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The YMCA Of South Hampton Roads - Deep Creek Central

Inspection · 2026-03-24

Date
2026-03-24
Complaint Related
No
Licensing Inspector
Heather Harrell
(757) 334-4329
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

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 Background Checks
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 3/24/26. The on-site inspection began at 3:05pm and ended at 4:05pm. The inspector reviewed compliance in the areas listed above. There were 71 children present and 5 staff. The inspector reviewed 7 children's records on-site and 7 staff records at a central location on 3/19/26. This inspection included document review, a 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.

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 4/6/26. A POC submitted after this date will not appear on the public website.

Violations

5
Standard 8VAC20-780-160-C
Repeat Violation
A tuberculosis (TB) screening is required every two years from the last screening. Staff 1's updated TB screening was completed five months after it was due.
Plan of Correction: Not available online. Contact Inspector for more information.
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 shall apply to the entire group. At the time of the inspection, there were 71 children in care, ages 5 years to 11 years, with 3 staff from approximately 3:00pm until 3:35pm. The required ratio for 5-year old's is 1 staff per 18 children. The number and ages of the children required 4 staff to be present.
Plan of Correction: The center responded with the following: Same-Day Response: The Site Supervisor adjusted group assignments and temporarily consolidated groups to ensure continuous supervision and safety of all children until coverage was restored. Support from Leadership: Additional coverage was provided by staff who left, and
the additional staff member who was picked up as they arrived during the inspection on March 24th, 2026. At the conclusion of the inspection, there were 5 staff present. Staff Meeting: All staff will attend a mandatory meeting on Wednesday, March 25th, 2026 to discuss the lack of procedure followed on Tuesday, March 24th, 2026. Training: All staff, completed required onboarding, including training on ratio compliance, active supervision, call-out/late procedures, and emergency response.
Staff Call Out Procedures: Staff are to call out each day by 10am to ensure the Youth Director has adequate time to obtain proper coverage. If staff are going to be
late, they are to notify their Youth Director immediately, again, so the Youth Director is able to find coverage. Staffing Contingency Plan: A substitute pool has been established to provide immediate backup coverage in the event of absences/tardiness. Ongoing Recruitment: Continuous recruitment efforts are maintained to sustain a pipeline of qualified staff. Weekly Audits: The Program Director will complete daily ratio audits and report findings to YMCA leadership. Professional Development: Ongoing coaching sessions will reinforce the importance of supervision, ratios, and program quality aligned with YMCA youth development principles of safety, responsibility, and caring supervision. As of March 24th, the Deep Creek Central Elementary program is in full compliance with required staff-to-child ratios and has remained compliant since that date.
Standard 8VAC20-780-510-E
Repeat Violation
The center's procedures for administering medication shall include duration of the parent's authorization. Long-term prescription drug use may be allowed with written authorization from the child's physician and parent. There is an emergency medication being stored at the center for child 1. There is no written authorization from the parent to adminster the medication.
Plan of Correction: The center replied with the following: Signed by parent on March 24, 2026.
Standard 8VAC20-790-600-D-1
All staff who work directly with children shall have current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care. Staff 2 (employed for over 2 years) and staff 3 (employed for 5 months) do not have documentation of current CPR certification.
Plan of Correction: The center responded with the following: Signed both up for session April 2, 2026.
Standard 8VAC20-790-600-D-2
All staff shall have current certification in first aid appropriate to the ages of children in care. Staff 2 (employed for over 2 years) and staff 3 (employed for 5 months) do not have documentation of current first aid certification.
Plan of Correction: The center responded with the following: Signed both up for session April 2, 2026.