Inspection · 2025-08-21
Licensing Inspector
Nanette Roberts
(757) 404-2322
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 Staffing and Supervision.
8VAC20-780 Programs.
8VAC20-780 Special Care Provisions and Emergencies
8VAC20-770 Background Checks (8VAC20-770)
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 monitoring inspection was initiated on 8/21/25 and completed on 9/29/25 in response to a self-report received by the licensing office on 8/17/25 relating to staff interactions and behavior guidance. The inspector reviewed (3) children?s records and (6) staff records on-site on 8/21/25 and 8/22/25. This inspection included document review, 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. Though not a part of the original self report, violations that were not reported were found related to staff records, background checks and supervision, and 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 10/7/25. A POC submitted after this date will not appear on the public website.
Standard 22.1-289.035-B-1
The center is required to obtain a complete sworn statement prior to the employee's first day of employment. The sworn statement for Staff #2, was completed eleven weeks after the date of hire.
Plan of Correction: The facility responded: The sworn statement for Staff #2 was completed. The program director wasretrained on the required background check process to ensure central registry searches are submitted prior to an employee?s first day of work.
Standard 22.1-289.035-B-2
The center must request a search of the central registry prior to the employee's first day of employment. Staff #2, who had been employed for 11 weeks, did not have documentation to demonstrate that a central registry search had been requested as required. Staff #2 was working alone with children when Staff #1 left the classroom to address a child in another group.
Plan of Correction: The facility responded: The central registry search for Staff #2. The program director was retrained on the required pre-employment background check process to ensure central registry searches are submitted prior to an employee?s first day of work.
Standard 8VAC20-780-240-B
Repeat Violation
Staff shall complete orientation training prior to working alone with children and no later than seven days of the date of assuming job responsibilities. Staff #2 documentation of orientation training was completed eleven weeks after the date of hire.
Plan of Correction: The facility responded: Orientation documentation for Staff #2 has been completed. The program director was retrained on orientation timelines and requirements. An onboarding checklist was implemented to ensure orientation is completed and documented within seven days of hire.
Standard 8VAC20-780-340-D
Each grouping of children shall have at least one staff regularly present who meets lead teacher qualifications. On 8/15/25 Staff #1 and Staff #2, who were not program leader qualified were alone with and supervising a group of 20, 7?8-year-old children.
Plan of Correction: The facility responded: Immediate staffing changes were made to ensure each group had a program lead.
Standard 8VAC20-780-400-B
Behavioral guidance shall be constructive in nature, age and stage appropriate, and shall be intended to redirect children to appropriate behavior and resolve conflicts. On 8/15/25 Staff #1 approached Child #1 and used inappropriate language and phrases that were not constructive or meant to resolve a conflict that Child #1 had with Child #2. Additionally, when Child #3 told Staff #1 that he was using unseemly language, Staff #1 used inappropriate language towards Child #3. Staff #2, Staff #3 and Staff #4 confirmed that Staff #1 used inappropriate language.
Plan of Correction: The facility responded: The staff member involved was immediately removed from the program and is no longer employed with the YMCA. All staff participated in a behavior guidance refresher training emphasizing positive, age-appropriate communication. Supervisors implemented a periodic spot checks and coaching
sessions to reinforce correct practices.
Standard 8VAC20-780-410-6
The following actions or threats thereof are forbidden; verbal remarks which are demeaning to the child. On August 15, 2025, Staff #1 used inappropriate and demeaning language during a verbal interaction with Child #1 and Child #2.
Plan of Correction: The facility responded: The staff member involved was immediately removed from the program and is no longer employed with the YMCA. All staff participated in a behavior guidance refresher training.
Standard 8VAC20-780-530-A
At least one staff member in each classroom or area where children are present shall have current certification in both CPR and first aid. On 8/15/25 staff #1 and staff #2 supervised a group of 20, seven and eight-year-old children and were not certified in CPR and first aid.
Plan of Correction: The facility responded: The program director was retrained on the licensing standards surrounding CPR / First Aid certification. Immediate staffing changes were made to ensure that every room had a CPR/First Aid certified staff member.
Standard 8VAC20-780-70
Repeat Violation
Staff records shall contain documentation to demonstrate that the individual possesses the education and experience required by the job position. Staff #1, who?s job title was program leader, did not have documentation of the required education and experience in the record.
Plan of Correction: The facility responded: The program director was retrained on the requirements and documentation needed to be a program lead.