Young Men’s Christian Association of Greater Richmond-Bryce Lane

***Repeat Violation*** The center is required to obtain background checks from any state in which the individual has resided in the preceding five years.

“The record for staff #2, who has been employed for over 10 months, did not have documentation of an out of state criminal record request, a child abuse and neglect record request, or a sex offender record request.”

Rule 22.1-289.035-B-4.

Staff are to complete the VDOE sponsored online orientation course within 90 days of hire.

“Staff #3, has not completed the course which is overdue by seven months.”

Rule 8VAC20-780-240-A.

The center shall ensure that areas and equipment of the center, inside and outside, are maintained in a clean, safe and operable condition.

“On the playground, the concrete anchor for the fence post to enter and exit the playground was visible with sharp edges, posing a tripping hazard.”

Rule 8VAC20-780-270-A.

At least one staff in each classroom or area where children are present shall have current certification in both CPR and first aid.

“Staff #1 was alone with a group of ten, four-year-old children and was not certified in CPR or first aid.”

Rule 8VAC20-780-530-A.

Documentation to demonstrate that the individual possesses the education and certification, required by the job position.

“Staff #1 and staff #5 were identified as program leaders and did not have documentation of the education required.”

Rule 8VAC20-780-70.

Shelter in place procedures shall be practiced a minimum of twice per year.

“The facility did not have documentation of two shelter in place drills in 2025.”

Rule 8VAC20-780-550-E.

Lockdown procedures shall be practiced at least annually.

“The facility did not have documentation of at least one lockdown drill for 2025.”

Rule 8VAC20-780-550-F.

The center is required to obtain background checks from any state in which the individual has resided in the preceding five years.

“The record for staff #4, who has been employed over 14 months, did not have documentation identifying staff #4 as the individual for whom the out of state child abuse and neglect search request was completed for.”

Rule 22.1-289.035-B-4.

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, enrolled for over 13 months did not have documentation of an immunization record.”

Rule 8VAC20-780-130-A.

Physical examinations completed by a physician shall be obtained prior to the first day of attendance or within 30 days after the first day of attendance.

“The record for child #2, enrolled for 13 months did not have documentation of a physical examination.”

Rule 8VAC20-780-140-A.

Immunizations and physical examination reports are required to be signed and dated by a physician, his designee, or an official of the local health department.

“The immunization and physical examination reports for child#3, enrolled for over 14 months were not signed by a physician, his designee, or an official of the local health department.”

Rule 8VAC20-780-150-B.

Each staff member shall submit documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with the children.

“The record for staff #3, who has been employed over 22 months, did not have documentation identifying staff #3 as the individual for whom the TB screening was completed for.”

Rule 8VAC20-780-160-A.

Hazardous substances such as cleaning materials shall be kept in a locked place using a safe locking method that prevents access by children.

“In room #2, one container of disinfectant was located on top of the changing table in reach of children.”

Rule 8VAC20-780-280-B.

Prescription medication may be given if the center administers only those drugs that were dispensed from a pharmacy and maintained in the original, labeled container.

“Prescription medication for child H, was not in the original, labeled container.”

Rule 8VAC20-780-510-I.

Each center shall maintain and keep at the center a separate record for each child enrolled that contains all of the required information.

“1.The record for child #1, enrolled for over six months, was missing the following required components: one of the two designated emergency contacts. 2.The record for child #4, enrolled for over 10 months, did not have documentation of viewing proof of the child’s identity and age.”

Rule 8VAC20-780-60-A.

Staff are to complete the VDOE sponsored online orientation course within 90 days of hire.

“The record for staff #6 contained documentation of completed course which was 425 days late.”

Rule 8VAC20-780-240-A.

When food is brought from home, the food container shall be sealed and clearly dated and labeled in a way that identifies the owner.

“Eight out of eight food containers observed were not dated and/ or labeled to identify owner.”

Rule 8VAC20-780-560-G.

Based on record review and interview, the center did not ensure one of five staff records had documentation of a completed sworn statement or affirmation prior to the first day of employment.

“Evidence: 1. The record of staff #5 (employed 6/27/21) had documentation of a completed sworn statement or affirmation dated 2/19/24. 2. A member of management stated that staff #5 did not complete a sworn statement prior to hire.”

Rule 22.1-289.035-B-1.

Based on a review of staff records and interview, the center did not ensure staff had the satisfactory results of the fingerprint-based national criminal background check prior to employment.

“Evidence: The record for staff #5 (employed 6/27/21) did not contain the results of the fingerprint-based national criminal background check until 02/19/24. A member of management confirmed the fingerprint-based national criminal background check for staff #1 were not obtained prior to employment.”

Rule 22.1-289.035-B-2.

Based on record review and interview, the center did not have documentation of central registry findings for one of the five staff members.

“Evidence: 1. The record for staff #5 (employed 6/27/21) did not contain documentation of central registry findings until 02/07/24. 2. A member of management confirmed that the central registry finding was not obtained. within the required timeframe.”

Rule 22.1-289.035-B-3.

Based on record review and interview, the center did not ensure one of five staff records contained documentation of criminal history record results and a sex offender registry check results from any state in which the individual has resided in the past five years.

“Evidence: 1. The record of staff #1 (employed 8/21/23) had documentation of out of state criminal history record results on 11/20/23 and out of state sex offender registry check results on 11/20/23. 2. The Sworn Statement or Affirmation of staff #1 stated that the individual lived outside of Virginia in the past five years. The out of state checks were not completed in the required time frame.”

Rule 22.1-289.035-B-4.

Based on a review of children’s records, the center did not ensure that each child shall have a physical examination by or under the direction of a physician before the child’s attendance or within one month after attendance.

“Evidence: The records for child #3 (enrolled 10/18/23) and child #5 (enrolled 7/18/23), did not have a physical examination.”

Rule 8VAC20-780-140-A.

Based on review of records and interview, the center did not ensure that each staff member shall submit documentation of a negative tuberculosis screening (TB) at the time of employment and prior to coming in contact with children.

“Evidence: The record for staff #5 (employed 6/27/21) had a TB screening dated 2/02/24. A member of management acknowledged that the TB screening was not completed prior to hire or before coming in contact with children.”

Rule 8VAC20-780-160-A.

Based on observation, the center did not ensure areas and equipment of the center, inside and outside, shall be maintained in a clean, safe and operable condition.

“In the two year old room, one broken toilet paper holder. In the four year old classroom, one broken ceiling tile with exposed wires.”

Rule 8VAC20-780-270-A.

Based on a review of the facility’s injury reports, all required information was not documented.

“Evidence: Two injury reports were reviewed and two injury reports did not have any future action to prevent recurrence of the injury and one staff and parent signature or two staff signatures. A member of management acknowledged that the injury reports did not have the required information documented.”

Rule 8VAC20-780-550-P.

Based on observation, the center did not ensure all hazardous substances such as cleaning materials insecticides and pesticides, were kept in a locked place using a safe locking method that prevents access by children.

“Evidence: In room #2, One container labeled sanitizer with a pink liquid substance and one container of Amazon basic disinfecting wipes were located in the window sill, unlocked and accessible to children. In room #3, one container of Glade air freshener was being stored in the window sill, unlocked and accessible to children.”

Rule 8VAC20-780-280-B.

Based on documentation review, it was determined that the center did not ensure that the emergency preparedness plan was updated as required.

“Evidence: 1.The emergency plan was not updated with the new program director information.”

Rule 8VAC20-780-550-B.

Based on review of children records, interview, and observation, the center failed to operate within the terms of their current license issued by the department.

“Evidence: 1. The center is currently licensed for children ages 3 years to 5 years, 11 months. The record for child #2 (enrolled: 9/25/23) was 2 years at time of enrollment. The record for child #5 (enrolled: 9/05/23) was 2 years, 7 months at the time of enrollment. 2. Administrator verified that child #2 and child #5 were not three years of age at time of enrollment.”

Rule 8VAC20-780-40-E. From a complaint.

Based on a review of children’s records, the center did not ensure that each child’s record contained documentation of immunizations required by the State Board of Health before the child can attend the center.

“Evidence: The records for child #5 and child #6 did not have documentation of immunizations.”

Rule 8VAC20-780-130-A.

Based on a review of children’s records, the center did not ensure that each child shall have a physical examination by or under the direction of a physician before the child’s attendance or within one month after attendance.

“Evidence: The records for child #4, child #5, and child #6 did not documentation of a physical examination by or under the direction of a physician.”

Rule 8VAC20-780-140-A.

Based on a review of the emergency drill log and interview, it was determined that the facility did not ensure that a monthly practice evacuation drill is completed.

“Evidence: 1. The emergency drill log did not have written documentation to demonstrate that an emergency evacuation drill was completed during the month of October 2022. 2. Staff #2 (Program Director) confirmed that there was no emergency evacuation drill completed during the month of October 2022.”

Rule 8VAC20-780-550-D.

Based on a review of children’s records, the center did not ensure that each record contains all required information.

“Evidence: 1. The record for child #1, child #3, child #4, child #5, child #6, and child #7 did not have first date of attendance. 2. The record for child #1, child #3, child #4, and child #7 did not 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.

Based on observation, the center did not ensure the diapering area contained a leakproof or plastic-lined storage system that is either foot operated or used in such a way that neither the staff member’s hand nor the soiled diaper touches an exterior surface of the storage system during disposal.

“Evidence: 1. In room A there was a diaper changing area without the required disposable diaper storage system. 2. The provider stated that the correct plastic lined storage system was not in room A.”

Rule 8VAC20-780-500-B.