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YMCA SACC at Falmouth Elementary School

Inspection · 2025-09-18

Date
2025-09-18
Complaint Related
No
Licensing Inspector
Laura Brindle
(540) 905-2062
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 Special Care Provisions and Emergencies.
8VAC20-780 Special Services.
22.1 Early Childhood Care and Education, 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 on 9/18/25 and completed on 9/25/25. The on-site inspection began at 6:50am and ended at 7:50am. The inspector reviewed compliance in the areas listed above. There were 16 children present and two staff. The inspector reviewed five children?s records and four staff records on-site and electronically. This inspection included document review, 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 (5) business days from today, which will be the close of business on 10/6/25. A POC submitted after this date will not appear on the public website.

Violations

3
Standard 8VAC20-780-150-B
Immunization and physical reports are required to be signed by a physician, his designee, or an official of a local health department.

The immunizations on record for Child A and Child D did not include a physician?s signature or stamps. The physical on record for Child D did not include a physician?s signature or stamp.
Plan of Correction: Reached out to parent to get updated physical.
Standard 8VAC20-780-160-B
Acceptable forms of documentation of tuberculosis (TB) screening are a clearance statement signed by a physician, the physician?s designee or an official of the health department; the statement shall include language that the individual does not have any current symptoms of active tuberculosis, does not have either a risk factor for acquiring tuberculosis infection or a risk factor for progression to active tuberculosis disease as defined by the local health department, or has been treated for these conditions in the past, and is currently free of tuberculosis in a communicable form.

The most recent TB screening on record for Staff #3 did not include language from a physician clearing the individual from showing symptoms of active tuberculosis. The documentation only included a self-assessment completed by the individual.
Plan of Correction: Ensure staff have proper paperwork for TB screening to clear individual from showing symptoms of active tuberculosis.
Standard 8VAC20-780-70
The program is required to ensure that staff records contain all of the required documentation.

The record for Staff #1 did not include documentation to demonstrate that the individual possesses the education, certification, and experience required by the job position.
Plan of Correction: Ensure staff member continues with education to qualify as Assistant Manager.
View original record on Virginia Department of Social Services