The YMCA of South Hampton Roads - Western Branch Primary School

22.1-289.011-F

“The license and any other documents required shall be posted in a conspicuous place on the licensed premises. The current license and the findings from the most recent inspection, dated 9/23/25, were not posted in a conspicuous place on the premises.”

Rule 22.1-289.011-F.

8VAC20-780-270-A

“Areas and equipment of the center, inside and outside, shall be maintained in a clean, safe condition. There was water spilled on tables and the floor and remained for more than an hour. Children were observed having to navigate the wet slick areas while staff made no effort to clean it up even after it had been pointed out to multiple staff.”

Rule 8VAC20-780-270-A.

8VAC20-780-350-B-5

“The staff-to-children ratios for children School age eligible up to 9 years is one staff to 18 children. However, there were 43 children ages 6 ? 7 with two staff where three staff were needed.”

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

8VAC20-780-430-K

“Provision shall be made for an individual place for each child’s personal belongings. There was not any individual place for each child’s belongings. Staff were observed picking backpacks up from the floor throughout the inspection.”

Rule 8VAC20-780-430-K.

8VAC20-780-510-G

“Medication shall be labeled with the child’s name. There is a bottle of over-the-counter allergy medication in the medication lock box that is not labeled with the child’s name.”

Rule 8VAC20-780-510-G.

8VAC20-780-540-B

“A first aid kit shall be accessible to outdoor play areas. Staff stated that a first aid kit was not taken to playground located at the opposite end of the school building and across a field.”

Rule 8VAC20-780-540-B.

8VAC20-780-540-E

“Required emergency supplies include one working, battery-operated radio. The radio available for review was not in working order during the inspection.”

Rule 8VAC20-780-540-E.

8VAC20-780-560-J

“Tables shall be sanitized before and after each use for feeding. The tables where children ate snack were not sanitized prior to them eating.”

Rule 8VAC20-780-560-J.

8VAC20-780-70

“Name, address, verification of age requirement, job title, and date of employment or volunteering; and name, address, and telephone number of a person to be notified in an emergency which shall be kept at the center. 2 out of 7 staff records reviewed on site did not contain the required information.”

Rule 8VAC20-780-70.

8VAC20-780-80-A

“For each group of children, the center shall maintain a written record of daily attendance that documents the arrival and departure of each child in care as it occurs. There was not any attendance documentation for the group of 43 6 ? 7-year-old children.”

Rule 8VAC20-780-80-A.

8VAC20-790-600-B

“Within the first 90 days of employment or subsidy vendor approval all staff who work directly with children shall complete Virginia Preservice Training for Child Care Staff. The records for Staff #3 and 5 did not contain documentation that the required preservice training was obtained.”

Rule 8VAC20-790-600-B.

8VAC20-790-600-D-1

“All staff who work directly with children shall have within 90 days of the date of employment current cardiopulmonary resuscitation (CPR) appropriate to the ages of children in care. The records for Staff #1 ? 4 did not contain documentation that the required first aid and CPR training was obtained within the required time frames.”

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 first aid appropriate to the ages of children in care. The records for Staff #1 ? 4 did not contain documentation that the required first aid and CPR training was obtained within the required time frames.”

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

22.1-289.035-B-4

“The center is required to obtain background checks from any state in which the individual has resided in the preceding five years. Staff #1, employed for more than 6 months, did not have documentation of a central registry finding from the state she previously lived within the past five years.”

Rule 22.1-289.035-B-4.

8VAC20-780-160-A

“Each staff member shall submit documentation of a negative tuberculosis screening before coming in contact with children. Documentation shall have been completed within 30 calendar days of the date of employment. The record provided for Staff #3 did not contain documentation that tuberculosis screening was obtained within the required time frames. Staff #3 has been employed for six months.”

Rule 8VAC20-780-160-A.

8VAC20-780-340-B

“During the center’s hours of operation, one adult on the premises shall be in charge of the administration of the center. This person shall be either the administrator or an adult appointed by the licensee or designated by the administrator. Today there was not any person designated as being in charge of the program during the operating hours.”

Rule 8VAC20-780-340-B.

8VAC20-780-430-K

“Provision shall be made for an individual place for each child’s personal belongings. There was not any space made available for children’s individual belongings.”

Rule 8VAC20-780-430-K.

8VAC20-780-560-J

“Tables shall be sanitized before each use for feeding. The tables were not sanitized prior to children eating the afternoon meal.”

Rule 8VAC20-780-560-J.

8VAC20-780-70

“Each staff record shall be kept and contain all required information. The records for Staff # 2- 5 did not contain documentation of verification of age.”

Rule 8VAC20-780-70.

8VAC20-780-80-A

“For each group of children, the center shall maintain a written record of daily attendance that documents the arrival and departure of each child in care as it occurs. The attendance available during the inspection was not accurate as there were 67 children present but the documentation showed 65 children present.”

Rule 8VAC20-780-80-A.

22.1-289.058

“Each building that was built before 2015 and that houses a child day program that is licensed that serves preschool-age children shall be equipped with at least one carbon monoxide detector. Staff present did know if there was a carbon monoxide detector in the building or where it may be located.”

Rule 22.1-289.058.

8VAC20-780-70

“Name, address, verification of age requirement, job title, and date of employment or volunteering; and name, address, and telephone number of a person to be notified in an emergency which shall be kept at the center. Two out of five staff working during the inspection did not have the required staff record documentation on site.”

Rule 8VAC20-780-70.

8VAC20-780-340-F

“Children under 10 years of age always shall be within actual sight and sound supervision of staff. Child #1 was observed in the bathroom located outside actual site and sound supervision of any staff present. The bathroom is located through double doors and across the hall way from the child care room.”

Rule 8VAC20-780-340-F.

8VAC20-780-340-B

“Based on observation the center failed to ensure that one adult on the premises is in charge of or appointed as the administrator during the center’s hours of operation. Evidence: On March 26, 2024 1 - Upon asking Staff #2 who was in charge of the center she responded, ?guess it’s me.? 2 ? Staff #2 stated that no one had told her she was in charge of the center during the administrator’s absence.”

Rule 8VAC20-780-340-B.

8VAC20-780-340-F

Rule 8VAC20-780-340-F.

8VAC20-780-360-A

“Based on observation the center failed to provide a variety of daily activities for all age groups that are age and stage appropriate and provide opportunities for active and quiet activities; individual and group activities. Evidence: 1 ? On March 26, 2024, from approximately 3:00pm until 3:46pm there were not any activities provided to children. a.Children’s activities were locked in a teacher closet b.Children occupied themselves by running around the space, screaming, hitting, and wondering without apparent purpose.”

Rule 8VAC20-780-360-A.

8VAC20-780-40-D

“Based on observation and interview the center failed to ensure that the license is posted in a conspicuous to the public. Evidence: 1 ? Upon entering the center on March 5 and 26, 2024 the license was not posted. 2 ? Staff #1 and #3 confirmed that that license was not posted on either occasion.”

Rule 8VAC20-780-40-D.

8VAC20-780-40-M

“Based on documentation review the center failed to ensure that allergy care plans are accessible to all staff who work with children. Evidence: On March 5, 2024 There was no action plan for medication for Child #1 with the written list of children’s allergies.”

Rule 8VAC20-780-40-M.

8VAC20-780-430-K

“Based on observation and interview the center failed to ensure that there were provision made for an individual place for each child’s personal belongings. Evidence: 1 ? Upon entering the child care space on March 5, 2024 and throughout the inspection on the 5th, there was not any individual place for each child to place their belongings. 2 ? Staff #1 confirmed that child’s belongings were piled on top of tables without any individual places set up.”

Rule 8VAC20-780-430-K.

8VAC20-780-510-E

“Based on medication review the center failed to obtain written parent authorization for medication. Evidence: On March 5, 2024 There was not any written authorization to administer an Epi Pen that is in the medication lockbox.”

Rule 8VAC20-780-510-E.

8VAC20-780-510-G

“Based on medication review the center failed to ensure that medication is labeled with the child’s name. Evidence: On March 5, 2024 There was a bottle of over-the-counter allergy medication in the medication lockbox without any name on the medication.”

Rule 8VAC20-780-510-G.

8VAC20-780-540-C

“Based review of first aid kit the center failed to ensure that all required items are a part of the kit. Evidence: On March 5, 2024 There was not any gauze pads in the first aid kit during the inspection.”

Rule 8VAC20-780-540-C.

8VAC20-780-550-A

“Based emergency preparedness plan review the center failed to ensure that staff responsibility and facility readiness with respect to emergency evacuation and relocation, shelter-in-place, and lockdown are in place. Evidence: On March 5, 2024 The emergency preparedness plan that was available at the center identifies staff who are no longer employed by the center as persons responsible for implementing portions of the emergency plan.”

Rule 8VAC20-780-550-A.

8VAC20-780-550-D

“Based on record review and interview the center failed to implement a monthly practice of evacuation drill. Evidence: On March 5, 2024 There was not any documentation that emergency evacuation drills were practiced during the months of January or February 2024.”

Rule 8VAC20-780-550-D.

8VAC20-780-70

“Based on record review the center failed to ensure that staff records are maintained as required. Evidence: On March 26, 2024 There was no emergency contact information on site for Staff #1.”

Rule 8VAC20-780-70.

8VAC20-780-340-B

“Based on observation and interview the center failed to ensure at during the hours of operation, one adult on the premises is in charge of the administration of the center. Evidence: Upon arrival Staff #2 and #4 stated that they were not in charge of the center, that no one was in charge of the center because the site director had left the program.”

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

8VAC20-780-360-A

“Based on observation the center failed to provide a variety of activities for children in care. Evidence: 1 - From the onset of the inspection at approximately 3:00pm through approximately 3:46 the children in care were not given any activities, toys, projects or materials for exploration. 2 - Children were observed chasing each other around the room, throwing items in the air and pushing and shoving each other. 3 - Staff #2 and #4 did not offer activities until they were asked to do so.”

Rule 8VAC20-780-360-A. From a complaint.

8VAC20-780-40-D

“Based on observation the center failed to ensure that the license is posted in a place conspicuous to the public. Evidence: 1 - The current was not visibly posted in the center. There was not any information posted in the center. 2 - Staff #2, #3, #4 confirmed that the parent board that contains all required postings was not put up in the center on this day.”

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

8VAC20-780-70

“Based on record review and interview the center failed to ensure that onsite staff records were maintained as required. Evidence: 1 - There was not any documentation of emergency contact onsite for Staff #4. 2 - Staff #4 confirmed that he did not have any emergency contact documentation at the center during the inspection.”

Rule 8VAC20-780-70. From a complaint.

8VAC20-780-350-B-5

“Based on observation and interview the center failed to ensure that ratio requirements are followed. Evidence 1 - At 2:26pm there were 38 children in care with two staff where three staff were required. a. Children present ranged in age from five to eight years old 2 - Attendance records documented that from 2:10pm there were 39 children present with two staff were three were required.”

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

8VAC20-780-70

“Based on record review and interview the center failed to ensure that staff records are maintained at the center as required. Evidence: 1 - There was not any staff record available for Staff #2 at the center during the inspection. a. Staff #2 was present providing direct to children enrolled in the program. 2 - Staff #1 confirmed that required staff information was not available for Staff #2 during the inspection.”

Rule 8VAC20-780-70.

8VAC20-780-350-C

“Based on observation and interview the center failed to ensure that when children are in ongoing mixed age groups the staff to children ratio and group size applicable to the youngest child in the group will apply to the entire group. Evidence: 1 - Upon arrival there were 32 children present ages four through nine years old with two staff where three staff would have been required. 2 - Staff #1 confirmed that there were 32 children present ages four through nine years with only two staff.”

Rule 8VAC20-780-350-C.

8VAC20-780-540-B

“Based on observation and interview the center failed to ensure that the first aid kit is accessible to staff but not to children. Evidence; The first aid kit was stored in an unlocked cabinet and an unlock back pack.”

Rule 8VAC20-780-540-B.

8VAC20-780-60-A

“Based on record review and interview the center failed to maintain and keep at the center a separate record for each child enrolled. Evidence: 1 - There was not a record for Child #1 in hard copy or accessible digitally during the inspection. 2 - Staff #1 confirmed that the record was not available during the inspection.”

Rule 8VAC20-780-60-A.

8VAC20-780-70

“Based on record review and interview the center failed to ensure that staff records are maintained as required. Evidence: 1 - The onsite record for Staff #1 was not available during the inspection 2 - Staff #1 confirmed that her onsite record was not available during the inspection.”

Rule 8VAC20-780-70.

8VAC20-790-600-D-1

“Based on record review the vendor failed to ensure that all staff who work directly with children have within 90 days of the date of employment current cardiopulmonary resuscitation (CPR) certification. Evidence: 1 - The records for Staff #2 and #4 do not contain documentation of CPR certification training. a. Staff #2 has a documented date of hire as September 30, 2022. b. Staff # 4 has documented date of hire as March 25, 2022.”

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

8VAC20-790-600-D-2

“Based on record review the vendor failed to ensure that all staff who work directly with children have within 90 days of the date of employment current first aid certification. Evidence: 1 - The records for Staff #2 and #4 do not contain documentation of first aid certification training. a. Staff #2 has a documented date of hire as September 30, 2022. b. Staff # 4 has documented date of hire as March 25, 2022.”

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

22.1-289.035-B-4

Rule 22.1-289.035-B-4.

8VAC20-770-60-C-2

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

8VAC20-780-240-A

Rule 8VAC20-780-240-A.

8VAC20-780-270-F

“Based on observation and interview the center failed to ensure that there was a working non pay telephone. Evidence: 1 - During the inspection the center cell phone was not operational. a. Two phone calls were placed to the telephone number provided as the number to reach the center. However, the phone never rang or gave in indication that a call had been received at the number. 2 - Staff #3 and 4 stated that the cell phone service was not relievable.”

Rule 8VAC20-780-270-F.

8VAC20-780-340-B

Rule 8VAC20-780-340-B.

8VAC20-780-340-F

Rule 8VAC20-780-340-F.

8VAC20-780-510-E

“Based on observation an d interview the center failed to ensure that all requirements for medication are implemented. Evidence: 1 - Child #2 stated that medication being reviewed belonged to her. The child offered this information without being asked. 2 - There is not a parent signature on the medication authorization. Nor is there written parent authorization anywhere in the record of Child #2. 3 - The doctor’s authorization had expired as it was dated September 12, 2022 through June 30, 2022.”

Rule 8VAC20-780-510-E.

8VAC20-780-60-A

“Based on record review and interview the center failed to ensure that all required children’s record information is obtained. Evidence: 1 - The record for Child #1 does not contain documentation of pages 1 - 3 of the agencies enrollment application. As a result information regarding age, parent’s names, parent place employment and contact phone numbers and emergency contact information was not available for review. 2 - Staff #3 and #4 who where present at the site confirmed that the information was not present in the record of Child #1.”

Rule 8VAC20-780-60-A.

8VAC20-780-70

“Based on record review the center failed to ensure that each staff record contains all required information. Evidence: The record for Staff #4 did not contain documentation of that the staff possesses the education and training required for the position of Program Leader”

Rule 8VAC20-780-70.

Based on review of two staff records, it was determined that the facility did not ensure that all staff members had a completed search of the central registry on file within 30 days of employment.

“Evidence: Staff #1 (9/21/21) and staff #2 (10/1/19), both of whom were on duty at the time of the inspection, neither had a completed search of the central registry on file.”

Rule 8VAC20-770-60-B.

Based on review of two staff records, it was determined that the facility did not ensure that all staff had a tuberculosis (Tb) screening prior to coming in contact with the children.

“Evidence: Staff #2, who was on duty at the time of the inspection, had a hire date of 10/1/19. However, her Tb screening was dated 1/21/22.”

Rule 8VAC20-780-160-A-1.

Based on review of center documents, it was determined that the facility did not ensure that all staff to child ratios were maintained,

“Evidence: On the Preliminary Request for Information, the facility stated and attendance sheets verified, that there were 42 children in care with only two staff. An additional staff member would have been needed.”

Rule 8VAC20-780-350-B.

Based on review of the emergency evacuation, shelter-in-place and lockdown drills log submitted by the facility, it was determined that the facility did not ensure that drills were practiced as required and that all information regarding the drills was documneted.

“Evidence: 1. There was no indication that emergency evacuation drills were practiced in either November or December of 2021. 2. The log indicates that a lockdown drill was held on December 9, 2021. However, it was missing the name of the person conducting the drill, the time of the drill, notification method, number of participating staff, number of participating children, special conditions, problems encountered and weather”

Rule 8VAC20-780-550-G.

Based on review of four children’s records, it was determined that the facility did not ensure that each child had a record available on site.

“Evidence: The record for child #4 was at the central office for the organization as a meeting was being held with the parent.”

Rule 8VAC20-780-60-A.