19, was dated 06/11/20. 2) During interviews, a member of management confirmed the results of the central finding for Staff #1 were not received within 30 days of employment. The records did not contain documentation of any further contact and the staff member had been continuously employed.”