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YMCA of the Virginia Peninsulas - A.T. Johnson

Inspection · 2025-08-01

Date
2025-08-01
Complaint Related
No
Licensing Inspector
Cindy Horne
(804) 297-4469
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.
8VAC20-820 THE LICENSING PROCESS.
8VAC20-820 HEARINGS PROCEDURES.
8VAC20-770 Background Checks

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 and completed on 8/01/2025. The on-site inspection began at 11:10 a.m. and ended at 12:30 p.m. The inspector reviewed compliance in the areas listed above. There were 10 children present and three staff. The inspector reviewed seven children?s records and five staff records on site. This inspection included document review (i.e. daily schedule, menu, license, previous inspection, attendance records, injury reports, and emergency drill logs), tour of the facility, interviews, and 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 violation will be or has been corrected. Submit your POC within five business days from today, which will be the close of business on 8/12/2025. A POC submitted after this date will not appear on the public website.

Violations

5
Standard 22.1-289.035-A
(Repeat/Systemic Violation) The center is required to have employees undergo a background check every five years. The most recent central registry check for staff #5 was overdue by two years and eight months.
Plan of Correction: Updated CR requested from HR.
Standard 8VAC20-780-160-A
Each center shall maintain and keep at the center a separate record for each child enrolled that contains all of the required information. There was no record for Child #6.

Children?s records must contain the name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached. The record of Child #4 contained one emergency contact.
Plan of Correction: Record was located in the bottom of file box. Will be placed in folder and audited. Updated EM contact requested for C4.
Standard 8VAC20-780-550-P
The center shall maintain a written record of children's serious and minor injuries in which entries are made the day of occurrence. The record shall include the date and time when parents were notified and be signed by two staff or one staff and one parent. The injury report for Child #7 did not contain the date and time when parents were notified or any staff or parent signatures.
Plan of Correction: Injury reports will have time stamp for parent notification. Staff retrained on topic.
Standard 8VAC20-780-70
(Repeat/Systemic Violation) The name, address, and telephone number of a person to be notified in an emergency shall be kept at the center for each staff member. Staff #5 had no emergency contact information.

Documentation of at least 2 references to character, reputation, and competency are to be checked prior to employment. Staff #5, did not have any completed reference verifications on file.

Staff #5 did not have information about any health problems that may interfere with fulfilling the job responsibilities at the center as required.
Plan of Correction: Missing items requested from HR.
Standard 8VAC20-780-90-A
A written agreement between the parent and the center shall be in each child's record by the first day of the child's attendance that addresses emergency medical care, the policy to follow when the child is ill, and the policy to follow regarding communicable diseases. There was no agreement in the file of Child #5 that addressed these issues.
Plan of Correction: Agreement printed and added to file. Digital copies can be located online with registration.
View original record on Virginia Department of Social Services