Effingham Street Family YMCA

8VAC20-780-260-B

“Repeat Violation An annual approval from the health department shall be provided. There was no documentation at the center to show that an environmental sanitation report was completed.”

8VAC20-780-245-A

“Staff shall complete annually a minimum of 16 hours of training appropriate to the age of children in care. There was no documentation to show that Staff #1 completed 16 hours of annual training in 2025.”

8VAC20-780-510-P

“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. A medication authorization for Child #1 was expired; however, the medication was not picked up or the authorization was not renewed.”

8VAC20-780-550-D

“The center shall implement a monthly practice evacuation drill. There was no documentation to show that a evacuation drill was completed in December 2025.”

8VAC20-780-550-P

“Repeat Violation The center shall maintain a written record of children's serious and minor injuries which includes all the required information. Two injury reports reviewed did not contain all the information required to be on the reports.”

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 record for Staff #1 did not contain an up to date CPR certification; the CPR certification reviewed was expired. The record for Staff #2 did not contain documentation of CPR certification.”

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 record for Staff #1 did not contain an up to date first aid certification; the first aid certification reviewed was expired. The record for Staff #2 did not contain documentation of first aid certification.”

8VAC20-780-550-P

“The center shall maintain a written record of children's serious and minor injuries in which entries are made the day of occurrence. The record shall include all the required information. Six injury reports reviewed at the inspection did not contain all the information required to be on the reports.”

8VAC20-780-260-B

“An annual approval from the health department shall be provided. There was no documentation at the center to show that an environmental sanitation report was completed.”

8VAC20-780-70

“The following staff records shall be kept for each staff person: documentation that two or more references as to character and reputation as well as competency were checked before employment. In the record of Staff #1 (employed for five months), one reference was missing.”

8VAC20-780-150-B

“Repeat Violation Each immunization report shall be signed by a physician, his designee, or an official of a local health department. The immunization reports for Child #1 and Child #2 were not signed by a physician, his designee, or an official of a local health department, which is required.”

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 record for Staff #1 did not contain an up to date CPR certification; the CPR certification reviewed was expired. The record for Staff #2 did not contain documentation of CPR certification.”

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 record for Staff #1 did not contain an up to date first aid certification; the first aid certification reviewed was expired. The record for Staff #2 did not contain documentation of first aid certification.”

8VAC20-780-550-P

“The center shall maintain a written record of children's serious and minor injuries in which entries are made the day of occurrence. The record shall include all the required information. Six injury reports reviewed at the inspection did not contain all the information required to be on the reports.”

8VAC20-780-260-B

“An annual approval from the health department shall be provided. There was no documentation at the center to show that an environmental sanitation report was completed.”

8VAC20-780-70

“The following staff records shall be kept for each staff person: documentation that two or more references as to character and reputation as well as competency were checked before employment. In the record of Staff #1 (employed for five months), one reference was missing.”

8VAC20-780-150-B

“Repeat Violation Each immunization report shall be signed by a physician, his designee, or an official of a local health department. The immunization reports for Child #1 and Child #2 were not signed by a physician, his designee, or an official of a local health department, which is required.”

8VAC20-780-130-A

“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. The record for Child #1 (enrolled for eight months) did not contain documentation of immunizations, which is required.”

8VAC20-780-150-B

“Each immunization report shall be signed by a physician, his designee, or an official of a local health department. The immunizations for Child #3 (enrolled for eight months) were not signed by a physician, his designee, or an official of a local health department, which is required.”

8VAC20-780-60-A

“Each center shall maintain and keep at the center a separate record for each child enrolled which shall contain all the required information. The records for Child #2 (enrolled for eight months) and Child #4 (enrolled for eight months) did not contain all the required information.”

8VAC20-780-330-B

“Where playground equipment is provided, resilient surfacing shall comply with minimum safety standards (six inches of mulch). The resilient surfacing on the playground was measured at less than one inch, which does not meet the required minimum safety standard of six inches.”

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 license and most recent inspection findings were not posted in a conspicuous place on the licensed premises, which is required.”

8VAC20-780-130-A

“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. The record for Child #1 (enrolled for eight months) did not contain documentation of immunizations, which is required.”

8VAC20-780-150-B

“Each immunization report shall be signed by a physician, his designee, or an official of a local health department. The immunizations for Child #3 (enrolled for eight months) were not signed by a physician, his designee, or an official of a local health department, which is required.”

8VAC20-780-60-A

“Each center shall maintain and keep at the center a separate record for each child enrolled which shall contain all the required information. The records for Child #2 (enrolled for eight months) and Child #4 (enrolled for eight months) did not contain all the required information.”

8VAC20-780-330-B

“Where playground equipment is provided, resilient surfacing shall comply with minimum safety standards (six inches of mulch). The resilient surfacing on the playground was measured at less than one inch, which does not meet the required minimum safety standard of six inches.”

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 license and most recent inspection findings were not posted in a conspicuous place on the licensed premises, which is required.”

8VAC20-790-600-D-1

“All staff who work directly with children shall have cardiopulmonary resuscitation (CPR) training within 90 days of the date of employment. 1.There is no documentation to show that Staff #1 and Staff #2 (both employed for 2 and a half years) have completed CPR training. 2. The documentation of CPR training for Staff #3 (employed for seven months) show that the staff member did not complete CPR training within 90 days of employment, which is required.”

8VAC20-790-600-D-2

“All staff who work directly with children shall have first aid training within 90 days of the date of employment. 1.There is no documentation to show that Staff #1 and Staff #2 (both employed for 2 and a half years) have completed first aid training. 2. The documentation of first aid training for Staff #3 (employed for seven months) show that the staff member did not complete first aid training within 90 days of employment, which is required.”

8VAC20-780-240-A

“The Virginia Department of Education-sponsored orientation course shall be completed within 90 calendar days of employment. In the record for Staff #2 (employed seven months), the documentation for the Virginia Department of Education-sponsored orientation course show that the training was not completed within 90 calendar days of employment.”

8VAC20-780-240-A

“The Virginia Department of Education-sponsored orientation course shall be completed within 90 calendar days of employment. In the record for Staff #2 (employed seven months), the documentation for the Virginia Department of Education-sponsored orientation course show that the training was not completed within 90 calendar days of employment.”

8VAC20-780-160-A

“Documentation of a tuberculosis(TB) screening shall be submitted at the time of employment and prior to coming into contact with children. The record for Staff #2 hasTB results that were submitted after the time of employment and not prior to coming into contact with children.”

22.1-289.035-B-3

“Centers must request central registry results for all staff members. There is no documentation of a central registry search in the record of Staff #1 (employed for 2 and a half years). In the record of Staff #2 (employed for seven months), the documentation for the central registry search shows that the search results were not received until six months after the staff member's hire date.”

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. Documentation of orientation show that Staff #2 (employed for seven months) did not receive orientation training within the required timeframe. Orientation for the staff member was completed in the seventh month of being employed.”

8VAC20-790-600-D-1

“All staff who work directly with children shall have cardiopulmonary resuscitation (CPR) training within 90 days of the date of employment. 1.There is no documentation to show that Staff #1 and Staff #2 (both employed for 2 and a half years) have completed CPR training. 2. The documentation of CPR training for Staff #3 (employed for seven months) show that the staff member did not complete CPR training within 90 days of employment, which is required.”

8VAC20-790-600-D-2

“All staff who work directly with children shall have first aid training within 90 days of the date of employment. 1.There is no documentation to show that Staff #1 and Staff #2 (both employed for 2 and a half years) have completed first aid training. 2. The documentation of first aid training for Staff #3 (employed for seven months) show that the staff member did not complete first aid training within 90 days of employment, which is required.”

8VAC20-780-240-A

“The Virginia Department of Education-sponsored orientation course shall be completed within 90 calendar days of employment. In the record for Staff #2 (employed seven months), the documentation for the Virginia Department of Education-sponsored orientation course show that the training was not completed within 90 calendar days of employment.”

8VAC20-780-240-A

“The Virginia Department of Education-sponsored orientation course shall be completed within 90 calendar days of employment. In the record for Staff #2 (employed seven months), the documentation for the Virginia Department of Education-sponsored orientation course show that the training was not completed within 90 calendar days of employment.”

8VAC20-780-160-A

“Documentation of a tuberculosis(TB) screening shall be submitted at the time of employment and prior to coming into contact with children. The record for Staff #2 hasTB results that were submitted after the time of employment and not prior to coming into contact with children.”

22.1-289.035-B-3

“Centers must request central registry results for all staff members. There is no documentation of a central registry search in the record of Staff #1 (employed for 2 and a half years). In the record of Staff #2 (employed for seven months), the documentation for the central registry search shows that the search results were not received until six months after the staff member's hire date.”

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. Documentation of orientation show that Staff #2 (employed for seven months) did not receive orientation training within the required timeframe. Orientation for the staff member was completed in the seventh month of being employed.”

22.1-289.035-B-4

“Based on a review of six staff records, it was determined that the facility did not ensure that all staff who had lived out of state within the past five years had a sex offender registry check, and a child abuse and neglect registry check on file from the state the staff member had lived. Evidence: Staff #5 indicated on her sworn statement that she had lived out of state in the past five years. The state participates in the National Fingerprint File however, there was no documentation in the record that the required out of state sex offender registry check, or a search of the child abuse and neglect registry had been completed.”

8VAC20-780-160-A

“Repeat violation Based on a review of six staff records, it was determined the center did not ensure that each staff member submit documentation of a negative tuberculosis screening at the time of employment, prior to coming into contact with children and be completed within the last 30 calendar days of employment. Evidence: 1.The TB screening for staff #2 (date of hire 9/21/2023) was dated 1/24/2024, this was after the staff member began working at the center and after coming into contact with children. 2.The TB screening for staff #6 (date of hire 12/11/2023) was dated 1/24/2024 this was after beginning work and coming into contact with children. 3.The TB screening for staff #5 was dated 3/6/2023 which was more than 30 days prior to her start date of 10/25/2023. The TB screening was dated 7 months prior to the staff member's date of hire.”

8VAC20-780-60-A

“Based on review of five children’s records and interviews, it was determined that the center did not ensure that each child’s record contains all required information. Evidence: 1.The record for child #2 did not include parent contact information, physicians name and phone number and two emergency contacts. 2.The record for child #3 did not contain two emergency contacts. 3.The record for child #4 did not contain documentation of the child’s physician and phone number. 4.The record s for child #4 and child #5 did not include documentation of immunizations or physicals. 5. Staff #1 confirmed the information was not in the children's records.”

8VAC20-780-80-A

“Based on observation and record review it was determined the facility did not ensure that a written daily record of children’s daily attendance, including arrival and departure times, was maintained. Evidence: 1. Staff had a list of children and the schools they arrive from; however, this list did not include written documentation of children’s daily arrival and departure times. 2. Staff #1 confirmed the checklist used did not document arrival and departure times.”

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 sponsored orientation course is completed within 90 calendar days of employment. 1.The record for staff #4 (hire date of 9/8/2023) did not contain documentation that the VDOE orientation had been completed.”

8VAC20-780-270-A

“Based on observation and interviews, it was determined that the facility did not ensure all areas and equipment of the center shall be maintained in a safe and operable condition. Evidence: 1.There were exposed roots approximately 16? from the exit chute of the green slide that posed a tripping hazard. 2. Staff #1 confirmed the roots were exposed.”

8VAC20-780-330-B

“Based on observation, it was determined that the center did not ensure that where playground equipment is provided, resilient surfacing shall comply with minimum safety standards when tested in accordance with the procedures described in the American Society for Testing and Materials F1292-99 (Compressed Loose Fill Synthetic Materials Depth Chart) and shall be under equipment with moving parts or climbing apparatus to create a fall zone free of hazardous obstacles. Evidence: 1.The resilient surface (mulch) under the swings and at the end of both slides, measured 3? which was less than the required minimum depth of 6?. 2.Staff #1 confirmed the mulch was not 6? in depth.”

8VAC20-780-550-D

“Repeat violation Based on record reviews and interviews, it was determined the facility did not ensure that the center shall implement a monthly practice evacuation drill. Evidence: 1.There was no documentation of a practice evacuation drill for January 2023. 2.The Director confirmed the January evacuation drill was not documented.”

8VAC20-780-90-A

“Based on record review and interviews, it was determined the center did not ensure that the required signed, written agreements between the parents and the center were in the child’s record by the first day of the child’s attendance. Evidence: 1.The record for child #2, child #4 and child #5 did not include signed agreements for authorization of emergency medical care, the statement that the center will notify the parent when the child becomes ill, and the statement that the parent will notify the center within 24 hours if the child or a household member has developed a communicable disease.”

22.1-289.035-B-4

“Based on a review of six staff records, it was determined that the facility did not ensure that all staff who had lived out of state within the past five years had a sex offender registry check, and a child abuse and neglect registry check on file from the state the staff member had lived. Evidence: Staff #5 indicated on her sworn statement that she had lived out of state in the past five years. The state participates in the National Fingerprint File however, there was no documentation in the record that the required out of state sex offender registry check, or a search of the child abuse and neglect registry had been completed.”

8VAC20-780-160-A

“Repeat violation Based on a review of six staff records, it was determined the center did not ensure that each staff member submit documentation of a negative tuberculosis screening at the time of employment, prior to coming into contact with children and be completed within the last 30 calendar days of employment. Evidence: 1.The TB screening for staff #2 (date of hire 9/21/2023) was dated 1/24/2024, this was after the staff member began working at the center and after coming into contact with children. 2.The TB screening for staff #6 (date of hire 12/11/2023) was dated 1/24/2024 this was after beginning work and coming into contact with children. 3.The TB screening for staff #5 was dated 3/6/2023 which was more than 30 days prior to her start date of 10/25/2023. The TB screening was dated 7 months prior to the staff member's date of hire.”

8VAC20-780-60-A

“Based on review of five children’s records and interviews, it was determined that the center did not ensure that each child’s record contains all required information. Evidence: 1.The record for child #2 did not include parent contact information, physicians name and phone number and two emergency contacts. 2.The record for child #3 did not contain two emergency contacts. 3.The record for child #4 did not contain documentation of the child’s physician and phone number. 4.The record s for child #4 and child #5 did not include documentation of immunizations or physicals. 5. Staff #1 confirmed the information was not in the children's records.”

8VAC20-780-80-A

“Based on observation and record review it was determined the facility did not ensure that a written daily record of children’s daily attendance, including arrival and departure times, was maintained. Evidence: 1. Staff had a list of children and the schools they arrive from; however, this list did not include written documentation of children’s daily arrival and departure times. 2. Staff #1 confirmed the checklist used did not document arrival and departure times.”

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 sponsored orientation course is completed within 90 calendar days of employment. 1.The record for staff #4 (hire date of 9/8/2023) did not contain documentation that the VDOE orientation had been completed.”

8VAC20-780-270-A

“Based on observation and interviews, it was determined that the facility did not ensure all areas and equipment of the center shall be maintained in a safe and operable condition. Evidence: 1.There were exposed roots approximately 16? from the exit chute of the green slide that posed a tripping hazard. 2. Staff #1 confirmed the roots were exposed.”

8VAC20-780-330-B

“Based on observation, it was determined that the center did not ensure that where playground equipment is provided, resilient surfacing shall comply with minimum safety standards when tested in accordance with the procedures described in the American Society for Testing and Materials F1292-99 (Compressed Loose Fill Synthetic Materials Depth Chart) and shall be under equipment with moving parts or climbing apparatus to create a fall zone free of hazardous obstacles. Evidence: 1.The resilient surface (mulch) under the swings and at the end of both slides, measured 3? which was less than the required minimum depth of 6?. 2.Staff #1 confirmed the mulch was not 6? in depth.”

8VAC20-780-550-D

“Repeat violation Based on record reviews and interviews, it was determined the facility did not ensure that the center shall implement a monthly practice evacuation drill. Evidence: 1.There was no documentation of a practice evacuation drill for January 2023. 2.The Director confirmed the January evacuation drill was not documented.”

8VAC20-780-90-A

“Based on record review and interviews, it was determined the center did not ensure that the required signed, written agreements between the parents and the center were in the child’s record by the first day of the child’s attendance. Evidence: 1.The record for child #2, child #4 and child #5 did not include signed agreements for authorization of emergency medical care, the statement that the center will notify the parent when the child becomes ill, and the statement that the parent will notify the center within 24 hours if the child or a household member has developed a communicable disease.”

8VAC20-780-270-A

“Based on observation and inspection of the physical plant, it was determined that the facility did not ensure that all areas were safe and operable. Evidence: There cracks in the plastic finger guards on the doors leading to the classroom area.”

8VAC20-780-160-A

“Based on a review of six staff records, it was determined that the facility did not ensure that each staff member had a tuberculosis (Tb) screening within 30 days prior to coming into contact with children. Evidence: 1. Staff #1 (date of hire 6/7/22) had a Tb screening on file dated 1/16/23 which was not within the prescribed time frame. 2. Staff #2 (date of hire 12/15/22) had a Tb screening on file dated 9/2/21 which was not within the prescribed time frame. 3. Staff #5 (date of hire 6/22/22) had a Tb screening on file dated 7/21/22 which was not within the prescribed time frame. 4. Staff #6 (date of hire 6/10/22) had a Tb screening on file dated 1/16/23 which was not within the prescribed time frame.”

8VAC20-780-550-D

“Based on a review of logs for emergency drills, it was determined that the facility did not ensure that it implemented monthly practice evacuation drills. Evidence: Evacuation drills were not conducted in July or August of 2022.”

8VAC20-780-70

“Based on a review of six staff records, it was determined that the facility did not ensure that each staff person had three references on file as to character and reputation prior to employment. Evidence: 1. Staff #1 (date of hire 6/7/22) did not have documentation of references on file. 2. Staff #2 (date of hire 6/10/22) did not have documentation of references on file.”