Inspection · 2025-02-03
(757) 404-1784
Areas Reviewed
8VAC20-780 Administration.
8VAC20-780 Staff Qualifications and Training.
8VAC20-780 Physical Plant.
8VAC20-780 Staffing and Supervision.
8VAC20-780 Programs.
8VAC20-780 Special Care Provisions and Emergencies
8VAC20-780 Special Services.
8VAC20-820 THE LICENSE.
8VAC20-770 Background Checks (8VAC20-770)
20 Access to minor?s records
22.1 Background Checks Code, Carbon Monoxide
During the inspection, the inspector reviewed the areas listed above to include standards found out of compliance during the previous inspection. Unless otherwise noted as a violation within this inspection report, the provider was in compliance with the standards reviewed. If there were any serious injuries or fatalities related to a violation, the details will be included in the description of the violation.
Inspector Notes
An unannounced , on-site monitoring inspection was initiated on 02/03/2025 and completed on 02/03/2025. The on-site inspection began at 3:10 pm and ended at 4:55 pm. The inspector reviewed compliance in the areas listed above. There were 48 children present and 2 staff. The inspector reviewed 8 children's records on-site and 1 staff record electronically on 02/04/2025.
The inspection included:
*Document Review
*Tour of the Facility
*Interviews
*Observations
Information gathered during the inspection determined non-compliance with applicable standards or law, and violations are documented on the violation notice issued to the program.
Please complete the plan of correction (POC) and date to be corrected sections for each violation cited on the violation notice. Specify how the deficient practice will be or has been corrected. Submit your POC within five (5) business days from today, which will be the close of business on 02/14/2025. A POC submitted after this date will not appear on the public website.
Violations
5Ratio Requirements:
*School age eligible up to 9 years - 1:18
*9 years through 12 years - 1:20
There were 2 staff supervising 48 children, ages 5 years - 12 years, at 3:10 pm. 3 staff were needed to meet the required ratio of 1:18.
2 staff continued to supervise more than 36 children until approximately 4:15 pm.
Steps taken to prevent concerns/violations from occurring in the future for ALL YMCA programs:
Revision of current operating policies relating to program coverage when employees are late or don't show to work. All employees are expected to arrive at the program no later than 30 minutes prior to the program start time. If the employee has not shown and cannot be reached by phone within 20 minutes of the program start time, the Youth Development Director will be notified by phone and he/she will ultimately provide shift coverage if a substitute is unable to be secured. To help staff with communication, program phones (part of the Y's enhanced technology package) will be pre-programmed with the Youth Development Director's contact information. In the event the Youth Development Director cannot be contacted, the employee will initiate the Emergency Site Coverage Procedures, calling for support using the center-specific phone tree.
Timeline: Hiring staff currently, expect to have two more staff members this week. (2/10/25 - 2/14/25)
The facility did not follow YMCA policy for departure when a child was picked up during the inspection.
The program director stated that a practice fire drill was not conducted in January 2025.
The emergency practice log for the program did not have written documentation of the required 2nd shelter-in-place practice drill for 2024.
*6 of 9 injury reports reviewed lacked written documentation of the time the parent was notified of the injury.
*5 of 9 injury reports reviewed lacked a second signature from either a parent or staff.
*3 of 9 injury reports reviewed lacked written documentation of how the parent was notified of the injury.