DHSS MO
MISSOURI DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION

OFFICE OF CHILDHOOD

SCHOOL AGE INSPECTION REPORT
Facility Information

Y-CLUB @ THOMAS JEFFERSON MIDDLE SCHOOL

002782878

(573) 659-3250

1201 FAIRGROUNDS RD
JEFFERSON CITY
MO  65109-5445

JEFFERSON CITY AREA YOUNG MEN'S CHRISTIAN ASSOCIATION

PO BOX 104176
JEFFERSON CITY
MO  65110-4176

KEVER, JESSICA RENEE

jkever@jcymca.org

Incorporated

LAUREN R RAYWARNKE

11 YEARS - 14 YEARS

60

SCHOOL AGE

BEFORE SCHOOL CARE ONLY
 
Inspection Information

04/12/2023

7:00 AM

8:08 AM

UNANNOUNCED

COMPLIANCE MONITORING

2445024272


DocumentDocument-Date
APPLICATION 07/30/2019
ARTICLES OF INCORPORATION 07/15/2019
REGISTERING FICTITIOUS NAMES 07/25/2019
CERTIFICATE OF GOOD STANDING 07/25/2019
DISCIPLINE POLICIES 07/25/2019
DISASTER AND EMERGENCY PREPAREDNESS PLAN 07/25/2019
DAILY SCHEDULE 07/25/2019
LINES OF ADMINISTRATIVE AUTHORITY 07/25/2019
SAMPLE FORMS 07/25/2019
POLICIES 07/25/2019
STAFF SHEET 08/13/2019
LOCAL FIRE DEPARTMENT NOTIFICATION 08/13/2019
JOB RESPONSIBILITIES 08/13/2019
CHILD CARE PRACTICES 08/13/2019
DIRECTOR'S JOB RESPONSIBILITIES 08/13/2019
CERTIFICATE OF INCORPORATION 07/25/2019
DIRECTOR'S QUALIFICATIONS 08/26/2019
EQUIPMENT LIST 03/23/2023
ANNUAL DECLARATION 03/23/2023
LISTING OF CHILD CARE STAFF/HOUSEHOLD MEMBERS 03/23/2023




Inspection determined facility to be in compliance with licensing rules.
Compliance Licensing Rules
Open Violations: 3
NOTE
The licensee is responsible for compliance with all licensing rules, including but not limited to the rules listed on this compliance report form.
Attendance at Time of Inspection
Total Staff 2
Total Children 4
StaffChildClass AgeNote
2 4 SCHOOL AGE Brayden Langendoerfer and Kelly Black with 4 children ages 12-13 year's old.

Compliance List
5 CSR 25-500.032 Organization and Administration
Compliance
5 CSR 25-500.042 Licensing Process
Compliance
5 CSR 25-500.052 Annual Requirements
Compliance
5 CSR 25-500.082 Physical Requirements of Group Day Care Homes and Day Care Centers
Compliance
5 CSR 25-500.090 Disaster and Emergency Preparedness
Compliance
5 CSR 25-500.092 Furniture, Equipment and Materials
Violation
 Provider Comments
Violation
The facility did not meet requirements for large muscle activities. The facility needed an additional 4 items in this category.
Licensing Rule Reference
5 CSR 25-500.092 Furniture, Equipment and Materials (2) (B) 2. D. states: Large muscle activities;
Correction Required
The facility shall provide appropriate equipment for children as required.

Correction Verification
Submit Documentation

Compliance Date

5 CSR 25-500.102 Personnel
Compliance
5 CSR 25-500.112 Staff/Child Ratios
Compliance
5 CSR 25-500.122 Medical Examination Reports
Compliance
5 CSR 25-500.132 Admission Policies and Procedures
Compliance
5 CSR 25-500.172 Emergency School Closings
Compliance
5 CSR 25-500.182 Child Care Program
Compliance
5 CSR 25-500.192 Health Care
Violation
 Provider Comments
Violation
Requirements for immunization reports on file were not met as evidenced by 1 child's immunization record(s) was/were not on file .
Licensing Rule Reference
5 CSR 25-500.192 Health Care (4) (A) states: No child shall be permitted to enroll in or attend any day care facility caring for ten (10) or more children unless the child has been immunized adequately against vaccine preventable childhood illnesses specified by the department in accordance with recommendations of the Immunization Practices Advisory Committee (ACIP). The parent or guardian of the child shall provide satisfactory evidence of the required immunizations. Satisfactory evidence means a statement, certificate or record from a physician or other recognized health facility or personnel, stating that the required immunizations have been given to the child and verifying the type of vaccine and the month, day and year of administration.
Correction Required
Child immunization requirements shall be on file as required.

Correction Verification
Submit Documentation

Compliance Date

5 CSR 25-500.202 Nutrition and Food Service
Compliance
5 CSR 25-500.212 Transportation and Field Trips
Compliance
5 CSR 25-500.222 Records and Reports
Violation
 Provider Comments
Violation
1 child(ren) records did not include employers' address of parent(s), guardian or legal custodian.
Licensing Rule Reference
5 CSR 25-500.222 Records and Reports (2) (B) states: Full name of the parent(s), guardian or legal custodian, home address, employers' name and address, work schedule, and home and work telephone numbers;
Correction Required
Child enrollment information shall be completed and on file as required.

Correction Verification
Corrected on Site

Compliance Date
4/12/2023
Violation
1 child(ren) records did not include address of another individual who might be reached in an emergency.
Licensing Rule Reference
5 CSR 25-500.222 Records and Reports (2) (C) states: Name, address and telephone number of another individual (friend or relative) who might be reached in an emergency when the parent(s), guardian or legal custodian cannot be reached;
Correction Required
Child enrollment information shall be completed and on file as required.

Correction Verification
Submit Documentation

Compliance Date

Violation
1 child(ren) records did not include work telephone number of parent(s), guardian or legal custodian.
Licensing Rule Reference
5 CSR 25-500.222 Records and Reports (2) (B) states: Full name of the parent(s), guardian or legal custodian, home address, employers' name and address, work schedule, and home and work telephone numbers;
Correction Required
Child enrollment information shall be completed and on file as required.

Correction Verification
Corrected on Site

Compliance Date
4/12/2023
5 CSR 25-600.020 General Requirements
Compliance
5 CSR 25-600.040 Background Screening Findings
Compliance
RSMo 210.115. Reports of abuse, neglect, and under age eighteen deaths — persons required to report — supervisors and administrators not to impede reporting — deaths required to be reported to the division or child fatality review panel, when — report made to another state, when. —
Compliance
RSMo 210.211.  License required - exceptions - written notice of licensure status, when.
Compliance