Young Men's Christian Association of Greater Richmond - Bellwood

8VAC20-780-70

“Documentation to demonstrate that the individual possesses the education and certification, required by the job position. Staff #1 was identified as a program leader and did not have documentation of the education required.”

8VAC20-780-560-F

“A menu listing food to be served for meals and snacks during the current one-week period shall: List any substituted food and be kept on file for one week at the center. The center served a substitute pm snack and did not list substituted foods.”

8VAC20-780-60-A

“Each center shall maintain and keep at the center a separate record for each child enrolled that contains all of the required information. The record for child #4, enrolled for 181 days, was missing the following required components: name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached.”

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. The record for child #2 did not have documentation of immunizations.”

8VAC20-780-560-F

“Children shall be allowed second helpings of food listed in the USDA's child and adult care meal patterns. Children in attendance asked for second helpings and staff stated there are no second helpings.”

8VAC20-780-240-A

“Repeat Violation Based on records review, and interview, the center failed to ensure that the Virginia Department of Education sponsored orientation course shall be completed within 90 calendar days of employment. Evidence: 1. The record for staff #1, date of employment 08/11/22, and the record for staff #2, date of employment 05/18/23 did not contain documentation of completion of the VDOE course. 2. The record for staff #3, date of employment 01/16/23, contained documentation of the Virginia Department of Education sponsored orientation course dated 08/30/2023.”

8VAC20-780-190-A

“Based on a review of staff files and an interview with Administrative staff , it was determined that the program director does not meet he qualifications for the position. Evidence: The record for staff #3, date of employment 01/16/2023, identified as the program director, did not contain documentation to demonstrate that they are qualified for their position . When interviewed, administration confirmed that the program director did not have the required qualifications.”

8VAC20-780-240-A

“Based on records review, the center failed to ensure that The Virginia Department of Education (VDOE) sponsored orientation course is completed within 90 calendar days of employment. Evidence: The record for staff #1, date of employment 8/11/22, did not contain documentation of the VDOE training being completed.”

8VAC20-780-60-A

“Based on records review, the center failed to maintain and keep at the center a separate record for each enrolled child that contained documentation of the name, address, and phone number of two designated people to call in an emergency and the name and phone number of a child's physician. Evidence: 1) 4 children's records were reviewed. The record for child #2, child #3, and child #4, only listed 1 emergency contact. 2) the record for child #2, child #3, and child #4 did not contain the name and phone number of the child's physician.”

8VAC20-780-260-A

“Based on interview, the center failed to provide an annual fire inspection report from the school where the center is housed. Evidence: The Director could not locate the fire inspection report. When asked she stated that the school used to have it posted in the cafeteria but did not know where it was located now.”

8VAC20-780-260-B

“Based on interview, the center failed to provide an annual health inspection report. Evidence: The Director could not locate the health inspection report. When asked she stated that the school used to have it posted in the cafeteria but did not know where it is located now.”

8VAC20-780-550-H

“Based on interview, the center failed to document that a monthly practice evacuation drill took place. Evidence: When interviewed the Director stated that she had done the practice evacuation drills but did not know she had to document it.”

8VAC20-780-240-B

“Based on records review, the center failed to document that staff #1 (date of employment 08/11/22) completed orientation training no later than seven days of the date of assuming job responsibilities. Evidence: Staff #1 was observed working with children. Staff #1?s record did not contain documentation of orientation training.”

8VAC20-780-550-P

“Based on a review of records and interview on April 27, 2022, the center did not ensure that written records of children's serious and minor injuries contained all the required information. Evidence: 1. An incident report for child #1 did not contain documentation of treatment received, the date and time when parents were notified, any future action to prevent recurrence of the injury, and documentation on how the parent was notified. 2. Administration acknowledged the missing components.”

8VAC20-780-70

“Based on a review of staff records and interview on April 27, 2022, the center did not ensure all the required information shall be kept for each staff. Evidence: 1. Documentation of the minimum requirements of staff records to be kept on-site (name, address, phone number of a person to be notified in an emergency and information about any health problems that may interfere with fulfilling job responsibilities) were not present at the center. Administration confirmed the center did not have this information on-site. 2. The record of staff #1 (hired 12/13/21) did not contain documentation of program director qualifications.”

8VAC20-770-60-B

“Based on a review of staff records and interview on April 29, 2022, the center did not ensure to obtain a sworn statement from each staff prior to employment. Evidence: 1. The record of staff #3 (hired 3/8/22) did not contain documentation of a sworn statement. 2. Administration acknowledged the sworn statement was not complete.”

8VAC20-780-60-A

“Based on a review of records and interview on April 27, 2022, the center did not ensure that each child's record contained the required information. Evidence: 1. Per administration the record of child #2 was not on-site and not accessible electronically. 2. The record of child #3 (enrolled 6/24/21) contained documentation of a physical and immunizations dated 10/12/21. 3. The record of child #4 did not contain documentation of a date of enrollment and last date of attendance. Administration stated the child was expelled from the program. Administration was unable to access child's electronic file. 4. The record of child #6 did not contain documentation of a date of enrollment. 5. The record of child #9 did not contain documentation of a date of enrollment.”

8VAC20-770-60-C-2

“Based on a review of staff records and interview on April 29, 2022, the center did not ensure that each staff record reviewed contained a central registry finding within 30 days of employment. Evidence: 1. The record of staff #2 (hired 11/17/21) contained documentation of central registry results dated 1/4/22. 2. The record of staff #3 (hired 3/8/22) contained documentation of central registry results dated 4/18/22. 3. Administration acknowledged the central registry checks were late.”

8VAC20-780-550-D

“Based on an interview with administration and record review on April 27, 2022, the center did not ensure to implement a monthly practice evacuation drill. Evidence: 1. Administration reported that no fire drills have been conducted since she arrived at the center in December 2021. 2. Documentation of the last fire drill recorded was dated February 9, 2022.”

22VAC40-185-280-B

“Based on observation and interview, the center did not ensure that hazardous substances such as cleaning materials were kept in a locked place using a safe locking method that prevents access by children. Evidence: 1. The center's Hillyard's Sanitizer is kept on a table on the stage in the gym. The label on the sanitizer states "keep out of reach of children" and "caution." 2. The administrator said they don't have a way to lock it up.”

22VAC40-185-40-E

“Based on a review of records, the center failed to comply with the center's own policies and procedures for medication. Evidence: 1. The center's policy on medication states "if medication is found to be out-of-date, the medication must be immediately returned to the locked location. The parent/legal guardian must be informed immediately that the child did not receive their medication as scheduled. When the child is picked up that same day, the medication must be handed in person to the parent/legal guardian for their disposal. Staff are responsible for completing a medication checklist in the appendices once a month in order to stay on top of expiring medicines and authorization forms. If the medicine has expired, the staff must return the medicine to the parent." 2. The label on the medication for Child #4 stated discard after 3/30/21.”

22VAC40-185-140-A

“Based on a review of records, the center did not ensure to obtain documentation of a physical examination by or under the direction of a physician for each child before the child's attendance or within one month after attendance. Evidence: The record of Child #1 (DOE 8/23/21) did not contain documentation of a physical.”

22VAC40-185-40-G

“Based on a review of records, the center did not ensure that regulated child day programs require proof of child identity and age; report to law enforcement agencies. Evidence: The record of Child #1 (DOE 8/23/21) did not contain evidence of viewing of proof of the child's identity and age. There was no documentation of the center notifying law enforcement when proof of age and identity was not received within seven business days of initial attendance.”

22VAC40-185-70-A

“Based on a review of records, the center did not ensure that two or more references were checked before employment. Evidence: 1. The record of Staff #2 (DOH 10/15/21) did not contain documentation of references and orientation. 2. Administration confirmed there were no references on file. Administration said that Staff #2 did complete orientation but didn't have documentation of such.”

63.2(17)-1720.1-B-4

“Based on a review of staff records, the center did not ensure to obtain a copy of the results of a criminal history record check and sex offender registry check prior to the first day of employment from any state in which the applicant has resided in the preceding five years. Evidence: The record of Staff #3 (DOH 8/10/20) contained documentation of sex offender registry results dated 3/19/21.”

22VAC40-191-60-C-2

“Based on a review of records, the center id not ensure that each staff record reviewed contained a central registry finding within 30 days of employment. Evidence: The record of Staff #1 (DOH 9/3/20) contained a central registry result dated 10/16/20.”