Inspection · 2025-06-16
Licensing Inspector
Rene Old
(757) 404-1784
SHSIA monitoring inspection of an approved subsidy vendor to determine compliance with current subsidy requirements regarding the health and safety of children and to promote quality standards for the children in their care.
No
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)
22.1 Background Checks Code, Carbon Monoxide
63.2 Child Abuse & Neglect
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 06/16/2025 from 3:20 pm - 4:30 pm. There were 29 children present and 5 staff. The inspector reviewed 2 children's records on-site on 06/16/2025.
The inspection was completed on 06/17/2025 (10:00 am - 10:45 am) with a review of five staff records at the Greenbrier North YMCA which is the central location for staff records.
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 06/30/2025. A POC submitted after this date will not appear on the public website.
Standard 22.1-289.011-F
The most recent inspection finding documents required by the Superintendent shall be posted in a conspicuous place on the licensed premises.
The most recent inspection summary and violation notice, for the monitoring inspection conducted on 01/29/2025, were not posted when the inspection arrived on 06/16/2025 at 3:20 pm
Plan of Correction: The program director will retrain the staff on-site to ensure that they put the licensing board up daily during their opening duties. The program director will complete weekly audits to ensure this is being done.
Standard 22.1-289.035-B-1
Provide a sworn statement or affirmation disclosing whether he has ever been convicted of or is the subject of pending charges for any offense within or outside the Commonwealth and whether he has been the subject of a founded complaint of child abuse or neglect within or outside the Commonwealth.
The sworn statement or affirmation completed by staff 3 lacks documentation regarding out-of-state residence within the past five years. Staff 3 has a hire date of 03/11/2025.
Plan of Correction: The program director will ensure all new hires complete the Sworn Statement or Affirmation prior to being hired.
Standard 8VAC20-780-160-A
The documentation of the TB screening shall have been completed within the last 30 calendar days of the date of employment.
The TB screening for staff 3 was obtained on 03/25/2025 which is after the hire date of 03/11/2025.
Plan of Correction: The youth director will ensure that staff will not be hired until they have completed a TB screening.
Standard 8VAC20-780-200-A
The center shall have a qualified program director or a qualified back-up program director who meets one of the director qualifications who shall regularly be on site at least 50% of the center's hours of operation.
The individual designated as the program director is not present at the facility at least 50% of the center's hours of operation according to staff interviews. Staff stated that the designated program director was at the site once every 2 weeks. The program director was not on site during the inspection on 06/16/2025 and the individual designated as being in charge does not meet program director qualifications.
Plan of Correction: The program director will ensure that they are at each of their designated programs at least 50% of the time. The program director will notify their supervisor if there are any changes to their schedule so that they can ensure this standard is continually met.
Standard 8VAC20-780-240-A
The Virginia Department of Education-sponsored orientation course shall be completed within 90 calendar days of employment.
Staff 2, hire date 02/07/2025, lacks documentation of completion of the VDOE sponsored orientation course.
Plan of Correction: The program director will ensure that all staff complete the VDOE orientation courses within 90 days of hire.
Standard 8VAC20-780-40-D
The license shall be posted in a place conspicuous to the public (? 22.1-289.011 of the Code of Virginia).
The current license issued by the Virginia Department of Education was not posted when the inspector arrived on 06/16/2025 at 3:20 pm.
Plan of Correction: The program director will retrain the staff on-site to ensure that they put the licensing board up daily during their opening duties. The program director will complete weekly audits to ensure this is being done.
Standard 8VAC20-780-550-C
Emergency evacuation and shelter-in-place procedures or maps shall be posted in a location conspicuous to staff and children on each floor of each building.
The emergency evacuation and shelter-in-place procedures were not posted in the facility when the inspector arrived at 3:20 pm on 06/16/2025.
Plan of Correction: The program director will retrain the staff on-site to ensure that they put the licensing board up daily during their opening duties. The program director will complete weekly audits to ensure this is being done.
Standard 8VAC20-780-550-I
A 911 or local dial number for police, fire and emergency medical services and the number of the regional poison control center shall be posted in a visible place at each telephone.
Emergency phone numbers were not posted when the inspector arrived at 3:20 pm on 06/16/2025.
Plan of Correction: The program director will retrain the staff on-site to ensure that they put the licensing board up daily during their opening duties. The program director will complete weekly audits to ensure this is being done.
Standard 8VAC20-780-560-F
When centers choose to provide snacks a menu listing foods to be served during the current one-week period shall be posted in a location conspicuous to parents.
The snack menu was not posted when the inspector arrived at 3:20 pm on 06/16/2025.
Plan of Correction: The program director will retrain the staff on-site to ensure that they put the licensing board up daily during their opening duties. The program director will complete weekly audits to ensure this is being done.
Standard 8VAC20-780-70
Staff records shall contain all required elements.
The employment file for staff 1 lacked documentation of a hire date.
The employment file for staff 2 lacked documentation of all required orientation training.
Plan of Correction: The program director will ensure all staff files are properly completed with a hire date and orientation training is done on the first day that they are on the floor.
Standard 8VAC20-780-80-B-2
The center shall inform the department's representative as soon as practicable, but not to exceed two business days, of any injury to a child that occurs while the child is under the supervision of the center and requires outside medical attention.
Child 1 received an injury, while in care on 05/30/2025, that required outside medical attention. The facility did not report this injury to the department's representative until 06/05/2025.
Plan of Correction: Staff have been retrained on incident and accident procedures, including notifying their supervisor so that injuries can be reported within two business days.