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YMCA of Metropolitan Washigton at First Assembly of God

Inspection · 2025-08-19

Date
2025-08-19
Complaint Related
No
Licensing Inspector
Kimberly Weaver
(571) 596-3662
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 (8VAC20-770)
20 Access to minor?s records
22.1 Background Checks Code, Carbon Monoxide
22.1 Potable Water Lead Testing
63.2 Child Abuse & Neglect

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 monitoring inspection was conducted on 08/19/2025 from 9:40am to 11:56am. There were 28 chldren and 11 staff present. The inspector reviewed 6 child records and 3 staff records on-site.The inspection included document review, interviews, observations, and a tour of the facility. 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.

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 8/28/2025. A POC submitted after this date will not appear on the public website.

Violations

9
Standard 22.1-289-036-B-4
SYSTEMIC DEFICIENCY
The child day center is required to obtain background checks from any state in which the individual has resided in the presceding 5 years.

The record for Staff #1, employed for almost 2 months, did not contain documentation of an out of state central registry search.

The record for Staff #2, employed for almost 2 years, did not contain documentation of an out of state central registry or criminal history search for one state. The center did not obtain the results of a central registry check for the second state until 22 months after the first date of employment.
Plan of Correction: A central registry request was first submitted and paid for on 7/1/2025. It was returned for revisions and resubmitted 8/8/2025. Waiting for resutls for Staff #1 from central registry.

Staff #2 out of state background check for one state was found in records after the time of inspection. It was filed in binder correctly (8/19/2025). Staff #2 has also now went to complete the out of state background checks for the other state. Awaiting findings (8/25/2025).
Standard 8VAC20-780-130-E
The center shall obtain documentation of additional immunizations once every 6 months for children under the age of 2 years.

The record for Child #2, #3, and #4 did not contain documentation of updated immunizations.
Child #2 was overdue by 14 months.
Child #3 was overdue by 10 months.
Child #4 was overdue by 11 months.
Plan of Correction: Review the health forms of chlidren under the age of 2 every 6 months to ensure immunizations are updated.
Standard 8VAC20-780-160-A
Each staff member shall submit documentatin of a negative tuberculosis (TB) screening at the time of employment and prior to coming into contact with children.

The record for Staff #1, employed for almost 2 months and working with children, did not contain results of a TB screening.
Plan of Correction: Ensrue all staff TB screenings are complete during the required deadlines.
Staff #1 competed TB screening with results.
Standard 8VAC20-780-240-B
Staff shall complete orientation training, which includes child abuse and neglect, prior to the staff member working alone with children and no later than 7 days of the date of assuming job responsibilities.

The record for Staff #1, employed for almost 2 months, did not contain documentation of orientation completion.
Plan of Correction: Staff #1 has completed child abuse and neglect taining and orientation training.
Standard 8VAC20-780-270-A
Areas and equipment of the center shall be maintained in a safe condition.

In the Purple classroom, 1 out of 3 infant cribs contained a loose fitting sheet, causing it to bunch up and pose a suffocation risk.
Plan of Correction: Advised staff to ensure crib sheets are fitted correctly on mattresses to ensure safety of children. Instructed staff to re-take Safe Sleep Training as a refresher course.
Standard 8VAC20-780-420-E-3
At least annually, staff shall request parent confirmation that the required information in the child's record is up to date.

The record for Child #5, enrolled for 17 months, did not contain documentation of an annual update.
Plan of Correction: Send out letter to parents requesting that anytime their child is given any immunizations to inform the center so that the childs health information on record at the center is up to date.
Standard 8VAC20-780-430-B
Materials and equipment shall be age and stage appropriate for the child.

The crib for Child #1, age 9 months, was observed with the crib mattress raised. Based on the manufacturer recommendations, the mattress was not at the appropriate level for the stage of the child.
Plan of Correction: Speak wiht staff regarding safety in the classrooms. Review the classroom checklist to ensure all items listed are checked daily, which includes the height levels on cribs and shelves.
Standard 8VAC20-780-520-C
If diaper ointment or cream is used, the center shall obtain written parent authorization noting any known adverse reactions.

In the Purple classroom, 3 out of 3 children had diaper ointments or creams without written authorizations from parents. Staff stated the ointments/creams are used as needed.
Plan of Correction: Send out to parents a copy of the authorization form giving the staff authorization to apply any and all over the counter skin creams, ointments or repellent on child.
Standard 8VAC20-780-70
The center must keep a separate record for each staff that contains all of the required information.

The record for Staff #1, employed for almost 2 months, did not contain a name, address, and telephone number of a person to be notified in an emergency; documentation of 2 reference checks; health problems that may interfere with fulfilling the job responsibilities.
Plan of Correction: Check each staff binder to ensure all upddated documentation is included according to the licesning deadlines.
View original record on Virginia Department of Social Services