THE YMCA OF SOUTH HAMPTON ROADS - INDIAN RIVER FAMILY YMCA

8VAC20-780-240-A

“The Virginia Department of Education-sponsored orientation course shall be completed within 90 calendar days of employment. Staff C, employed since March 2006 did not have documentation of having taken the The Virginia Department of Education-sponsored orientation course.”

Rule 8VAC20-780-240-A.

8VAC20-780-270-A

“Areas and equipment of the center shall be maintained in a clean, safe and operable condition. a. There was a water spill in the boys bathroom and a second spill in the main daycare room, causing a slipping hazard. b. There was peeling paint on the large window ledge and on the wall in the main daycare room.”

Rule 8VAC20-780-270-A.

8VAC20-780-280-B

“Hazardous substances such as cleaning materials shall be kept in a locked place using a safe locking method that prevents access by children. Multiple bottles of acetone and bottle of 91% isopropyl alcohol were in unlocked cabinets. Staff keys were sitting on a shelf inside one of the locked cabinets.”

Rule 8VAC20-780-280-B.

When staff are supervising children, they shall always ensure their care, protection, and guidance. Staff did not ensure the care and protection of children when:

“The center’s medication policy does not align with one of the MAT program’s 5 Rights. The “Right Dose” states, “ Give the exact amount of the medication specified on the Consent Form and the pharmacy label. The center’s medication policy says they are not responsible for missed doses. The policy states, “Please understand that it may not always be possible to administer medications as requested, and we cannot be responsible for missed doses.””

Rule 8VAC20-780-340-A.

Children under 10 years shall be within actual sight and sound supervision of staff and that staff need only be able to hear a child who is using the restroom provided there is a system to assure individuals who are not staff members do not enter the restroom area while in use by children.

Rule 8VAC20-780-340-F.

The operational responsibilities of the licensee shall include ensuring that the center’s activities, services, and facilities are maintained in compliance with these standards.

“The center’s medication policy does not align with a requirement in the Medication Administration Training (MAT) program’s 5 Rights. The “Right Dose” states, “ Give the exact amount of the medication specified on the Consent Form and the pharmacy label. The center’s medication policy says they are not responsible for missed doses. The policy states, “Please understand that it may not always be possible to administer medications as requested, and we cannot be responsible for missed doses.””

Rule 8VAC20-780-40-E.

8VAC20-780-50-A

“Staff and children’s records shall be treated confidentially. A notebook containing all of the children’s names, addresses, phone numbers and medical information was observed sitting on the floor of a stairwell. The center is open to the public and non-daycare employees whom could gain access to this information.”

Rule 8VAC20-780-50-A.

8VAC20-780-510-E

“The center is required to have a procedure on how to prevent the use of outdated medication. The center’s medication policy did not address how staff are to prevent the use of outdated medication.”

Rule 8VAC20-780-510-E.

8VAC20-780-510-F

“The medication authorization shall be available to staff during the entire time it is effective. Staff B took medications for children on a field trip, however the authorizations for those medications were not available to the staff during transportation or at the destination.”

Rule 8VAC20-780-510-F.

8VAC20-780-510-I

“The center may administer prescription medication that would normally be administered by a parent or guardian to a child provided the center administers drugs only to the child identified on the prescription label in accordance with the prescriber’s instructions pertaining to dosage, frequency, and manner of administration. The center’s medication policy says they are not responsible for missed doses. The policy states, “Please understand that it may not always be possible to administer medications as requested, and we cannot be responsible for missed doses.””

Rule 8VAC20-780-510-I.

8VAC20-780-580-B

“Any vehicle used by the center for the transportation of children shall be insured with at least the minimum limits established by Virginia state statutes. One of the vans used during to transport children was not insured. The insurance card provided had expired in January 1, 2025.”

Rule 8VAC20-780-580-B.

8VAC20-780-580-I

“Before leaving on a field trip, a schedule of the trip’s events and locations shall be posted and visible at the center site. The center had multiple field trips scheduled on the day of the inspection and did not have the schedule or locations posted and visible at the center site.”

Rule 8VAC20-780-580-I.

The center shall keep a record for each staff person that contains all required information.

“1. The records provided for Staff A (Program Director) and Staff E (Program Leader) did not have documentation to demonstrate that the individuals possessed the education and/or experience required by the job positions. 2. The center did not provide the following required records for Staff E: a. Name, age verification, job title, date of hire, emergency contact, 2 references checked prior to employment or documentation to demonstrate that the individual has the education, certification, and/or experience required by the job position.”

Rule 8VAC20-780-70.

8VAC20-780-150-B

“Immunizations are required to be signed by a physician, his designee, or an official of a local health department. Child #4 and #5 did not have a physician’s signature on their immunization forms stating each child was adequately immunized.”

Rule 8VAC20-780-150-B.

8VAC20-780-270-A

“Areas and equipment of the center, inside and outside, shall be maintained in a safe condition. There was sections of peeling paint in the main daycare room and the girl’s bathroom vanity had peeling linoleum.”

Rule 8VAC20-780-270-A.

8VAC20-780-400-B

“Behavioral guidance shall be constructive in nature, age and stage appropriate, and shall be intended to redirect children to appropriate behavior and resolve conflicts. Using a harsh tone Staff said statements to children in care such as, “STOP! That’s why you do childish stuff.” and “Hey! I said now, not your time.””

Rule 8VAC20-780-400-B.

22.1-289.035-B-2

“(REPEAT VIOLATION) Staff are required to submit fingerprinting. Staff F did not have documentation of fingerprinting and was observed in assisting with the program and records.”

Rule 22.1-289.035-B-2.

22.1-289.035-B-3

“Staff are required to obtain a copy of the results of a search of the central registry for any founded complaint of child abuse and neglect against them. Staff F did not have documentation of the results of a search of the central registry and was observed participating in the programming and records.”

Rule 22.1-289.035-B-3.

8VAC20-780-245-J-3

“Any child for whom emergency medications have been prescribed shall always be in the care of a staff member who has Medication Administration Training (MAT). There was not a MAT trained staff available from 3:45pm - 4:10pm, where 5 children in care had emergency medications.”

Rule 8VAC20-780-245-J-3.

8VAC20-780-340-A

“(REPEAT VIOLATION) When staff are supervising children, they shall always ensure their care, protection, and guidance. There were 60 children (ages 5-12yrs) present between 2 rooms. Staff A and Staff B whom were responsible for the children in the main daycare room, did not know how many children were present, were not able to identify which children arrived from the last bus run nor could they identify if any of the children they were responsible for were present.”

Rule 8VAC20-780-340-A.

8VAC20-780-350-B-5

“The required ratio for school-age children up to 9 years is 1:18. When 2 staff members left the main daycare room, Staff B was alone with 35 children for about 5 minutes (5years & up).”

Rule 8VAC20-780-350-B-5.

(REPEAT VIOLATION) The operational responsibilities of the licensee shall include ensuring that the center’s activities, services, and facilities are maintained in compliance with the center’s own policies and procedures that are required by these standards.

“The center’s medication policy states, “If your child requires medication during care, we must have a signed authorization through a Medication Administration Form.” Child #2 had 2 emergency medications without the parent’s signed authorization.”

Rule 8VAC20-780-40-E.

8VAC20-780-510-E

“The center’s procedures for administering medication are required to include methods to prevent the use of outdated medication. The center’s medication policy does not include methods to prevent use of outdated medication.”

Rule 8VAC20-780-510-E.

8VAC20-780-340-D

“In each grouping of children there shall be at least one staff member who meets the qualifications of a program leader or program director. A teacher assistant (Staff B) was supervising a group of 17 school-age children by herself from around 2:45pm-5:15pm. Staff #B did not have documentation that she met the qualifications of the program leader position.”

Rule 8VAC20-780-340-D.

Behavioral guidance shall be constructive and intended to redirect children to appropriate behavior.

“Staff did not redirect children to appropriate behavior when participating in the following behaviors: 1. Freely roaming between rooms in which they were not assigned to 2. Wrestling on the hard floor 3. Pushing chairs 4. One child flipped himself over in his chair”

Rule 8VAC20-780-400-B.

8VAC20-780-510-E

“The center’s procedures for administering medication shall include methods to prevent use of outdated medication. A procedure that addresses methods to prevent the use of outdated medication was not included in the center’s medication policy.”

Rule 8VAC20-780-510-E.

8VAC20-780-560-F

Rule 8VAC20-780-560-F.

8VAC20-780-60-A

“(Repeat Violation) Each center shall maintain and keep at the center a separate record for each child enrolled which shall contain all required information. Child #3 did not have a record at the center. The record was requested again following the inspection and it was not received.”

Rule 8VAC20-780-60-A.

8VAC20-780-340-A

Rule 8VAC20-780-340-A. From a complaint.

8VAC20-780-340-A

Rule 8VAC20-780-340-A. From a complaint.

8VAC20-780-340-C

“There shall always shall be on field trips when one or more children are present one staff who meets the qualifications of a program leader or director and an immediately available staff member, volunteer or other employee who is at least 16 years of age, with direct means for communication between the two of them. The center sent 1 staff member, where 2 are required to local schools to wait for children until the bus arrives to take them to the center.”

Rule 8VAC20-780-340-C. From a complaint.

8VAC20-780-340-F

“Children under 10 years of age always shall be within actual sight and sound supervision of staff. Seventy three children ages 5-9 years were not in sight and sound supervision of staff when they were dropped off in front of the center’s building, when entering the building or while they walked up the staircase and into their classroom.”

Rule 8VAC20-780-340-F. From a complaint.

8VAC20-780-340-G

“Children 10 years of age and older shall be within actual sight and sound supervision of staff . Seventeen children, ages 10-12 years, were not in sight and sound supervision of staff when they were dropped off in front of the center’s building, when entering the building or while they walked up the staircase and into their classroom.”

Rule 8VAC20-780-340-G. From a complaint.

8VAC20-780-340-I

“Staff shall greet each child upon arrival at the center. Children in the afterschool program were not greeted by staff when they arrived at the center or when entering their classroom.”

Rule 8VAC20-780-340-I. From a complaint.

8VAC20-780-40-E

“The operational responsibilities of the licensee shall include ensuring that the center’s own policies and procedures are maintained in compliance with the required standards. The center’s transportation policy states, “We will only release children in our care to an authorized adult.” Ninety children on 7 different bus runs whom were transporting to the center’s afterschool program were released off the buses and not received by an adult. The children entered the building via a propped open door with no adult supervision.”

Rule 8VAC20-780-40-E. From a complaint.

8VAC20-780-580-J

“There shall be a communication plan between center staff and staff who are transporting children or on a field trip. Seven groups of children were permitted by staff to exit the center’s bus and enter the building via a propped open door. The bus staff did not communicate with the center staff to let them know children were entering the building, nor did they provide the center staff with the roster of children they transported and dropped off in front if the building.”

Rule 8VAC20-780-580-J. From a complaint.

22.1-289.035-B-4

“Out of state background checks to include a criminal record check, central registry check and sex offender check, are required for staff who have lived outside of Virginia within the past 5 years. Staff C listed living outside the state of Virginia on her sworn statement of affirmation and did not have documentation of sending off for the required background checks for the state that was listed.”

Rule 22.1-289.035-B-4.

Staff shall complete orientation training in subsection C of this section prior to the staff member working alone with children and no later than seven days of the date of assuming job responsibilities.

“Staff A, Staff B and Staff C did not have documentation that they completed the required orientation training.”

Rule 8VAC20-780-240-B.

8VAC20-780-245-A

“Staff shall complete annually a minimum of 16 hours of training appropriate to the age of children in care. Staff A did not have documentation of having completed the required 16 hours of annual training for 2024.”

Rule 8VAC20-780-245-A.

8VAC20-780-270-A

“(REPEAT VIOLATION) Areas and equipment of the center shall be maintained in a safe condition. There was peeling paint on the walls of the rooms used for the care of children.”

Rule 8VAC20-780-270-A.

8VAC20-780-280-B

“Hazardous substances such as cleaning materials, insecticides, and pesticides shall be kept in a locked place using a safe locking method that prevents access by children. There was an unlocked cabinet with various cleaning products in the front room and a large container of multipurpose cleaner in an unlocked cabinet in the boys bathroom.”

Rule 8VAC20-780-280-B.

8VAC20-780-340-A

“When staff are supervising children, they shall always ensure their care, protection, and guidance. 1. The designated person in-charge, Staff B did not know the real names of the staff that were supervising children nor was he able to identify which children at the camp had medication. 2. When asked how many children she had in care, Staff A replied, “21 children.” The attendance sheet showed there were 24 children in care. It was later confirmed that there were in fact 24 children present at the time of inspection.”

Rule 8VAC20-780-340-A.

8VAC20-780-40-E

“The operational responsibilities of the licensee shall include ensuring that the center’s activities, services, and facilities are maintained in compliance with the terms of the current license issued by the department. The center has been using the first floor izone area, which is not a approved by the Department for childcare. The terms of the license only permits use of the first floor multipurpose room.”

Rule 8VAC20-780-40-E.

8VAC20-780-530-A

“At least one staff in each classroom or area where children are present shall have Current certification in cardiopulmonary resuscitation (CPR). Staff A and Staff B were supervising an area where children were present. Staff A did not have a current CPR and First Aid Certification and Staff B did not have a current CPR certification.”

Rule 8VAC20-780-530-A.

8VAC20-780-550-G

“The center is required to maintain documentation of emergency evacuations, shelter-in-place, and lockdown drills. The center did not have any emergency drills documented for January, February and March 2025.”

Rule 8VAC20-780-550-G.

8VAC20-780-60-A-8

“The center is required to maintain 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. Child #2 had a documented food allergy, however did not have a written care plan in his record.”

Rule 8VAC20-780-60-A-8.

Based on a record review the center did not ensure a repeat tuberculosis(TB) screening at least every 2 years from the date of the first screening/test.

“Evidence: Staff #1’s last TB test was dated 01/19/2022.”

Rule 8VAC20-780-160-C.

8VAC20-780-245-A

“Based on a record review the center did not ensure all staff completed a minimum of 16 hours of training. Evidence: Staff #1 (hired 12/09/2022) did not have documentation of having received at least 16 hours of training in 2023.”

Rule 8VAC20-780-245-A.

8VAC20-780-270-A

Rule 8VAC20-780-270-A.

8VAC20-780-270-A

Rule 8VAC20-780-270-A.

8VAC20-780-60-A

“Based on record review the center did not ensure all required information was kept for each enrolled child. 1. Child #1, who was in care at the time of inspection, did not have a file. 2. Child #3 did not have documentation of the child’s first day of enrollment. 3. None of the child enrollment forms used by the center included a space to document the child’s nickname.”

Rule 8VAC20-780-60-A.

8VAC20-780-60-A

“Based on record review the center did not ensure all required information was kept for each enrolled child. 1. Child #1, who was in care at the time of inspection, did not have a file. 2. Child #3 did not have documentation of the child’s first day of enrollment. 3. None of the child enrollment forms used by the center included a space to document the child’s nickname.”

Rule 8VAC20-780-60-A.

8VAC20-780-70

“Based on a record review the center did not ensure all required information was kept for each staff person. Evidence: 1. Staff #2, #3 and # 6 did not have documentation of their date of hire. 2. Staff #1 (hired 12/09/2022) did not have documentation of having an orientation. 3. Staff #3 did not have documentation to demonstrate that the individual possessed the education, certification, and/or experience required by the job position as a program leader.”

Rule 8VAC20-780-70.

22.1-289.035-B-4

“Based on a record review the center did not ensure all required background checks were completed for each staff. Evidence: Staff #4, hired 10/09/2022 indicated living outside the state of Virginia on a sworn statement of affirmation dated 09/22/2022. The center did not have criminal record check, central registry check or a sex offender check for the state indicated on the statement. The director confirmed the checks had not been requested.”

Rule 22.1-289.035-B-4.

8VAC20-780-270-A

“Based on observation the center did not ensure all areas and equipment of the center were maintained in a safe condition. Evidence: 1. There was peeling paint and unfinished plaster on the walls of the rooms used for care of the children. 2. About 12 white plastic baskets used to store the children’s were broken and pieces of the plastic were seen on the floor. 3. The mini basketball hoop had missing screws at the hinges, making it unstable.”

Rule 8VAC20-780-270-A.

Based on observation and interview the center did not ensure the emergency evacuation and shelter-in-place procedures or maps were be posted in a location conspicuous to staff and children on each floor of each building.

“Evidence: The center staff were unable to locate where the emergency procedures were located and were not posted in a location conspicuous to staff and children on each floor of each building.”

Rule 8VAC20-780-550-C.

8VAC20-780-70

“Based on a record review the center did not ensure all required information was kept for each staff person. Evidence: Staff #1, hired 12/09/2022, did not have documentation of at least 2 references checked prior to employment.”

Rule 8VAC20-780-70.

Based on observation the center did not ensure hazardous substances were kept ion a locked place using a safe locking method to prevent access by children.

“Evidence: In the main after-school room there was a tall black cabinet that was unlocked and contained various cleaning agents and chemicals. Children were observed sitting next to the cabinet during the inspection.”

Rule 8VAC20-780-280-B.

Based on observation the center did not ensure all requirements were met when using sunscreen. Evidence:

“In the back school-age room there were 3 bottles of sunscreen in an unlocked and accessible cabinet.”

Rule 8VAC20-780-520-B.

8VAC20-780-60-A

“Based on a record review the center did not ensure all required information was kept for each enrolled child. Evidence: Child #4 did not have documentation of the parent’s place and phone number of employment.”

Rule 8VAC20-780-60-A.

Based on a review of six staff records, it was determined that the vendor did not ensure that all staff have a current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care. The training shall include an in-person competency demonstration.

Rule 8VAC20-790-600-D-1.

Based on a review of six staff records, it was determined that the vendor did not ensure that all staff have a current certification in first aid appropriate to the ages of children in care. The training shall include an in-person competency demonstration.

Rule 8VAC20-790-600-D-2.

Based on a review of six staff records, it was determined that the licensee did not ensure that an employee is allowed to begin employment without a completed national criminal history record check (finger printing).

“Evidence: 1. The record for staff #5, working during the inspection did not contain documentation of a completed national criminal history record check (finger printing). 2. Staff #7 (Program Director) reviewed the record for the staff #5 and confirmed that she had not received the results of the national criminal record check (finger printing).”

Rule 22.1-289.035-B-2.

Based on a review of nine staff records, it was determined that the licensee did not ensure that they obtain a copy of the results of a sex offender registry check, and 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.

“Evidence: 1. The record for staff #5 (date of hire 8/12/21) did not contain documentation of a completed sex offender registry check and search of the central registry from New York. The sworn statement indicated staff #5 had previously lived in New York within the last 5 years. 2. Staff #7 (Program Director) confirmed the sex offender registry check and search of the central registry from the State of New York.”

Rule 22.1-289.035-B-4.

Based on a review of six staff records, it was determined that the licensee did not deny continued employment of a staff who did not have a search of the central registry finding within 30 days of employment.

“Evidence: 1. The record for staff #2 (date of hire 1/21/22) did not contain documentation of a completed search of the central registry finding. 2. Staff #7 (Program Director) reviewed the record for the staff #2, and confirmed that there was not a search of the central registry finding available for viewing during the inspection.”

Rule 8VAC20-770-60-C-2.

Based on a review of six children’s records, it was determined that the licensee did not ensure that each child in attendance had a completed physical within one month of attendance.

“Evidence: 1. The record for child #3 did not contain a physical examination. 2. Staff #7 (Program Director) confirmed that the record for child #3 did not contain a physical examination, and that child #3 had been enrolled for more than 30 days.”

Rule 8VAC20-780-140-A.

Based on a review of six staff records, it was determined that the licensee did not ensure that each staff member shall submit documentation of a negative tuberculosis screening. Documentation of the screening shall be submitted at the time of employment and prior to coming into contact with children. The documentation shall have been completed within the last 30 calendar days of the date of employment and be signed by a physician, physician’s designee, or an official of the local health department.

“Evidence: 1. The record for staff #2, working during the inspection, did not contain documentation of a negative tuberculosis screening. 2. Staff #7 (Program Director) reviewed the record for staff #2, and confirmed that the documentation of a negative tuberculosis screening had not been received prior to employment.”

Rule 8VAC20-780-160-A.

Based on a review of six staff records, it was determined that the licensee did not ensure that all new staff complete the Virginia Department of Education-sponsored orientation course shall be completed within 90 calendar days of employment.

Rule 8VAC20-780-240-A.

Based on on observation and interviews, it was determined that the licensee did not ensure that for children, from the age of eligibility to attend public school through eight years, one staff member for every 18 children is maintained at all times children are in care.

“Evidence: 1. The Licensing Inspector observed staff #8 working alone in the main classroom with 29 children, so the facility was not maintaining the required 1 staff for every 18 children. 2. Staff #7 (Program Director) confirmed that the facility did not maintain the required staff-to-child ratio for approximately 10 minutes.”

Rule 8VAC20-780-350-B-5.

Based on a review of six staff records and interviews, it was determined that the licensee did not ensure that there shall be at least one staff member trained in first aid, cardiopulmonary resuscitation, and rescue breathing as appropriate to the age of the children in care who is on the premises during the center’s hours of operation and also one person on field trips and wherever children are in care.

“Evidence: 1. Staff #5 and staff #6 were each driving one of the facility’s buses to transport children to the facility from the local school. and staff #2 were working at the facility during the inspection. 2. The records for staff #5 and staff #6 did not contain a current certification in cardiopulmonary resuscitation (CPR) and First Aid. 3. Staff #7 (Program Director) confirmed that neither staff driving a bus had a current certification in cardiopulmonary resuscitation (CPR) and First Aid.”

Rule 8VAC20-780-530-A.

Based on a review of the emergency supplies at the center, it was determined that the licensee did not ensure that there is one working battery-operated radio in each building used by children.

“Evidence: 1. There was not a working battery-operated radio available during the inspection. 2. Staff #7 (Program Director) could not find batteries during the inspection to demonstrate that the battery-operated radio was working.”

Rule 8VAC20-780-540-E.

Based on observation and interviews, it was determined that the licensee did not ensure that no child shall be allowed to drink or eat while walking around.

“Evidence: 1. The Licensing Inspector observe two children walking around while eating food. 2. Staff #7 (Program Director) confirmed that the two children were walking around while eating.”

Rule 8VAC20-780-560-L.

Based on a review of six children’s records and interview, it was determined that the licensee did not ensure that they maintain and keep at the center a complete record for each child enrolled that contains all required information.

“Evidence: 1. The record for child #3 did not contain the employment information for the parents, information for the two emergency contacts and the contact information for the child’s physician. 2. The record for child #6 did not contain the enrollment agreement with all of the required information about the child and the parents. 3. Staff #7 (Program Director) confirmed that the record for child #4 did not contain all of the required information.”

Rule 8VAC20-780-60-A.

Based on a review of five children’s records, it was determined that the facility did not ensure that they obtain documentation that each child has received the immunizations required by the State Board of Health before the child can attend the center

“Evidence: 1. The record for child #4 did not contain documentation of a current immunization record. 2.Staff #1 (Program Director) confirmed that the record for child #4 did not contain documentation of a current immunization record.”

Rule 22VAC40-185-130-A.

Based on a review of five children’s records, it was determined that the facility did not ensure that each child in attendance had a completed physical within one month of attendance.

“Evidence: 1. The record for child #4 did not contain a physical examination. 2. The record for child #5 did not contain a physical examination. 3. Staff #1 (Program Director) confirmed that the records for child #4 and child #5 did not contain a physical examination, and that both children had been enrolled for more than 30 days.”

Rule 22VAC40-185-140-A.

Based on a review of five children’s records and interview, it was determined that the facility did not ensure that they maintain and keep at the center a complete record for each child enrolled that contains all required information.

“Evidence 1. There was no record available for viewing during the inspection for child #4. 2. Staff #1 (Program Director) confirmed that there was no record available for viewing during the inspection for child #4.”

Rule 22VAC40-185-60-A.

Based on a review of eight staff records, it was determined that the provider did not ensure that the center obtain a copy of the results of a criminal history record information check and search of the central registry check from any state in which the applicant has resided in the preceding five years.

Rule 63.2(17)-1720.1-B-4.