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YMCA SACC at Falmouth Elementary School

Inspection · 2025-10-22

Date
2025-10-22
Complaint Related
Yes
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 Staffing and Supervision.
8VAC20-780 Programs.

During the inspection, the inspector reviewed the areas listed above. 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 inspection was initiated and completed on 10/22/25 in response to a complaint received by the licensing office on 10/20/25 relating to allegations regarding the care and protection of children and operating outside of the license. This inspection included document review, interviews, and observations. The preponderance of evidence gathered during the investigation supports the allegations; therefore, the complaint is determined to be valid. Information gathered during the inspection determined non-compliance with applicable standards or law and the violations are documented on the violation notice issued to the program. Though not a part of the original complaint, a violation that was not reported was found related to ratio and is 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 11/13/25. A POC submitted after this date will not appear on the public website.

Violations

2
Standard 8VAC20-780-350-C
When children are in ongoing mixed age groups, the staff-to-children ratio applicable to the youngest child in the group is required to apply to the entire group.

On 10/22/25 at approximately 3:00pm, 37 children were observed being supervised by two staff. Another child and another staff member arrived moments later, leaving 38 children supervised by three staff. The youngest child on site was four-years-old and required a ratio of 1 staff to 10 children. The four-year-old had attended daily since August and the program was operating at a 1:18 ratio.
Plan of Correction: Ensure staff are complying with ratio during program hours.
Standard 8VAC20-780-40-E
The licensee is required to ensure that the center?s activities, services, and facilities are maintained in compliance with the standards, the center?s own policies and procedures that are required by the standards, and the terms of the current license issued by the department.

The program is a school age childcare program licensed for children aged five-years to 12-years-old. On 10/22/25 a four-year-old was observed in the program and interview revealed that the child has been attending daily since August 2025.
Plan of Correction: Ensure all children attend the program are between the ages of 5-12.