West End Center For Youth

8VAC20-780-130-A

“The center shall obtain documentation that each child has received the immunizations required by the State Board of Health before the child can attend the center. Record for Child #1 who has been enrolled for over a year did not include documentation of immunizations.”

8VAC20-780-160-A

“Documentation of a negative tuberculosis (TB) screening must be submitted at the time of employment and shall have been completed within the last 30 days of employment. There was no documentation of a TB screening for Staff 1 who has been employed for one week. The TB screening for Staff 2 was completed one week after employment.”

22.1-289.035-B-2

“Providers must obtain a completed national criminal background check prior to the employee’s first day of employment. The national criminal background check was dated 2 days after their first day of employment.”

22.1-289.035-B-1

“The center is required to obtain a completed sworn statement prior to the employee’s first day of employment. The sworn statement for Staff 1 was dated 2 days after their first day of employment.”

8VAC20-780-210-A

“Program leaders must have fulfilled a high school program completion or the equivalent. Records for program leaders did not include documentation of a high school diploma or the equivalent.”

8VAC20-780-60-A

“Based on record review, the center failed to ensure that the separate record for each child enrolled shall contain all of the elements are required by the standards. Evidence: 1.The record for Child 1 did not contain the first date of attendance. 2. The record for Child 2 did not contain the following information: the name, address and phone number of two designated people to call in an emergency if a parent cannot be reached (the addresses for both designated people were incomplete); and the first date of attendance. 3. The record for Child 3 did not contain the first date of attendance. 4. The record for Child 5 did not contain the first date of attendance. 5. The record for Child 6 did not contain the name, address and phone number of two designated people to call in an emergency if a parent cannot be reached (the addresses for both designated people were incomplete).”

8VAC20-780-260-B

“Based on document review, the center failed to obtain an annual approval from the health department. Evidence: The most recent approval from the Health Department was dated 11/03/2022; an annual update was not obtained by 11/03/2023.”

8VAC20-780-130-A

“Based on record review, the center failed to obtain documentation that each child has received the immunizations required by the State Board of Health before the child can attend the center. Evidence: The record for Child 1 did not contain documentation that Child 1 has received the required immunizations as required by the State Board of Health.”

8VAC20-780-140-A

“Based on staff interviews, the center failed to obtain a copy of the child’s physical examination before the child’s attendance or within 30 days after the first day of attendance. Evidence: The record for Child 3 did not contain a copy of the child’s physical examination.”

8VAC20-780-160-C

“Based on record review, the center failed to ensure that staff shall submit documentation of a negative tuberculosis screening at least every two years from the date of the initial screening or testing. Evidence: The most recent tuberculosis screening in the record for Staff 2 was dated 10/14/2021; there was not a follow-up tuberculosis screening available for review which would have been required by 10/14/2023.”

8VAC20-780-280-D

“Based on observation, the center failed to ensure that cleaning and sanitizing materials shall not be located above food, food equipment, utensils or single-service articles and shall be stored in areas physically separate from food. Evidence: There was a clear plastic spray bottle labeled ?bleach/water? on the top shelf of the shelving unit located in the food service corner of the cafeteria area that was located above the following items: a box of apples; a box of individual Ranch Dressing containers; plastic forks; paper plates; and napkins.”

8VAC20-780-280-B

“Based on observation, the center failed to ensure that hazardous substances, such as cleaning materials, insecticides, and pesticides shall be kept in a locked place using a safe locking method that prevents access by children. Evidence: 1. There was a clear plastic spray bottle labeled ?bleach/water? on the top shelf of a shelving unit located beside of the kitchen service window that was not locked to prevent access by children. 2. There was a clear plastic spray bottle labeled ?bleach/water? on the top shelf of the shelving unit located in the food service corner of the cafeteria area that was not locked to prevent access by children.”

8VAC20-780-270-A

“Based on observation, the center failed to ensure that the areas and equipment of the center, inside and outside, shall be maintained in a clean, safe and operable condition. Evidence: 1. The metal seals around a pipe under the sink in the girl’s restroom were rusted and sharp. The pipe was exposed and accessible to the children. 2. There was a hole in the wall of the boy’s restroom. 3. There was a metal plate on the outside wall of the facility that was sharp. The metal plate was accessible to the children.”

8VAC20-780-320-B

“Based on observation, the center failed to ensure that each restroom area provided for children shall be equipped with soap, toilet paper, and disposable towels or an air dryer within reach of children. Evidence: There was no soap in the boys or girls restrooms.”

8VAC20-780-530-C

“Based on record review and discussion with staff, the center failed to ensure that there shall be at least two people who are currently certified in CPR and First Aid on the premises during the center’s hours of operation, on fieldtrips, and wherever children are in care. Evidence: Staff 1 was the only staff on the premises with a current certification in CPR and First Aid during the 04/05/2022 inspection.”

8VAC20-780-340-F

“Based on observation and discussion with staff, the center failed to ensure that children shall always be within actual sight and sound supervision of staff. Evidence: Four children were observed in an office space participating in an activity with a volunteer from an outside partner agency. There was not a staff member present in the office space. The children were not within the sight and sound supervision of a staff member during this time.”

8VAC20-780-80-A

“Based on document review and discussion with staff, the center failed to ensure that for each group of children, the center shall maintain a written record of daily attendance that documents the arrival and departure of each child in care as it occurs. Evidence: The written record of daily attendance did not document the departure of each child.”

8VAC20-780-70

“Based on record review and discussion with staff, the center failed to ensure that staff records contain all of the elements as required by the standards. Evidence: 1. The record for Staff 3 did not contain the following information: name, address and telephone number of a person to be notified in an emergency. 2. The record for Staff 4 did not contain the following information: documentation that two or more references as to character and reputation as well as competency were checked before employment. 3. The record for Staff 6 did not contain the following information: documentation that two or more references as to character and reputation as well as competency were checked before employment; and health information as required.”

8VAC20-780-60-A

“Based on record review and discussion with staff, the center failed to ensure that the separate record for each child enrolled contains all of the elements as required by the standards. Evidence: 1. The record for Child 1 did not contain the following information: the name and phone number of the child’s physician; documentation of viewing proof of the child’s identity and age; and documentation of health information as required. 2. The record for Child 2 did not contain the following information: name, address and phone number of two designated people to call in an emergency if a parent cannot be reached (the addresses for both designated people were incomplete). 3. The record for Child 3 did not contain the following information: name, address and phone number of two designated people to call in an emergency if a parent cannot be reached (the addresses for both designated people were incomplete) 4. The record for Child 4 did not contain the following information: work phone number of each parent (an employer was listed but the record did not contain a work phone number); phone number of child’s physician; name, address and phone number of two designated people to call in an emergency if a parent cannot be reached (the addresses for both designated people were incomplete); and documentation of health information as required. 5. The record for Child 6 did not contain the following information: allergies and intolerance to medication or any other substances, and actions to take in an emergency; name, address and phone number of two designated people to call in an emergency if a parent cannot be reached (no addresses were provided); and documentation of health information as required by 8VAC20-780-130. 6. The record for Child 7 did not contain the following information: name, address and phone number of two designated people to call in an emergency if a parent cannot be reached (the addresses for both designated people were incomplete).”

8VAC20-780-160-C

“Based on record review and discussion with staff, the center failed to ensure that at least every two years from the date of the initial screening or testing, staff member shall obtain and submit the results of a follow-up tuberculosis screening. Evidence: 1. The most recent tuberculosis test/screening for Staff 2 was dated 11/27/2018; there was not a follow-up test/screening for 2020 available for review. 2. The most recent tuberculosis test/screening for Staff 6 was dated 11/20/2018; there was not a follow-up test/screening for 2020 available for review.”

22.1-289.036-A

“Based on record review and discussion with staff, the center failed to ensure that every applicant for licensure as a child day center shall undergo a background check in accordance with the Code of Virginia prior to issuance of a license and every five years thereafter. Evidence: The record for Agent 3 contained the following: a sworn statement dated 04/07/2016; a search of the central registry dated 04/12/2016; and a criminal record dated 06/02/2016. There were no repeat background check documents obtained in 2021.”

22.1-289.035-B-2

“Based on record review and discussion with staff, the center failed to ensure that no person shall be hired for compensated employment prior to the facility obtaining an employment eligibility letter upon the completion of a fingerprint background check as required by the Code of Virginia. Evidence: 1. The record for Staff 1 contained a documented hire date of 07/20/2020. There was not an employment eligibility letter available for review. 2. The record for Staff 4 contained a documented hire date of 09/03/2020. There was not an employment eligibility letter available for review. 3. The hire date for Staff 6 was 10/04/2021 as verified by Agent 5. There was not an employment eligibility letter available for review.”

22.1-289.035-B-2

“Based on record review and discussion with staff, the center failed to ensure that no person shall be hired for compensated employment prior to the facility obtaining an employment eligibility letter upon the completion of a fingerprint background check as required by the Code of Virginia. Evidence: 1. The record for Staff 1 contained a documented hire date of 07/20/2020. There was not an employment eligibility letter available for review. 2. The record for Staff 4 contained a documented hire date of 09/03/2020. There was not an employment eligibility letter available for review. 3. The hire date for Staff 6 was 10/04/2021 as verified by Agent 5. There was not an employment eligibility letter available for review.”

22.1-289.035-B-2

“Based on record review and discussion with staff, the center failed to ensure that all applicants submit to fingerprinting. Evidence: 1. There were no fingerprint results available for Agent 1 during the 04/06/2022 inspection. Agent 4 verified that Agent 1 took office in 03/2020. 2. There were no fingerprint results available for Agent 2 during the 04/06/2022 inspection. Agent 4 verified that Agent 1 took office in 03/2020.”

8VAC20-770-60-C-2

“Based on record review and discussion with staff, the center failed to obtain the finding from a search of the central registry within 30 days of employment. Evidence: 1. The record for Staff 3 contained a documented hire date of 09/11/2020. There were no finding from a search of the central registry available for review. 2. The hire date for Staff 6 was 10/04/2021 as verified by Agent 5. The findings from a search of the central registry were dated 12/12/2021.”

8VAC20-770-40-D-1-a

“Based on record review and discussion with staff, the center failed to obtain the required sworn statements and findings from a search of the central registry for all applicants and agents. Evidence: 1. There was not a sworn statement or findings from a search of the central registry available for Agent 1. Agent 4 verified that Agent 1 took office in 03/2020. 2. There was not a sworn statement or findings from a search of the central registry available for Agent 2. Agent 4 verified that Agent 2 took office in 03/2020. 3. There was not findings from a search of the central registry available for Agent 4. Agent 4 took their position on 11/08/2021.”

8VAC20-780-560-J

“Based on observation and discussion with staff, the center failed to ensure that tables shall be sanitized before and after each use for feeding. Evidence: Various groups of children were observed eating their afternoon snack at various times using the same tables. The tables were not sanitized between each use by the various groups of children.”

8VAC20-780-500-A

“Based on observation and discussion with staff, the center failed to ensure that children’s hands shall be washed with soap and running water or disposable wipes before and after eating meals and snacks. Evidence: Children were observed arriving to the program and immediately eating their afternoon snack without washing hands before or after eating the snack.”