YMCA-SACC and Summer Camp at Lewis & Clark

The license and any other documents required shall be posted in a conspicuous place on the licensed premises.

“The findings from the most recent inspection, dated 12/10/2025, were not posted in a conspicuous place on the premises.”

Rule 22.1-289.011-F.

A tuberculosis (TB) screening is required every two years from the last screening.

“Staff #2 updated screening was due 11 months ago. The updated screenings have not yet been completed.”

Rule 8VAC20-780-160-C.

The center shall implement a monthly practice evacuation drill.

“The evacuation drill log did not contain documentation of an evacuation drill for the month of December 2025. Staff acknowledged a drill had not been documented for December 2025.”

Rule 8VAC20-780-550-D.

The following staff records shall be kept for each staff person: Name, address, verification of age requirement, job title, and date of employment and name, address, telephone number of a person to be notified in an emergency which shall be kept at the center and information about any health problems that may interfere with fulfilling the job responsibilities.

“Staff #1, who had been employed for at least two months, did not have information onsite about personal information, emergency contact and health problems that may interfere with job responsibilities.”

Rule 8VAC20-780-70.

The center is required to obtain background checks from any state in which the individual has resided in the preceding five years.

“The center did not maintain documentation showing that required background checks were requested and completed for two agents. Documentation was not available for Agent #1 regarding child abuse and neglect registry searches, fingerprint-based criminal history check, and sex offender registry checks from two states, and for Agent #2 regarding the completed child abuse and neglect registry search from one state.”

Rule 22.1-289-036-B-4.

The center shall obtain documentation that each child has received the immunizations required by the State Board of Health before the child can attend the center.

“Child #4, who had been attending for three months, did not have documentation of an immunization record on file.”

Rule 8VAC20-780-130-A.

REPEAT VIOLATION A tuberculosis (TB) screening is required every two years from the last screening.

“Staff #2 updated screening was due nine months ago. The updated screenings have not yet been completed.”

Rule 8VAC20-780-160-C.

Each center shall maintain and keep at the center a separate record for each child enrolled which shall contain the name and phone number of child’s physician.

“Child #4’s record did not contain the name and phone number of the child’s physician. Child # 4 has been in care for three months.”

Rule 8VAC20-780-60-A.

Systemic deficiency

Rule 8VAC20-780-70.

The program is required to submit to VDH and implement a plan to test potable water for lead.

“The program did not have evidence of a testing plan submitted to VDH and/or the program did not have evidence of the implementation of the required testing plan.”

Rule 22.1-289.057-A.

A tuberculosis (TB) screening is required every two years from the last screening.

“Staff #2 updated screening was due two months ago. The updated screenings have not yet been completed.”

Rule 8VAC20-780-160-C.

When applicable, work phone number and place of employment of each parent who has custody.

“Five children records were reviewed and in four of the children’s records, there were no work phone numbers provided for the parent’s place of employment.”

Rule 8VAC20-780-60-A.

REPEAT VIOLATION: The following staff records shall be kept for each staff person: Name, address, verification of age requirement, job title, and date of employment and name, address, telephone number of a person to be notified in an emergency which shall be kept at the center and information about any health problems that may interfere with fulfilling the job responsibilities.

“Staff record was not provided for Staff #1 upon request. The center was given seven days to present a record for Staff#1, record was never provided for review. Personal information, emergency contact and health information were not available onsite for Staff #1, who was working with children on the date of inspection. Staff #1, who has been employed for 3 weeks, did not have information onsite about health problems that may interfere with job responsibilities.”

Rule 8VAC20-780-70.

The center is required to obtain a completed sworn statement prior to the employee’s first day of employment.

“There was not a sworn disclosure statement in the record for Staff #1. Staff #1 has been employed for one day and was observed working with children on the day of the inspection.”

Rule 22.1-289.035-B-1.

Providers must obtain a completed national criminal background check prior to the employee’s first day of employment.

“Staff #1, who has been employed for one day, did not have a completed national criminal background check.”

Rule 22.1-289.035-B-2.

The center must request a search of the central registry prior to the employee’s first day of employment.

“Staff #1, who has been employed for one day, did not have a central registry search requested.”

Rule 22.1-289.035-B-3.

Documentation of a negative tuberculosis (TB) screening must be submitted at the time of employment, before coming into contact with children, and shall have been completed within the last 30 days of the date of employment.

“Staff #1 had no documentation of TB screening and has been employed for one day and was working with children.”

Rule 8VAC20-780-160-A.

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.

“Child #1 had two medication authorizations forms on file, that expired six months ago. Medication on file for Child #1 had expired four months ago. The medications had not been administered past the expiration of the authorizations. The authorizations had not been renewed and the medications were not returned or disposed of as required.”

Rule 8VAC20-780-510-P.

REPEAT VIOLATION: The following staff records shall be kept for each staff person: Name, address, verification of age requirement, job title, and date of employment and name, address, telephone number of a person to be notified in an emergency which shall be kept at the center and information, about any health problems that may interfere with fulfilling the job responsibilities. Documentation of at least two references to character, reputation, and competency are to be checked prior to employment.

“Personal information, emergency contact and health information were not available onsite for Staff #1, who was working with children on the date of inspection. Staff #1?s record only contained one of two required references, and position title. Staff #2, who has been employed for 2 years and Staff #3, who has been employed for 3 years, did not have information onsite about health problems that may interfere with job responsibilities.”

Rule 8VAC20-780-70.

Based on a review of three staff records and interviews, the vendor did not ensure two staff had current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care within the required time frame.

“Evidence: 1. The CPR certification in the record of Staff #1, employed on 08/11/23, was obtained on 12/02/23, exceeding 90 days of the date of employment. 2. The CPR certification in the record of Staff #2, employed on 11/12/22, expired on 04/20/23. Staff #2 was observed working directly with children during the inspection on 05/14/24.”

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

Based on a review of three staff records and interviews, the vendor did not ensure two staff had current certification in First Aid appropriate to the ages of children in care within the required time frame.

“Evidence: 1. The First Aid certification in the record of Staff #1, employed on 08/11/23, was obtained on 12/02/23, exceeding 90 days of the date of employment. 2. The First Aid certification in the record of Staff #2, employed on 11/12/22, expired on 04/20/23. Staff #2 was observed working directly with children during the inspection on 05/14/24.”

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

Based on a review of three staff records and interviews, the center did not ensure one staff completed the Virginia Department of Education-sponsored orientation within 90 calendar days of employment.

“Evidence: The record of Staff #1, employed on 08/11/23, did not contain documentation that the staff completed the Virginia Department of Education-sponsored orientation course. During interview, a member of management confirmed the center did not have documentation that the staff completed the training within 90 days of employment.”

Rule 8VAC20-780-240-A.

Based on a observation, a review of documentation, and interviews, the center did not ensure that any child for whom emergency medications have been prescribed shall always be in the care of a staff member or independent contractor who meets the requirements for medication administration training (MAT).

“Evidence: 1. During the inspection on 05/14/24, the inspector observed two emergency medications on site for two children that were present during the inspection. 2. During interview, Staff #1 was identified as the MAT certified staff member on site. 3. The record of Staff #1 indicated her MAT certification expired on 03/22/2024. 4. Staff #1 acknowledged her MAT certification was expired and there were no other MAT certified staff on site at the time of the inspection.”

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

Based on documentation reviewed, observations, and interviews, the center did not maintain, in a way that is accessible to all staff who work with children, a current list of all children’s allergies, sensitivities, and dietary restrictions.

“Evidence: The record of Child #2 indicated the child has a diagnosed food allergy. During interviews, staff reported Child #2 has a diagnosed food allergy and was present on 05/14/24, but a current written list of all children’s allergies, sensitivities, and dietary restrictions could not be located at the time of the inspection.”

Rule 8VAC20-780-40-M.

Based on a review of documentation and interviews, the center did not ensure the emergency evacuation documentation contained the required information.

“Evidence: The center’s emergency evacuation drills for 2024 were reviewed. The documentation for drills conducted from January 2024 through April 2024 did not include the method used for notification of the drill; the number of staff participating; the number of children participating; or the time it took to complete the drill. During interview, a member of management confirmed the form that was used to document the drills did not contain all the required information.”

Rule 8VAC20-780-550-G.

(Repeat Violation) Based on a review of five children’s records and interviews, the center did not ensure one child’s record contained the required information.

“Evidence: One of the emergency contacts in the record of Child #2, enrolled on 08/14/23, did not contain the emergency contact’s address and a second emergency contact was not listed. During interview, a member of management confirmed the center did not have two complete emergency contacts on file for Child #2. Each child record shall contain the name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached.”

Rule 8VAC20-780-60-A.

Based on observations and a review of documentation on 05/14/24, the center did not ensure that the required information for each staff was kept at the center.

Rule 8VAC20-780-70.

8VAC20-790-600-D-1

“(Repeat Violations) Based on review of staff records, the center failed to ensure that all staff had current certification in CPR. Evidence: 1. Staff #2’s CPR certification expired on 4/20/2023. 2. Administration verified that the CPR certification was expired.”

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

8VAC20-790-600-D-2

“(Repeat Violations) Based on review of staff records, the center failed to ensure that all staff held a current certification in First Aid. Evidence: 1. Staff #1’s first aid certification expired on 4/20/2023. 2. Administration verified that the first aid certification had expired.”

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

(Repeat violation) Based on record review, the center failed to have staff complete the departments annual update health and safety course.

“Evidence: 1. The record for staff #1 did not contain documentation of the annual update health and safety course. 2. The director confirmed the annual 3-hour update for staff #1 had not been completed.”

Rule 8VAC20-790-600-F.

8VAC20-780-510-E

“Based on review of medication and staff interview, the center did not ensure that their procedures for the administration of medication are followed. Evidence: 1. There was a bottle of Benadryl stored for emergency administration to child A. There was no written parent authorization for the medication to be administered.”

Rule 8VAC20-780-510-E.

8VAC20-780-60-A

“Based on review of children’s records, the center did not ensure that all children’s records contain all required information. Evidence: 1. Child #4’s record was missing both parents work name, work phone numbers, and work addresses.”

Rule 8VAC20-780-60-A.

Based on a review of documents, the vendor did not ensure two staff members had current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care.

“Evidence: 1) The CPR certification in the record of Staff #1 expired on 04/20/2023. 2) The CPR certification in the record of Staff #5 expired on 11/14/22.”

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

Based on a review of documents, the vendor did not ensure two staff members had current certification in first aid appropriate to the ages of children in care.

“Evidence: 1) The first aid certification in the record of Staff #1 expired on 04/20/2023. 2) The first aid certification in the record of Staff #5 expired on 11/14/22.”

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

Based on a review of four staff records and interview, the center did not ensure two staff had the satisfactory results of the fingerprint-based national criminal background check prior to employment.

“Evidence: 1) The fingerprint-based national criminal background check in the record of Staff #1, employed on 11/12/22, was dated 01/04/23. 2) The record of Staff #3, employed on 02/01/23, did not contain the results of the fingerprint-based national criminal background check requested by the current employer. 3) During interview, a member of management confirmed the fingerprint-based national criminal background check for Staff #1 and Staff #3 were not obtained at the time of employment.”

Rule 22.1-289.035-B-2.

Based on a review of four staff records and interview, the center did not obtain 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 one staff member had resided in the preceding five years within the required timeframe.

Rule 22.1-289.035-B-4.

Based on a review of four staff records and interview, the center did not ensure one staff had a completed sworn statement or affirmation prior to employment.

“Evidence: 1) The sworn statement in the record of Staff #1, employed on 11/12/22, was not signed. 2) During interview, a member of management confirmed the sworn statement for Staff #1 was not complete at the time of employment.”

Rule 8VAC20-770-60-B.

Based on a review of four staff records and interview on 04/25/23, the center did not ensure two staff members had a central registry finding within 30 days of employment.

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

Based on a review of five children’s records and interview, the center did not obtain documentation that one child had received the immunizations required by the State Board of Health before the child attended the center.

“Evidence: 1) The immunization documentation in the record of Child #2, date of attendance 02/27/23, was dated 02/28/23. 2) During interview, a member of management confirmed the center did not obtain documentation of the child’s immunizations before the child attended the center.”

Rule 8VAC20-780-130-A.

Based on a review of four staff records and interview, the center did not ensure four staff members submitted documentation of a negative tuberculosis screening within the required timeframe.

Rule 8VAC20-780-160-A.

Based on a review of records, observation, and interview, the center did not ensure that there shall be at least one staff member with current certification in cardiopulmonary resuscitation (CPR) and current certification in first aid where children are present.

“Evidence: 1) On 4/12/23, Staff #5 was observed providing transportation to four children that attend the program from another school. Staff #5 was the only staff member present during transportation. 2) The First Aid and CPR certificate in the record of Staff #5 expired on 11/14/22. 3) During interview, a member of management confirmed the CPR and First Aid certification of Staff #5 was expired.”

Rule 8VAC20-780-530-A.

Based on a review of documentation and interview, the center did not implement a monthly practice evacuation drill.

“Evidence: 1) The licensing inspector observed the emergency drill log for the year 2022. An evacuation drill was not conducted for January, March, or May 2022. 2) During interview, management reported the documentation of the drills could not be located and was not able to determine if the drills were conducted. The center shall implement a monthly practice evacuation drill.”

Rule 8VAC20-780-550-D.

Based on a review of documentation and interview, the center did not practice shelter-in-place procedures a minimum of twice per year.

“Evidence: 1) The licensing inspector observed the emergency drill log for the year 2022. There was no documentation that shelter-in-place drills were practiced. 2) During interview, management reported the documentation of the drills could not be located and was not able to determine if the drills were conducted. Shelter-in-place procedures shall be practiced a minimum of twice per year.”

Rule 8VAC20-780-550-E.

Based on a review of documentation and interview, the center did not practice lockdown procedures at least annually.

“Evidence: 1) The licensing inspector observed the emergency drill log for the year 2022. There was no documentation that a lockdown drill was practiced. 2) During interview, management reported the documentation of the drills could not be located and was not able to determine if a lockdown drill was conducted. Lockdown procedures shall be practiced at least annually.”

Rule 8VAC20-780-550-F.

Based on a review of documentation on 04/12/2023, the center did not ensure that written injury records contained the required information.

Rule 8VAC20-780-550-P.

Based on a review of five children’s records and interview, the center did not ensure one child’s record contained the required information.

“Evidence: 1) The record of Child #2, enrolled on 02/27/23, did not contain documentation of two emergency contacts. 2) During interview, a member of management confirmed the center did not have documentation of two emergency contacts for Child #2. Each child record shall contain the name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached.”

Rule 8VAC20-780-60-A.

Based on staff interview and observations on 04/12/23, the center did not ensure that the required information for each staff was kept at the center.

“Evidence: 1) Staff #1, Staff #2, Staff #4, Staff #5, and Staff #6 were observed at the center on 04/12/23. 2) Staff interviewed stated that an emergency contact and information about any health problems staff have were not available for review at the center. The center should maintain at the center the name, address, and telephone number of a person to be notified in an emergency and information about any health problems that may interfere with fulfilling the job responsibilities for each staff member.”

Rule 8VAC20-780-70.

Based on a review of four medications and interview, the center did not ensure the medication authorization for four medications were available to staff during the entire time they were effective.

“Evidence: 1) On 08/04/22, two medications were observed on site for Child #4. 2) During interview, staff reported the medication authorizations were not available on site. 3) On 08/04/2022, two medications were observed on site for Child #5. 4) During interview, staff reported the medication authorizations were not available on site.”

Rule 8VAC20-780-510-F.

Based on observation and interview, the center did not ensure that two medications were labeled with the child’s name, the name of the medication, the dosage amount, and the time or times to be given.

“Evidence: 1) On 08/04/2022, two prescription medications were observed on site for Child #4. The medications were observed in a plastic bag, but the medications did not have a label with the child’s name, the name of the medication, the dosage amount, and the time or times to be given. 2) Staff interviewed stated the label for the medications were not given to staff upon receipt of the medications.”

Rule 8VAC20-780-510-G.

Based on a review of five children’s records and interview, the center did not ensure two children with a diagnosed food allergy had a written care plan, 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.

“Evidence: 1) Child #4, enrolled 06/21/22, has a diagnosed food allergy. During the inspection on 08/04/22, staff interviewed reported the child’s written care plan was not available for review on site. 2) Child #5, enrolled on 10/25/21, has a diagnosed food allergy. During the inspection on 08/04/22, staff interviewed reported the child’s written care plan was not available for review on site.”

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

Based on staff interview on 08/04/2022, the center did not ensure that the required information for each staff was kept at the center.

“Evidence: 1) Staff #1, Staff #2, and Staff #3 were observed at the center on 08/04/2022. Staff interviewed stated that an emergency contact and information about any health problems staff have were not available for review at the center. The center should maintain at the center the name, address, and telephone number of a person to be notified in an emergency and information about any health problems that may interfere with fulfilling the job responsibilities for each staff member.”

Rule 8VAC20-780-70.

Based on a review of three staff records and interviews, the center did not ensure that one staff member had a central registry finding within 30 days of employment.

“Evidence: 1) The record for Staff #2, hired on 07/26/21, did not contain the results of a central registry finding. The record did not contain documentation of any further contact, and the staff has been continuously employed. 2) During interviews, a member of management reported the central registry finding for Staff #2 could not be located.”

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

Based on a review of three staff records and interviews, the center did not ensure that one staff resubmit tuberculosis (TB) test results at least every two years from the date of the first initial screening or testing.

“Evidence: 1) The most recent TB screening in the record for Staff #3, hired on 10/24/19, was dated 11/13/2019. The TB screening expired on 11/13/2021. 2) During interview, a member of management reported the TB screening for Staff #3 expired on 11/13/2021 and a new one has not been obtained.”

Rule 8VAC20-780-160-C.

Based on a review of three children’s records, the center did not ensure one child’s record contained the required information.

“Evidence: 1) The record for Child #1, enrolled on 11/29/21, did not contain the address for the second emergency contact listed. Each child record shall contain the name, address, and phone number of two designated people to call in an emergency if a parent cannot be reached.”

Rule 8VAC20-780-60-A.

Based on a review of three staff records, observations, and interviews, the center did not ensure three staff records contained the required information.

Rule 8VAC20-780-70.