Caroline Family YMCA

Systemic Deficiency

“A tuberculosis (TB) screening is required every two years from the last screening. Staff #2’s updated screening was due two years ago. The updated screening has not yet been completed.”

Rule 8VAC20-780-160-C.

Repeat Violation

“Staff shall annually complete the department’s health and safety update course. Staff #2 did not complete the health and safety update training for 2025.”

Rule 8VAC20-790-600-F.

A tuberculosis (TB) screening is required every two years from the last screening.

“Staff #1 and Staff #2 updated screenings were due 6 months ago. The updated screenings have not yet been completed.”

Rule 8VAC20-780-160-C.

8VAC20-780-270-A

“In the classroom, chipping and peeling paint was discovered in multiple areas along the walls.”

Rule 8VAC20-780-270-A.

Staff shall annually complete the department’s health and safety update course.

“Staff #1 and Staff #2 did not complete the health and safety update training for 2024.”

Rule 8VAC20-790-600-F.

Staff shall complete annually a minimum of 16 hours of training appropriate to the age of children in care.

“Staff #1 and Staff #2 obtained zero of the 16 required hours in 2024.”

Rule 8VAC20-780-245-A.

(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.”

Rule 22.1-289.035-B-2.

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.”

Rule 8VAC20-770-40-D-6.

(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.”

Rule 8VAC20-770-60-B.

(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.

Rule 8VAC20-780-160-A.

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.”

Rule 8VAC20-780-60-A.

(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.”

Rule 8VAC20-780-70.

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.”

Rule 8VAC20-790-600-F.

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.

Rule 22.1-289.035-B-4.

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.”

Rule 8VAC20-780-245-A.

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.”

Rule 22.1-289.035-B-2.

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.

Rule 8VAC20-770-60-B.

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.

Rule 8VAC20-770-60-C-2.

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.

Rule 8VAC20-780-160-A.

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.”

Rule 8VAC20-780-560-G.

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.”

Rule 8VAC20-780-70.

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.”

Rule 8VAC20-780-270-A.

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.”

Rule 8VAC20-780-280-B.

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.”

Rule 8VAC20-780-540-C.

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.”

Rule 8VAC20-780-560-G.

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.”

Rule 22.1-289.035-B-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.”

Rule 8VAC20-770-60-C-2.

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.”

Rule 8VAC20-780-160-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.”

Rule 8VAC20-780-240-A.

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.”

Rule 8VAC20-780-70.

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.”

Rule 8VAC20-770-60-C-2.

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.”

Rule 8VAC20-780-160-C.