Rappahannock Area Young Men’s Christian Association-Bowling Gree

(Repeat Violation/Systemic Deficiency) The center is required to have employees undergo a background check every five years.

“The most recent central registry check for staff #3 was overdue by more than three weeks.”

Rule 22.1-289.035-A.

(Repeat Violation/Systemic Deficiency) The center must request a search of the central registry prior to the employee’s first day of employment.

“The central registry search results for Staff #5 were dated five months after beginning employment. There was no documentation that the center requested a search of the central registry prior to the first day of employment for Staff #5.”

Rule 22.1-289.035-B-3.

(Repeat Violation/Systemic Deficiency) The center is required to obtain a completed sworn statement prior to the employee’s first day of employment.

“There was no sworn statement for Staff #5, who has been employed for more than eight months.”

Rule 22.1-289.036-B-1.

(Repeat Violation/Systemic Deficiency) Each staff member shall submit documentation of a negative tuberculosis screening at the time of employment and prior to coming into contact with children.

“There was no documentation of negative tuberculosis screenings in the files of Staff #4, Staff #5, or Staff #6. Staff #4 has been employed for more than eight months. Staff #5 has been employed for more than four months. Staff #6 has been employed for more than three years.”

Rule 8VAC20-780-160-A.

Program leaders shall have six months of supervised programmatic experience and a minimum of 24 hours of training shall be received related to the care of children within six months before being promoted or beginning work or one month after being promoted or beginning work.

“The records for Staff #2 and Staff #6 did not include documentation of completion of 24 hours of training required to be promoted to a Program Leader. Staff #2 and Staff #6 have both been serving as Program Leader for over three years.”

Rule 8VAC20-780-210-A-4.

(Repeat Violation) Emergency evacuation and shelter-in-place procedures or maps shall be posted in a location conspicuous to staff and children on each floor of each building.

“Emergency evacuation and shelter-in-place procedures or maps were not posted as required.”

Rule 8VAC20-780-550-C.

(Repeat Violation/Systemic Deficiency) Staff records shall be kept for each staff person and shall include:

Rule 8VAC20-780-70.

(Repeat Violation) Staff who work directly with children shall, annually attend at least 16 hours of training and staff development activities, to include the department’s health and safety update course.

“Staff #2, Staff #3, and Staff #6 have not completed the annual health and safety update training. The training is overdue by 3 months for Staff #2, Staff #3 and Staff #6.”

Rule 8VAC20-790-600-F.

22.1-289.011-F

“The license and any other documents required by the Superintendent shall be posted in a conspicuous place on the licensed premises. The last inspection dated 12/15/25 was not posted as required.”

Rule 22.1-289.011-F.

22.1-289.035-A

“The center is required to have employees undergo a background check every five years. The most recent sworn statement for Staff #1 was more than 8 years old. The most recent central registry check for Staff #3 was overdue by six days.”

Rule 22.1-289.035-A.

22.1-289.057-A

“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.

8VAC20-780-160-C

“(Repeat Violation) A tuberculosis (TB) screening is required every two years from the last screening. The most recent screening for Staff #1 was more than four years old. The updated screening for Staff #3 was overdue by three days. Staff #3 stated that the updated screening has not yet been completed.”

Rule 8VAC20-780-160-C.

8VAC20-780-200-A

“The center shall have a qualified program director or a qualified back-up program director who meets one of the director qualifications who shall regularly be on site at least 50% of the center’s hours of operation. Staff #1 and Staff #2 stated that the Program Director (Staff #3) is on site approximately once a week for less than an hour.”

Rule 8VAC20-780-200-A.

8VAC20-780-550-C

“Emergency evacuation and shelter-in-place procedures or maps shall be posted in a location conspicuous to staff and children on each floor of each building. Emergency evacuation and shelter-in-place procedures or maps were not posted.”

Rule 8VAC20-780-550-C.

8VAC20-780-550-D

“The center shall implement a monthly practice evacuation drill. There were no drills completed in January or February of 2026.”

Rule 8VAC20-780-550-D.

8VAC20-780-550-E

“Shelter in place procedures shall be practiced a minimum of twice per year. There was no documentation of shelter in place drills.”

Rule 8VAC20-780-550-E.

8VAC20-780-550-F

“Lockdown procedures shall be practiced at least annually. There was no documentation of lockdown drills.”

Rule 8VAC20-780-550-F.

8VAC20-780-90-A

“A written agreement between the parent and the center shall be in each child’s record by the first day of the child’s attendance. The agreement shall be signed by the parent and include authorization for emergency medical care should an emergency occur when the parent cannot be located immediately. There was no authorization for emergency medical care contained in the record of Child #1.”

Rule 8VAC20-780-90-A.

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. The certification in cardiopulmonary resuscitation (CPR) for Staff #1 expired more than 5 weeks ago.”

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

8VAC20-790-600-D-2

“All staff who work directly with children shall have current certification in first aid appropriate to the ages of children in care. The certification in first aid for Staff #1 expired more than 5 weeks ago.”

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

8VAC20-790-600-F

“Staff who work directly with children shall annually attend at least 16 hours of training and staff development activities, to include the department’s health and safety update course. Completion of the course for Staff #1 was overdue by 5 days. The most recent course completion for Staff #3 was more than two years old.”

Rule 8VAC20-790-600-F.

22.1-289.035-B-1

“The center is required to obtain a completed sworn statement prior to the employee’s first day of employment. The was no sworn statement for Staff #2 at the time of the inspection. Staff #2 has been actively working at the center for over 2 years.”

Rule 22.1-289.035-B-1.

8VAC20-780-160-C

“A tuberculosis (TB) screening is required every two years from the last screening. The updated screening for Staff #2 was due 6 months ago. The updated screening has not yet been completed.”

Rule 8VAC20-780-160-C.

8VAC20-780-240-A

“Staff are to complete the VDOE sponsored online orientation course within 90 days of hire. Staff #2, who is working with children, had not yet completed this course at the time of the inspection. It was overdue by more than 2 years.”

Rule 8VAC20-780-240-A.

8VAC20-780-240-B

“Staff shall complete orientation training prior to the staff member working alone with children and no later than seven days of the date of assuming job responsibilities. There was no documentation of orientation training for Staff #2 at the time of the inspection. Staff #2 has been actively working at the center for over 2 years.”

Rule 8VAC20-780-240-B.

8VAC20-780-70

“Documentation of at least 2 references to character, reputation, and competency are to be checked prior to employment. Staff #2, who has been actively working at the center for over 2 years, did not have any completed reference verifications on file at the time of the inspection.”

Rule 8VAC20-780-70.

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

“The sworn statement for Staff #2, who has been employed for over three months, was dated more than six weeks after their first day of employment.”

Rule 22.1-289.035-B-1.

The center must obtain a completed national fingerprint-based criminal background check prior to the employee’s first day of employment.

“The fingerprint-based criminal background check in the record of Staff #2, who has been employed for over three months, was obtained seven days after employment.”

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.

“The request of the central registry search for Staff #2 was requested 23 days after employment.”

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.

“The TB in the record of Staff #2 was dated four months prior to date of employment and has been employed for over three months.”

Rule 8VAC20-780-160-A.

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

“Staff #1’s updated screening was due a year and eight months ago. The updated screening has not yet been completed.”

Rule 8VAC20-780-160-C.

Documentation of at least 2 references to character, reputation, and competency are to be checked prior to employment.

“The references in the record of Staff #2 were obtained after employment. 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 which may interfere with fulfilling the job responsibilities for each staff member. Staff #2, who has been employed for over three months, was present at the center during the inspection on 05/13/2025, but their emergency contact information and information about any health problems were not observed at the center.”

Rule 8VAC20-780-70.

There shall always be at least one staff member on duty who has obtained within the last three years instruction in performing the daily health observation of children.

“Staff #1 and Staff #2, who were present during the inspection on 11/19/24, did not have a current certificate in daily health observation training.”

Rule 8VAC20-780-245-L.

(Repeat Violation) Based on a review of two staff records and interviews, the center did not obtain documentation that two staff had a follow-up tuberculosis (TB) screening at least every two years from the date of the first initial screening or testing.

Rule 8VAC20-780-160-C.

Based on a review of two staff records and interviews, the vendor did not ensure one staff member had current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care within 90 days of the date of employment.

“Evidence: The record of Staff #2, employed on 06/08/23, did not contain documentation that the staff has current certification in CPR. During interview, a member of management reported the center did not have documentation of current certification in CPR for Staff #2.”

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

Based on a review of two staff records and interviews, the vendor did not ensure one staff member had current certification in first aid appropriate to the ages of children in care within 90 days of the date of employment.

“Evidence: The record of Staff #2, employed on 06/08/23, did not contain documentation that the staff has current certification in first aid. During interview, a member of management reported the center did not have documentation of current certification in first aid for Staff #2.”

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

Based on a review of two staff records and interviews, the vendor did not ensure one staff member who works directly with children completed the department’s health and safety update course annually.

“Evidence: The record of Staff #1, employed on 06/07/21, did not contain the department’s health and safety update course. During interview, a member of management confirmed Staff #1 has not completed the training. The center was approved as a vendor on 03/28/22, therefore, the annual training should have been completed no later than 03/28/23.”

Rule 8VAC20-790-600-F.

(Repeat Violation) Based on a review of two staff records and interview, the center did not ensure one staff obtained a fingerprint-based national criminal background check prior to employment.

“Evidence: The results of the fingerprint-based national criminal background check in the record of Staff #2, employed on 06/08/23, were completed on 06/15/23. During interview, a member of management acknowledged the fingerprints for Staff #2 were received after Staff #2 received orientation training, for which she was compensated for on 06/08/23.”

Rule 22.1-289.035-B-2.

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

“Evidence: The record of Staff #2, employed on 06/08/23, did not contain documentation of a completed sworn statement. During interview, a member of management acknowledged that a completed sworn statement was not on file for Staff #2.”

Rule 8VAC20-770-60-B.

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

“Evidence: The record of Staff #2, employed on 06/08/23, did not contain the results of the central registry finding. During interview, a member of management reported the results of the central registry finding for Staff #2 could not be located.”

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

Based on a review of two staff records and interviews, the center did not ensure one staff member submitted documentation of a negative tuberculosis (TB) screening within the required timeframe.

“Evidence: The record of Staff #2, employed on 06/08/23, did not contain documentation of a negative TB screening. During interview, a member of management reported documentation of a negative TB screening could not be located for Staff #2.”

Rule 8VAC20-780-160-A.

Based on a review of two staff records and interviews, the center did not obtain documentation that one staff had a follow-up tuberculosis (TB) screening at least every two years from the date of the first initial screening or testing.

“Evidence: The most recent TB screening in the record of Staff #1, employed on 06/14/21, was dated 09/03/21. During interview, a member of management reported an updated TB screening was not on file for Staff #1. An updated TB screening should have been obtained no later than 09/03/23.”

Rule 8VAC20-780-160-C.

(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: The record of Child #1 (DOA: 05/28/19) did not contain documentation of child updates and confirmation of up-to-date information in the child’s record as required by 8VAC20-780-420-E.3. During interview, a member of management acknowledged the record did not contain confirmation of up-to-date information.”

Rule 8VAC20-780-60-A.

(Repeat Violation) Based on observations and a review of documentation on 02/27/24, the center did not ensure that the required information for each staff was kept at the center.

“Evidence: During the inspection on 02/27/24, Staff #1 and Staff #2 were observed at the center. The emergency contact information and information about any health problems which may interfere with fulfilling the job responsibilities were not observed at the center for the staff. 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 which may interfere with fulfilling the job responsibilities for each staff member.”

Rule 8VAC20-780-70.

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

“Evidence: The CPR certification in the record of Staff #1 expired on 11/14/2022.”

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

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

“Evidence: The first aid certification in the record of Staff #1 expired on 11/14/2022.”

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

Based on a review of two staff records and interview, the vendor did not ensure two staff members who work directly with children completed the department’s health and safety update course annually.

“Evidence: 1) The record of Staff #1 (DOE: 06/07/21) and the record of Staff #2 (DOE: 06/14/21) did not contain the department’s health and safety update course. 2) During interview, a member of management confirmed Staff #1 and Staff #2 have not completed the training. The center was approved as a vendor on 03/28/22, therefore, the annual training should have been completed no later than 03/28/23.”

Rule 8VAC20-790-600-F.

Based on a review of two staff records, 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 documentation and interview, the center did not ensure all children with a diagnosed food allergy were included in the center’s written list of children with allergies, sensitivities, and dietary restrictions.

“Evidence: 1) The record of Child #3, enrolled 08/16/22, and the record of Child #5, enrolled 08/17/22, indicated the children had diagnosed food allergies. 2) The inspector reviewed the center’s written list of all children’s allergies, sensitivities, and dietary restrictions during the inspection on 03/29/23. The list did not include Child #3 or Child #5. 3) During interview, staff reported they were aware of the children’s allergies, but did not realize they were not listed on the written allergy list on site.”

Rule 8VAC20-780-40-M.

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 #3, enrolled 8/16/22, indicated the child had a diagnosed food allergy, but the record did not include 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. 2) During interview, staff confirmed a written allergy care plan was not available for Child #3.”

Rule 8VAC20-780-60-A.

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

“Evidence: 1) The record of Staff #1, employed 06/14/21, did not contain the results of a fingerprint-based national criminal background check. 2) During interview, management confirmed the fingerprint-based national criminal background check for Staff #1 could not be located.”

Rule 22.1-289.035-B-2.

Based on a review of two staff records, 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 documentation on 09/27/2022, the center did not ensure that written injury records contained the required information.

Rule 8VAC20-780-550-P.

Based on staff interview and observation on 09/27/2022, the center did not ensure that the required information for each staff was kept at the center.

“Evidence: 1) Staff #1 and Staff #2 were observed at the center on 09/27/2022. 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 interviews, the center has not developed a written policy and procedure that describes how the center will ensure that each group of children receives care by consistent staff or team of staff members.

“Evidence: 1) During interview, a member of management reported the center is practicing care by consistent staff, but written policies and procedures are not listed in official policy format.”

Rule 8VAC20-780-350-F.

Based on interviews, the center has not developed written procedures for prevention of shaken baby syndrome or abusive head trauma, including coping with crying babies, safe sleeping practices, and sudden infant death syndrome awareness.

“Evidence: 1) During interview, a member of management reported the required written procedures for prevention of shaken baby syndrome or abusive head trauma have not been developed.”

Rule 8VAC20-780-40-K.

Based on a review of documentation, the center’s emergency preparedness plan does not contain all the required information.

“Evidence: 1) The center’s emergency preparedness plan was reviewed, the plan did not include procedural components for the continuity of operations to ensure that essential functions are maintained during an emergency.”

Rule 8VAC20-780-550-B.

Based on observations and a review of documentation on 03/08/22, the center did not ensure that the required information for each staff was kept at the center.

“Evidence: 1) During the inspection, Staff #1 and Staff #2 were observed at the center. 2) The emergency contact information and information about any health problems which may interfere with fullfilling the job responsibilities were not observed at the center for Staff #2 (DOH: 01/17/20). 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 which may interfere with fulfilling the job responsibilities for each staff member.”

Rule 8VAC20-780-70.