Inspection · 2026-03-24
Date
2026-03-24
Complaint Related
No
Licensing Inspector
Emily Walsh
(757) 404-2575
(757) 404-2575
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.
Yes
Areas Reviewed
Areas of Standards 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
8VAC20-821 Licensure Requirements
8VAC20-821 Renewal
8VAC20-821 Application Fees
8VAC20-821 Background Checks
8VAC20-821 Standards of Conduct
8VAC20-821 Violation Review
8VAC20-821 Sanctions
8VAC20-821 Appeals
20 Access to minor?s records
22.1 Early Childhood Care and Education
63.2 Child Abuse & Neglect
8VAC20-790 Introduction
8VAC20-790 Administration
8VAC20-790 Staff Qualifications & Training
8VAC20-790 Physical Plant
8VAC20-790 Staffing & Supervision
8VAC20-790 Programs
8VAC20-790 Special Care Provisions & Emergencies
8VAC20-790 Special Services
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 03/24/2026, as a part of the licensure period. The on-site inspection began at 3:30 PM and ended at 6:15 PM. The inspector reviewed compliance in the areas listed above. There were 48 children present and 5 staff. The inspector reviewed 8 children?s records and 1 staff orientation record on-site and 3 staff records electronically on 03/25/2026.
This inspection included:
? document review,
? tour of the facility,
? interviews, and
? observations.
A subsidy health and safety inspection (SHSI) was conducted in conjunction with the licensing inspection. Subsidy standards that are not covered in licensing standards were reviewed during this SHSI, and this single inspection report reflects findings related to licensing standards and subsidy standards.
Information gathered during the inspection determined noncompliance 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 April 1, 2026. A POC submitted after this date will not appear on the public website.
Violations
16Standard 22.1-289-036-B-4
Authorize the child day center to obtain a copy of the results of a search of the child abuse and neglect registry or equivalent registry from any state in which the individual has resided in the preceding five years.
Staff 3 resided in Florida within the past years. The facility did not obtain results of a search of the abuse and neglect registry in Florida. Staff 3 has been employed over 90 days.
Staff 3 resided in Florida within the past years. The facility did not obtain results of a search of the abuse and neglect registry in Florida. Staff 3 has been employed over 90 days.
Plan of Correction: Facility response
The facility immediately submitted a request to the Florida Abuse and Neglect Registry to obtain the required out-of-state search results for Staff 3.A full audit of all staff background-check files was conducted to ensure no additional
out-of-state registry checks were missing.
The facility immediately submitted a request to the Florida Abuse and Neglect Registry to obtain the required out-of-state search results for Staff 3.A full audit of all staff background-check files was conducted to ensure no additional
out-of-state registry checks were missing.
Standard 8VAC20-780-160-A
Repeat violationEach staff member and individual from an independent contractor shall submit documentation of a negative tuberculosis screening. The documentation shall have been completed within the last 30 calendar days of the date of employment.
The tuberculosis screening for staff 3 was not obtained until 17 days after employment.
The tuberculosis screening for staff 3 was not obtained until 17 days after employment.
Plan of Correction: Facility response
All administrative staff responsible for onboarding will complete refresher training within on: TB screening requirements.Required timelines (within 30 calendar days of employment) Documentation and verification procedures.
All administrative staff responsible for onboarding will complete refresher training within on: TB screening requirements.Required timelines (within 30 calendar days of employment) Documentation and verification procedures.
Standard 8VAC20-780-240-E
Within 30 days of the first day of employment, staff must complete orientation training in first aid and cardiopulmonary resuscitation (CPR), as appropriate to the age of the children in care.
Staff 3 has been employed over 90 days and the record id not include documentation that staff 3 had orientation regarding first aid and CPR,
Staff 3 has been employed over 90 days and the record id not include documentation that staff 3 had orientation regarding first aid and CPR,
Plan of Correction: Facility response
Administrative staff reviewed all current employee files to verify First Aid/CPR orientation documentation, in which it was completed within the required 30-day timeframe.
Any missing or outdated documentation was identified and corrected.
Administrative staff reviewed all current employee files to verify First Aid/CPR orientation documentation, in which it was completed within the required 30-day timeframe.
Any missing or outdated documentation was identified and corrected.
Standard 8VAC20-780-350-B-5
The staff to child ratio required for school age eligible up to 9 years is a follows: ratio 1:18 (staff:children).
From 3:40 PM to 4:03 PM there were 48 children from age 5 and older in care in the gymnasium with two staff. Staff were entering and leaving the gymnasium but until 4:03 PM there were never more than 2 staff on duty at the same time.
From 3:40 PM to 4:03 PM there were 48 children from age 5 and older in care in the gymnasium with two staff. Staff were entering and leaving the gymnasium but until 4:03 PM there were never more than 2 staff on duty at the same time.
Plan of Correction: Facility response
Staff were assigned to all arrival zones: bus unloading, entry doors and classroom entrances/zones.Children remain with staff at all times during transitions with no unsupervised movement.Bus riders escort children to the program and ensure physical transfer of care with onsite staff. Staff greet and receive children directly from the bus.Children are not permitted to exit a vehicle or enter the building without supervision.
Staff were assigned to all arrival zones: bus unloading, entry doors and classroom entrances/zones.Children remain with staff at all times during transitions with no unsupervised movement.Bus riders escort children to the program and ensure physical transfer of care with onsite staff. Staff greet and receive children directly from the bus.Children are not permitted to exit a vehicle or enter the building without supervision.
Standard 8VAC20-780-50-A
Children's records shall be treated confidentially.
There were two notebooks containing the children's reenrollment and health records on an open table in the gymnasium.
There were two notebooks containing the children's reenrollment and health records on an open table in the gymnasium.
Plan of Correction: Facility response
The two notebooks containing children?s reenrollment and health records were immediately removed from the open table in the gymnasium and secured in the locked administrative office.
Staff on duty were instructed to ensure no confidential records are ever left unattended or accessible to unauthorized individuals.
A full review of the notebooks was conducted to confirm all documents were accounted for.
The two notebooks containing children?s reenrollment and health records were immediately removed from the open table in the gymnasium and secured in the locked administrative office.
Staff on duty were instructed to ensure no confidential records are ever left unattended or accessible to unauthorized individuals.
A full review of the notebooks was conducted to confirm all documents were accounted for.
Standard 8VAC20-780-500-A
Children's hands shall be washed with soap and running water or disposable wipes before and after eating snacks.
Children were observed eating snack without washing or using wipes before or after eating the snacks.
Children were observed eating snack without washing or using wipes before or after eating the snacks.
Plan of Correction: Facility response
All staff, including those assigned to snack supervision, will receive refresher training on:Proper handwashing procedures. When handwashing or wipes are required (before and after meals/snacks). Supervisory responsibilities during meal and snack times.
All staff, including those assigned to snack supervision, will receive refresher training on:Proper handwashing procedures. When handwashing or wipes are required (before and after meals/snacks). Supervisory responsibilities during meal and snack times.
Standard 8VAC20-780-510-B
Prescription medication shall be given to a child according to the written medication policies and only with written authorization from the parent.
Staff 5 administered a controlled prescription medication to child 9 nine times during September 2025 without written authorization from the parent. The staff did not follow the facility's medication policy requiring written parental permission.
Staff 5 administered a controlled prescription medication to child 9 nine times during September 2025 without written authorization from the parent. The staff did not follow the facility's medication policy requiring written parental permission.
Plan of Correction: Facility response
Staff 5 will complete retraining on the facility?s Medication Administration Policy, including: Requirements for written parental authorization prior to administering any prescription medication. Procedures for documenting medication administration. Handling and storage of controlled medications. Child 9?s parents was notified, and a full review of all medication logs for September 2025 was completed to ensure no additional unauthorized administrations occurred.
Staff 5 will complete retraining on the facility?s Medication Administration Policy, including: Requirements for written parental authorization prior to administering any prescription medication. Procedures for documenting medication administration. Handling and storage of controlled medications. Child 9?s parents was notified, and a full review of all medication logs for September 2025 was completed to ensure no additional unauthorized administrations occurred.
Standard 8VAC20-780-510-F
Medication authorization shall be available to staff during the entire time it is effective.
There were three prescription medications stored for potential administration to child 10 in an emergency without written parent authorization
There were two prescription medications stored for potential administration to child 11 in an emergency without written parent authorization.
There were two prescription medications stored for potential administration to child 12 in an emergency without parental permission.
There were three prescription medications stored for potential administration to child 10 in an emergency without written parent authorization
There were two prescription medications stored for potential administration to child 11 in an emergency without written parent authorization.
There were two prescription medications stored for potential administration to child 12 in an emergency without parental permission.
Plan of Correction: Facility response
A monthly medication check protocol is now in place.All staff administering medication were retrained on proper storage, documentation, and communication with parents.
A monthly medication check protocol is now in place.All staff administering medication were retrained on proper storage, documentation, and communication with parents.
Standard 8VAC20-780-510-P
When an authorization for medication expires, the parent shall be notified that the medication needs to be picked up within 14 days or the parent must renew the authorization. Medications that are not picked up by the parent within 14 days will be disposed of by the center by either dissolving the medication down the sink or flushing it down the toilet.
Staff 5 and 6 acknowledged that there were several medications stored in the medication box for children who were no longer in attendance that were not returned to the parents or disposed of by the previous facility director.
Staff 5 and 6 acknowledged that there were several medications stored in the medication box for children who were no longer in attendance that were not returned to the parents or disposed of by the previous facility director.
Plan of Correction: Facility response
All medications belonging to children no longer in attendance were immediately removed from the medication box.
Parents of currently enrolled children with expired authorizations were notified the same day and instructed to either renew the authorization and returned to parents.
Any medications past the 14-day window were disposed of according to policy (dissolved in the sink or flushed), and disposal was documented.
All medications belonging to children no longer in attendance were immediately removed from the medication box.
Parents of currently enrolled children with expired authorizations were notified the same day and instructed to either renew the authorization and returned to parents.
Any medications past the 14-day window were disposed of according to policy (dissolved in the sink or flushed), and disposal was documented.
Standard 8VAC20-780-560-F
When centers choose to provide snacks, the most recent, age appropriate nutritional requirements of the Child and Adult Care Food Program of the United States Department of Agriculture (USDA) shall apply, required two food components for each snack. A menu listing foods served during the current one-week period shall list any substituted food.
The children were given pretzels for afternoon snack, representing only one food group component.
The posted menu did not indicate that pretzels would be served for afternoon snack today.
The children were given pretzels for afternoon snack, representing only one food group component.
The posted menu did not indicate that pretzels would be served for afternoon snack today.
Plan of Correction: Facility response
A weekly YMCA snack menu template is posted in the designated snack space each month. Staff are trained to check that the menu reflects actual snack items available, and any substitutions are documented.Site leads are responsible for verifying that the menu is posted and matches what is served.
A weekly YMCA snack menu template is posted in the designated snack space each month. Staff are trained to check that the menu reflects actual snack items available, and any substitutions are documented.Site leads are responsible for verifying that the menu is posted and matches what is served.
Standard 8VAC20-780-560-J
Tables shall be sanitized before and after each use for feeding.
The tables were not sanitized before and after the children ate snack as the children were eating snacks while sitting at tables where children who were not eating were doing homework or other activities.
The tables were not sanitized before and after the children ate snack as the children were eating snacks while sitting at tables where children who were not eating were doing homework or other activities.
Plan of Correction: Facility response
The supervising staff were reminded of the requirement to sanitize tables before and after each feeding use.All staff will receive refresher training on:Proper sanitation procedures for tables used for meals and snacks. When and how to sanitize before and after feeding. Supervisory responsibilities during transitions between activities and snack time.
The supervising staff were reminded of the requirement to sanitize tables before and after each feeding use.All staff will receive refresher training on:Proper sanitation procedures for tables used for meals and snacks. When and how to sanitize before and after feeding. Supervisory responsibilities during transitions between activities and snack time.
Standard 8VAC20-780-560-M
No child shall be allowed to drink or eat while walking around.
Children were observed walking around the gymnasium and talking with children and staff while eating pretzels given to them by the facility for snack or while eating snack items from their school back packs.
Children were observed walking around the gymnasium and talking with children and staff while eating pretzels given to them by the facility for snack or while eating snack items from their school back packs.
Plan of Correction: Facility response
All staff received refresher training on:Proactive classroom management. Behavior guidance techniques appropriate for school-age youth. How to identify and respond to escalating behavior before it becomes disruptive or unsafe. Afternoon structure was revised to include:More active engagement (staff-led games, small group rotations) A designated staff member is stationed to oversee and redirect as needed. Leadership completes weekly observations and gives immediate feedback to staff when redirection is missed.
All staff received refresher training on:Proactive classroom management. Behavior guidance techniques appropriate for school-age youth. How to identify and respond to escalating behavior before it becomes disruptive or unsafe. Afternoon structure was revised to include:More active engagement (staff-led games, small group rotations) A designated staff member is stationed to oversee and redirect as needed. Leadership completes weekly observations and gives immediate feedback to staff when redirection is missed.
Standard 8VAC20-780-60-A
Each center shall maintain and keep at the center a separate record for each child enrolled which shall contain the names, addresses, employment information and telephone numbers for parents or custodians.
The record provided for child 6 did not include any information regarding the child's father.
The record provided for child 6 did not include any information regarding the child's father.
Plan of Correction: Facility response
The child?s enrollment record was immediately updated to include the information that the father?s name, address, employment information, and telephone number.
The parent was contacted the same day to obtain all missing information, and documentation was added to the child?s file upon receipt.
The child?s enrollment record was immediately updated to include the information that the father?s name, address, employment information, and telephone number.
The parent was contacted the same day to obtain all missing information, and documentation was added to the child?s file upon receipt.
Standard 8VAC20-780-60-A-8
Each child's record shall contain a written care plan for each child with a diagnosed food allergy, to include instructions from a physician regarding the food to which the child is allergic and the steps to be taken in the event of a suspected or confirmed allergic reaction.
The record provided for child 10 indicated a life threatening allergy, however there was no allergy management plan indicating actions to take in an emergency.
The record provided for child 10 indicated a life threatening allergy, however there was no allergy management plan indicating actions to take in an emergency.
Plan of Correction: Facility response
A Child File Tracker is maintained by program leadership to monitor the status of each child?s enrollment documents in real time. The tracker includes key elements such as physicals, emergency contacts, authorized pick-ups, immunization records, and signed consents.Files are color-coded or flagged (e.g., green = complete, yellow = pending, red = hold). The tracker is reviewed weekly by site leadership and is used to ensure no child is admitted to the program until all required documentation is collected and verified.Any file placed on ?hold? is communicated to the parent and documented in the tracker with a reason code (e.g., missing immunization form).Leadership performs monthly audits to ensure all records remain up to date and compliant.
A Child File Tracker is maintained by program leadership to monitor the status of each child?s enrollment documents in real time. The tracker includes key elements such as physicals, emergency contacts, authorized pick-ups, immunization records, and signed consents.Files are color-coded or flagged (e.g., green = complete, yellow = pending, red = hold). The tracker is reviewed weekly by site leadership and is used to ensure no child is admitted to the program until all required documentation is collected and verified.Any file placed on ?hold? is communicated to the parent and documented in the tracker with a reason code (e.g., missing immunization form).Leadership performs monthly audits to ensure all records remain up to date and compliant.
Standard 8VAC20-790-600-D-1
Staff shall have current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care within 90 days of employ. The training shall include an in-person competency demonstration.
The record provided for staff 3 did not include documentation of current CPR certification. Staff 3 has been employed over 90 days.
The record provided for staff 3 did not include documentation of current CPR certification. Staff 3 has been employed over 90 days.
Plan of Correction: Facility response
Administrative staff reviewed all current employee files to verify First Aid/CPR orientation documentation, in which it was completed within the required 30-day timeframe.
Any missing or outdated documentation was identified and corrected.
Administrative staff reviewed all current employee files to verify First Aid/CPR orientation documentation, in which it was completed within the required 30-day timeframe.
Any missing or outdated documentation was identified and corrected.
Standard 8VAC20-790-600-D-2
Staff shall obtain current certification in first aid appropriate to the ages of children in care within 90 days of hire.
The record provided for staff 3 did not include documentation of current first aid certification. Staff 3 has been employed over 90 days.
The record provided for staff 3 did not include documentation of current first aid certification. Staff 3 has been employed over 90 days.
Plan of Correction: Facility response
Administrative staff reviewed all current employee files to verify First Aid/CPR orientation documentation, in which it was completed within the
required 30-day timeframe.
Any missing or outdated documentation was identified and corrected.
Administrative staff reviewed all current employee files to verify First Aid/CPR orientation documentation, in which it was completed within the
required 30-day timeframe.
Any missing or outdated documentation was identified and corrected.