THE YMCA OF SOUTH HAMPTON ROADS - DEEP CREEK ELEMENTARY

22.1-289.035-B-4

“Repeat Violation 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 have documentation of a completed out of state child abuse and neglect registry background check for Staff 1, who had been employed for 12 months. There was no documentation in the record of a follow-up with the state to determine results within 45 days of a search request.”

Rule 22.1-289.035-B-4.

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, has not yet completed all components of this course which is overdue by more than 3 months.”

Rule 8VAC20-780-240-A.

8VAC20-780-550-P

“The center shall maintain a written record of children’s serious and minor injuries in which entries are made on the day of occurrence and include all the required information. The injury records for 4 children did not include the date and time the parent was notified.”

Rule 8VAC20-780-550-P.

22.1-289.011-F

“The license and any other documents required shall be posted in a conspicuous place on the licensed premises. The inspection summary from the most recent inspection, dated 9/8/25 was not posted in a conspicuous place on the premises.”

Rule 22.1-289.011-F.

22.1-289.035-B-4

“Repeat Violation 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 request a search of the child abuse and neglect registry from one state for Staff #3, who has been employed for more than five months.”

Rule 22.1-289.035-B-4.

8VAC20-780-140-A

“Physical examinations completed by a physician shall be obtained prior to the first day of attendance or within 30 days after the first day of attendance. There was no physical examination in the record of Child 4, who had been enrolled for six months.”

Rule 8VAC20-780-140-A.

8VAC20-780-160-C

“A tuberculosis (TB) screening is required every two years from the last screening. Staff #1 updated screening was due one month ago. The updated screenings had not yet been completed.”

Rule 8VAC20-780-160-C.

8VAC20-780-510-N

“Centers shall keep a record of medication given children which shall include all of the required information. Documentation of medication given to Child 3 did not include the type of medication administered.”

Rule 8VAC20-780-510-N.

8VAC20-780-510-P

“When an authorization for medication expires, the facility shall notify parents that the medication must be picked up within 14 days of the authorization expiring or that a new authorization should be completed. Medication for Child 2 was onsite, but the medication authorization had expired over 20 days ago. The medication had not been administered past the expiration of the authorization. The authorization had not been renewed and the medication was not returned or disposed of as required.”

Rule 8VAC20-780-510-P.

8VAC20-780-550-P

“Repeat Violation The center shall maintain a written record of children’s serious and minor injuries in which entries are made the day of occurrence and contain all of the required information. The injury record for Child #1 did not contain all of the required information.”

Rule 8VAC20-780-550-P.

8VAC20-790-600-D-1

“Repeat Violation All staff who work directly with children shall have within 90 days of the date of employment current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care. Staff #2 and Staff #3, employed for over 160 days, did not have documentation of current CPR certification.”

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

8VAC20-790-600-D-2

“Repeat Violation All staff who work directly with children shall have within 90 days of the date of employment current certification in first aid appropriate to the ages of children in care. Staff #2 and Staff #3, employed for over 160 days, did not have documentation of current first aid certification.”

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. The record for Staff #1 did not contain documentation that the 2025 annual health and safety update course was completed.”

Rule 8VAC20-790-600-F.

8VAC20-790-600-D-1

“All staff who work directly with children shall have within 90 days of the date of employment, current certification in cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care. Staff #2 did not have current CPR certification.”

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

8VAC20-790-600-D-2

“All staff who work directly with children shall have within 90 days of the date of employment current certification in first aid appropriate to the ages of children in care. Staff #2 did not have current First Aid certification.”

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

22.1-289.035-B-2

“Providers must obtain a completed national criminal background check prior to the employee’s first day of employment. The criminal background check in the record for Staff #3 was completed more than two years after the employee’s hire date.”

Rule 22.1-289.035-B-2.

8VAC20-780-340-F

“Children under 10 years of age shall always be within actual sight and sound supervision of staff. During the inspection, 40 children under the age of 10 years old, were not in sight and sound supervision in the cafeteria when Staff #2 exited the building to meet a bus.”

Rule 8VAC20-780-340-F.

Repeat Violation The required ratio for children, school age eligible up to 9 years is one staff per eighteen children. During the inspection, the required ratio was not maintained. From 2:43 to 2:53pm Staff #1 was observed supervising 33 children during a bathroom transition time. Two staff were needed to maintain the required ratio.

“Staff #1 and Staff #2 were supervising 73 children (youngest child 5 years old) from 2:56pm to 3:04pm. Four staff were required. Staff #1, Staff #2 and Staff #3 supervised 60 to 71 children between 3:15pm and 4:30pm. Four staff were required.”

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

8VAC20-780-550-D

“The center shall implement a monthly practice evacuation drill. An evacuation drill was not practiced in June 2025.”

Rule 8VAC20-780-550-D.

8VAC20-780-550-E

“Shelter in place procedures shall be practiced a minimum of twice per year. There was only one shelter in place drill practiced during the 2024-2025 school year.”

Rule 8VAC20-780-550-E.

8VAC20-780-60-A

“Each center shall maintain and keep at the center a separate record for each child enrolled which shall contain all of the required information. The record for child #1 did not contain the name, address, and phone number of two designated people, other than the parents, to call in an emergency if a parent cannot be reached.”

Rule 8VAC20-780-60-A.

8VAC20-780-510-P

“Repeat Violation 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. The medication authorization, signed by a parent for Child #1 had expired 18 months ago. The medication had not been picked up and was not disposed of.”

Rule 8VAC20-780-510-P.

8VAC20-780-160-C

“At least every two years from the date of the initial screening or testing, staff members shall obtain and submit the results of a follow up tuberculosis (TB) screening. Evidence: The two year follow up TB screening for staff #2 was 2 months overdue. The updated TB screening was not completed.”

Rule 8VAC20-780-160-C.

8VAC20-780-340-J

“Repeat Violation Staff shall not allow a child to leave the center unsupervised. During the inspection, child #6 opened the exit door and walked out of the facility unsupervised.”

Rule 8VAC20-780-340-J.

8VAC20-780-350-B-5

“The required ratio for children school age eligible up to 9 years is one staff per eighteen children. Staff #1 and staff #2 were observed supervising thirty-nine children when transitioning from the cafeteria to the bathrooms. Based on the number and ages of the children, three staff members were required.”

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

22.1-289.011-F

Rule 22.1-289.011-F.

8VAC20-780-240-A

“Based on the review of records and interview, it was determined the center did not ensure that the Virginia Department of Education (VDOE) sponsored orientation course is completed within 90 calendar days of employment. Evidence: 1.The record for staff #3 did not contain documentation that the VDOE 10-hour orientation training had been completed. 2.Staff #6 confirmed the training certificate was not in the record.”

Rule 8VAC20-780-240-A.

8VAC20-780-130-A

“Based on record review and interviews, it was determined the center did not ensure that the documentation was obtained that each child in care had received immunizations as required by the State Board of Health before the child attends the center. Evidence: The record for Child #1, Child #5, and Child #8 did not contain documentation of immunizations.”

Rule 8VAC20-780-130-A.

8VAC20-780-320-B

“Based on observation and interviews, it was determined that the center did not ensure that bathrooms are equipped with paper towels. Evidence: Repeat Violation 1. In the girls bathroom a child was trying to dry her hands but the paper towel dispenser was not working. The child stated ?when there are no paper towels we just shake our hands?.”

Rule 8VAC20-780-320-B.

8VAC20-780-340-A

Rule 8VAC20-780-340-A.

8VAC20-780-40-M

“Based on a review of children’s records and interviews, it was determined the center did not ensure that the program maintained a current written list of all children’s allergies, sensitivities, and dietary restrictions. Evidence: Repeat Violation 1.The allergy list available to staff was no longer current as it was dated for the previous school year (2022-2023). a.Three out of the four children listed on the expired allergy list were no longer enrolled. 2.Staff #4 (Program Director) confirmed the allergy list was not current.”

Rule 8VAC20-780-40-M.

8VAC20-780-430-K

“Based on observation and interviews, it was determined the center did not ensure that a provision was made for an individual place for each child’s personal belongings. Evidence: 1. Children’s backpacks, lunchboxes and sweaters were piled on top of each other on a table in the cafeteria. 2. Backpacks and lunch boxes were falling on the floor as children attempted to reach their own belongings. 3. Staff #4 (Program Director) confirmed the children did not have an individual place for children to place their belongings.”

Rule 8VAC20-780-430-K.

8VAC20-780-510-G

“Based on observation and interviews, it was determined the center did not ensure that medication was labeled with the child’s name. Evidence: The box of emergency medication for Child #13 was not labeled with the child’s name. Staff #4 (Program Director) confirmed there was no name on the box.”

Rule 8VAC20-780-510-G.

8VAC20-780-510-P

“Based on observation and interviews, it was determined the center did not ensure that when medication expires, the parent is notified and the medication is returned to the parent within 14 days. Evidence: Repeat Violation Medication for Child #11 (enrollment ended 6/16/23) expired April 2023 was not returned to the parent and was on-site on the day of the inspection.”

Rule 8VAC20-780-510-P.

8VAC20-780-560-F

“Based on observation and interviews, it was determined that the center did not ensure that a menu listing foods to be served for meals and snacks was posted in a location conspicuous to parents. Evidence: Repeat Violation 1. The inspector observed that there was no snack menu posted on the Parent Board. 2. Staff #4 (Program Director) confirmed the snack menu was not posted.”

Rule 8VAC20-780-560-F.

8VAC20-780-60-A

Rule 8VAC20-780-60-A.

Based on record review and interviews, it was determined the center did not ensure that the required written and signed agreements between the parent and the center shall be in each child’s record by the first day of the child’s attendance.

“Evidence: 1. Seven out nine children (Child #1, #2, #3, #5, #6, #8, #9) who were in attendance on the day of the inspection, records did not contained signed agreements between the parent and the center. 2. Staff #4 (Program Director) confirmed the parental agreements were not signed.”

Rule 8VAC20-780-90-A.

8VAC20-780-320-B

“Based upon observation, the facility has not ensured that bathrooms are equipped with paper towels. Evidence: The girls were taken to the bathroom at the end of the hallway outside of the gymnasium to wash their hands prior to eating afternoon snack. The girls came out of the bathroom shaking off their hands to dry them and said that there were no paper towels. The inspector mentioned this to staff 2 who sent an assistant to retrieve paper towels.”

Rule 8VAC20-780-320-B.

8VAC20-780-510-E

“Based upon review of medication, the facility has not ensured that the procedures for administering medication include methods to prevent the use of outdated medication and that expired medication is returned to the parent within 14 days or the medication is disposed of by the facility. Evidence: 1. There was an EpiPen stored for emergency administration to child 9. The medication expired in April 2023 and was not returned to the parent or disposed of. 2. Staff 1 confirmed that the medication was expired.”

Rule 8VAC20-780-510-E.

8VAC20-780-550-D

“Based upon review pf records and staff interview, the facility has not ensured that they have implemented a monthly evacuation drill. Evidence: 1. The written record of emergency drills did not include documentation of an emergency evacuation drill in April 2023. 2. Staff 1 acknowledged that an evacuation drill had not been documented in the emergency drill record.”

Rule 8VAC20-780-550-D.

8VAC20-780-60-A

Rule 8VAC20-780-60-A.

8VAC20-780-245-J-3

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

8VAC20-780-260-A

“Based upon records provided, the facility has not ensured that there is an annual fire inspection from the fire official having jurisdiction. Evidence: The most recent fire marshal inspection provided is dated 11/10/2021.”

Rule 8VAC20-780-260-A.

8VAC20-780-340-A

Rule 8VAC20-780-340-A.

8VAC20-780-350-C

Rule 8VAC20-780-350-C.

8VAC20-780-510-E

“Based upon review of medication stored for emergency administration to the children, the facility has not followed their own policy requiring parent authorization for any medication to potentially be administered to the child by program staff. Evidence: There was diphenhydramine stored for potential administration to child 3. There was no written parent authorization for the diphenhydramine to be administered.”

Rule 8VAC20-780-510-E.

8VAC20-780-510-P

“Based upon observation and staff interview, the facility has not ensured that when medication expires, the parent is notified and the medication is returned to the parent within 14 days. Evidence: 1. There was epinephrine for potential emergency administration to child 2. The epinephrine expired in December 2022 and was not returned to the parent. 2. Staff 1 acknowledged that the epinephrine for child 2 had expired and the parent was not notifed.”

Rule 8VAC20-780-510-P.

8VAC20-780-550-F

“Based upon review of records, the facility has not ensured that lockdown procedures are practiced at least annually. Evidence: Based upon the records provided, there was no lockdown drill conducted last school year and no lockdown drill has been conducted this school year.”

Rule 8VAC20-780-550-F.

8VAC20-780-60-A

“Based upon review of records, the facility has not ensured that children’s records include all required information. Evidence: The record provided for child 2 did not include any information regarding the parents or the parent contact information. The record also did not include the names, addresses and telephone numbers for two persons to be contacted in an emergency when a parent cannot be reached.”

Rule 8VAC20-780-60-A.

8VAC20-780-140-A

“Based upon review of records, the facility has not ensured that each child has a physical examination by or under the direction of a physician. Evidence: The record provided for child 5, whose first date of attendance was recorded as 9/6/2022, did not have documentation of a physical examination.”

Rule 8VAC20-780-140-A.

8VAC20-780-160-A

“Based upon review of documentation, the facility ash not ensured that each staff member submits documentation of a negative tuberculosis screening that was completed within the last 30 calendar days of the date of employment. Evidence: 1. The date of employment of staff 1 was 4/20/2022. The date of the tuberculosis screening was 6/3/2021. 2. The date of employment of staff 2 was 10/31/2022. The date of the tuberculosis screening was 7/23/2022.”

Rule 8VAC20-780-160-A.

8VAC20-780-245-J-3

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

8VAC20-780-260-B

“Based upon review of documentation and staff interview, the facility has not ensured that there is documentation of annual approval of the health department. Evidence: 1. The facility could not provide documentation of annual approval of the health department. 2. Staff 1 verified that documentation of annual approval of the health department was not available.”

Rule 8VAC20-780-260-B.

8VAC20-780-40-E

Rule 8VAC20-780-40-E.

8VAC20-780-510-P

“Based upon observation and staff interview, the facility has not ensured that when medication expires, the parent is notified and the medication is returned to the parent within 14 days. Evidence: 1. There was epinephrine stored for potential administration to child 2. The epinephrine expired in December 2022 and was not returned to the parent. 2. Staff 1 acknowledged that the epinephrine for child 2 had expired and the parent ws not notified.”

Rule 8VAC20-780-510-P.

8VAC20-780-550-P

“Based upon review of records and staff interview, the facility has not ensured that they maintain a written record of children’s injuries that includes are required documentation. Evidence: 1. A written injury record dated 12/15/2021 did not include the time the parent was notified of the injury. 2. Staff 1 verified that the injury record of 12/15/2021 did not include the time the parent was notified of the injury.”

Rule 8VAC20-780-550-P.

8VAC20-780-560-F

“Based upon observation and staff interview, the facility has not ensured that a menu of foods to be served for snack was posted. Evidence: 1. There was no snack menu for the current week posted. 2. Staff 1 acknowledged that the menu had not been posted for the current week.”

Rule 8VAC20-780-560-F.

8VAC20-780-60-A

“Based upon review of records, the facility ahs not ensured that children’s records include all required information. Evidence: The record provided for child 2 did not include two persons other than the parents to be contacted in an emergency when a parent cannot be reached.”

Rule 8VAC20-780-60-A.

Based on review of our staff records, it was determined that the facility did not ensure that each staff member had an updated tuberculosis (Tb) screening every two years from the date of the last screening.

“Evidence: The Tb screening for staff #3, who was on duty at the time of the inspection, expired “this past summer” according to the Coordinator of the program.”

Rule 8VAC20-780-160-C.

Based on review of two children’s records it was determined that the facility did not ensure that there was a record available for each child enrolled.

“Evidence: The record was requested for child #1, who was in care at the time of the inspection, did not have a record on site.”

Rule 8VAC20-780-60-A.

Based on review of four staff records, it was determined that the facility did not ensure that all elements were present in each staff member’s record.

“Evidence: The record for staff #4, who was on duty at the time of the inspection, did not contain the telephone number for the emergency contact person.”

Rule 8VAC20-780-70.