YMCA School Age Child Care-Cedar Road Elementary

8VAC20-780-70

“Staff records shall contain all required elements. There was no documentation in the record of staff 2 to verify that the required orientation training had been completed. Staff 2 has been employed for more than 3 months and was present during the inspection.”

8VAC20-780-160-B

“Acceptable forms of documentation of tuberculosis screening shall include all required elements. The form used to document the TB screening for staff 1 and staff 2 lacked the results of the screening. The screening form submitted for staff 1 also lacked a signature from a physician, the physician's designee or an official of the local health department.”

8VAC20-780-60-A-7

“Children's records shall include a written care plan for each child with a diagnosed food allergy, 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. There was no written care plan for child 1's diagnosed food allergy.”

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. There is no documentation that staff 2 and staff 3 have current first aid certification. Both staff have been employed for more than 90 days.”

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. The training shall include an in-person competency demonstration. There is no documentation that staff 2 and staff 3 have current CPR certification. Both staff have been employed for more than 90 days.”

8VAC20-780-245-J-3

“Any child for whom emergency medications (such as albuterol, glucagon, and epinephrine auto injector) have been prescribed shall always be in the care of a staff member or independent contractor who meets the requirements in subdivision 1 of this subsection. None of staff present when the inspector arrived had MAT certification. There were children in care requiring emergency medications.”

8VAC20-780-80-B-2

“Repeat Violation The center shall inform the department's representative as soon as practicable, but not to exceed two business days, of any injury to a child that occurs while the child is under the supervision of the center and requires outside medical attention. A serious injury requiring outside medical attention that occurred on 09/25/2025 was not reported to the department until 11/14/2025. Staff 1 stated that the parent of child 1 notified them that the injury required medical attention on 09/26/2025.”

8VAC20-780-70

“Repeat Violation Staff records shall include the name, address and telephone number of a person to be notified in an emergency which shall be kept at the center. Written emergency contact information was not available at the program for staff 3. Staff 3 was working in the program during the inspection.”

22.1-289.011-F

“Repeat Violation Other documents required by the Superintendent shall be posted in a conspicuous place on the licensed premises. The Inspection Summary and Violation Notice from the most recent inspection conducted on 10/22/2025 was not posted.”

8VAC20-780-340-A

“Repeat Violation When staff are supervising children, they shall always ensure their care and protection. The facility failed to provide sufficient staffing during implementation of activities in the gym on 09/25/2025. Three staff members were required at approximately 3:50 pm however, two staff were present. During this time child 1 fell and sustained an injury that resulted in a fractured arm. Staff 2 stated that " A third staff would have helped as there are a lot of children that need extra attention." Staff 2 additionally indicated that being understaffed resulted in difficulty with managing activities.”

8VAC20-780-560-F

“Repeat Violation When centers choose to provide meals or snacks, the following shall apply: A menu listing foods to be served for snacks during the current one-week period shall be posted in a location conspicuous to parents. The menu for the week of 12/08/2025 - 12/19/2025 was not posted. The snack menu for November 2025 was posted on the parent board.”

8VAC20-780-350-B-5

“The staff-to-children ratios are required whenever children are in care. School age eligible up to 9 years: 1:18 Two staff were present with a total of 40 children ages 5 years - 8 years at approximately 3:50 pm on 09/25/2025 according to interviews with staff 1, staff 2 and review of written attendance records. Three staff were needed to meet the required staff-to-child ratio of 1:18.”

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. 3 children in care, child 2, 3 and 4, lacked documentation of all required immunizations.”

8VAC20-780-140-A

“Each child shall have a physical examination by or under the direction of a physician before the child's attendance or within 30 days after the first day of attendance. 3 children in care, child 2, 3 and 4, lacked documentation of a physical exam. All 3 children have been enrolled for more than 30 days.”

8VAC20-780-160-B

“Acceptable forms of documentation of tuberculosis screening shall include the date the test was given and results of the test and be signed by a physician, physician's designee or an official of the local health department. The TB screening for staff 1 lacked documentation of the results of the screening nor was it signed by a physician or an official of the local health department.”

8VAC20-780-40-E

“The operational responsibilities of the licensee shall include ensuring that the center's activities and services are maintained in compliance with the center's own policies and procedures that are required by these standards. The facility did not follow YMCA policy for departure when the door to the cafeteria was left open and unsupervised by staff. The YMCA policy requires the entry door to remain closed and locked unless actively supervised by staff during parent pick-up.”

8VAC20-780-70

“Repeat Violation The following staff records shall be kept for each staff person which shall contain all required elements. The name, address, and telephone number of a person to be notified in an emergency was not kept at the center for staff 1. Staff 1 was working in the licensed program during the inspection.”

22.1-289.011-F

“Repeat Violation The most recent inspection documents required by the Superintendent shall be posted in a conspicuous place on the licensed premises. The most recent Inspection Summary and Violation Notice, for the monitoring inspection conducted on 06/16/2025, was not posted.”

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 all required elements. There was no signed parent agreement on file for child 1. Child 1 was in care during the inspection.”

8VAC20-780-340-A

“When staff are supervising children, they shall always ensure their care and protection. 1. Staff were not aware that 2 children ran out of the cafeteria, through an open door, into an unidentified vehicle. When questioned, staff could not identify the 2 children who had departed nor the vehicle they entered. 2. The door from outside was left open and unsupervised allowing access into the cafeteria. Staff stated they were not aware the door had been left open nor did they see the 2 children leaving the cafeteria.”

8VAC20-780-340-J

“Staff may not allow a child to leave the center unsupervised. Staff did not supervise 2 children when they walked through an open door leading to outside and entered an unidentified vehicle with an unidentified adult.”

8VAC20-780-510-G

“Medication shall be labeled with the child's name. A bottle of non-prescription medication, intended for child 5, was not labeled with child 5's name.”

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 required documentation. 7 of 17 injury reports reviewed lacked written documentation of the time the parent was notified of the injury.”

8VAC20-780-60-A

“Each center shall maintain and keep at the center a separate record for each child enrolled which shall contain all required information: 1. There was no enrollment record for child 1. Child 1 was in care during the inspection. 2. The enrollment record for child 2, who was in care, lacked the following required information: a. Name, home address, and home phone number of each parent; b. Work phone number and place of employment of each parent.”

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. 3 children in care, child 2, 3 and 4, lacked documentation of all required immunizations.”

8VAC20-780-140-A

“Each child shall have a physical examination by or under the direction of a physician before the child's attendance or within 30 days after the first day of attendance. 3 children in care, child 2, 3 and 4, lacked documentation of a physical exam. All 3 children have been enrolled for more than 30 days.”

8VAC20-780-160-B

“Acceptable forms of documentation of tuberculosis screening shall include the date the test was given and results of the test and be signed by a physician, physician's designee or an official of the local health department. The TB screening for staff 1 lacked documentation of the results of the screening nor was it signed by a physician or an official of the local health department.”

8VAC20-780-40-E

“The operational responsibilities of the licensee shall include ensuring that the center's activities and services are maintained in compliance with the center's own policies and procedures that are required by these standards. The facility did not follow YMCA policy for departure when the door to the cafeteria was left open and unsupervised by staff. The YMCA policy requires the entry door to remain closed and locked unless actively supervised by staff during parent pick-up.”

8VAC20-780-70

“Repeat Violation The following staff records shall be kept for each staff person which shall contain all required elements. The name, address, and telephone number of a person to be notified in an emergency was not kept at the center for staff 1. Staff 1 was working in the licensed program during the inspection.”

22.1-289.011-F

“Repeat Violation The most recent inspection documents required by the Superintendent shall be posted in a conspicuous place on the licensed premises. The most recent Inspection Summary and Violation Notice, for the monitoring inspection conducted on 06/16/2025, was not posted.”

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 all required elements. There was no signed parent agreement on file for child 1. Child 1 was in care during the inspection.”

8VAC20-780-340-A

“When staff are supervising children, they shall always ensure their care and protection. 1. Staff were not aware that 2 children ran out of the cafeteria, through an open door, into an unidentified vehicle. When questioned, staff could not identify the 2 children who had departed nor the vehicle they entered. 2. The door from outside was left open and unsupervised allowing access into the cafeteria. Staff stated they were not aware the door had been left open nor did they see the 2 children leaving the cafeteria.”

8VAC20-780-340-J

“Staff may not allow a child to leave the center unsupervised. Staff did not supervise 2 children when they walked through an open door leading to outside and entered an unidentified vehicle with an unidentified adult.”

8VAC20-780-510-G

“Medication shall be labeled with the child's name. A bottle of non-prescription medication, intended for child 5, was not labeled with child 5's name.”

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 required documentation. 7 of 17 injury reports reviewed lacked written documentation of the time the parent was notified of the injury.”

8VAC20-780-60-A

“Each center shall maintain and keep at the center a separate record for each child enrolled which shall contain all required information: 1. There was no enrollment record for child 1. Child 1 was in care during the inspection. 2. The enrollment record for child 2, who was in care, lacked the following required information: a. Name, home address, and home phone number of each parent; b. Work phone number and place of employment of each parent.”

8VAC20-780-550-I

“A 911 or local dial number for police, fire and emergency medical services and the number of the regional poison control center shall be posted in a visible place at each telephone. Emergency phone numbers were not posted when the inspector arrived at 3:20 pm on 06/16/2025.”

8VAC20-780-80-B-2

“The center shall inform the department's representative as soon as practicable, but not to exceed two business days, of any injury to a child that occurs while the child is under the supervision of the center and requires outside medical attention. Child 1 received an injury, while in care on 05/30/2025, that required outside medical attention. The facility did not report this injury to the department's representative until 06/05/2025.”

22.1-289.011-F

“The most recent inspection finding documents required by the Superintendent shall be posted in a conspicuous place on the licensed premises. The most recent inspection summary and violation notice, for the monitoring inspection conducted on 01/29/2025, were not posted when the inspection arrived on 06/16/2025 at 3:20 pm”

8VAC20-780-70

“Staff records shall contain all required elements. The employment file for staff 1 lacked documentation of a hire date. The employment file for staff 2 lacked documentation of all required orientation training.”

8VAC20-780-40-D

“The license shall be posted in a place conspicuous to the public (? 22.1-289.011 of the Code of Virginia). The current license issued by the Virginia Department of Education was not posted when the inspector arrived on 06/16/2025 at 3:20 pm.”

8VAC20-780-160-A

“The documentation of the TB screening shall have been completed within the last 30 calendar days of the date of employment. The TB screening for staff 3 was obtained on 03/25/2025 which is after the hire date of 03/11/2025.”

22.1-289.035-B-1

“Provide a sworn statement or affirmation disclosing whether he has ever been convicted of or is the subject of pending charges for any offense within or outside the Commonwealth and whether he has been the subject of a founded complaint of child abuse or neglect within or outside the Commonwealth. The sworn statement or affirmation completed by staff 3 lacks documentation regarding out-of-state residence within the past five years. Staff 3 has a hire date of 03/11/2025.”

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. The individual designated as the program director is not present at the facility at least 50% of the center's hours of operation according to staff interviews. Staff stated that the designated program director was at the site once every 2 weeks. The program director was not on site during the inspection on 06/16/2025 and the individual designated as being in charge does not meet program director qualifications.”

8VAC20-780-240-A

“The Virginia Department of Education-sponsored orientation course shall be completed within 90 calendar days of employment. Staff 2, hire date 02/07/2025, lacks documentation of completion of the VDOE sponsored orientation course.”

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. The emergency evacuation and shelter-in-place procedures were not posted in the facility when the inspector arrived at 3:20 pm on 06/16/2025.”

8VAC20-780-560-F

“When centers choose to provide snacks a menu listing foods to be served during the current one-week period shall be posted in a location conspicuous to parents. The snack menu was not posted when the inspector arrived at 3:20 pm on 06/16/2025.”

8VAC20-780-245-J-3

“Any child for whom emergency medications (such as albuterol, glucagon, and epinephrine auto injector) have been prescribed shall always be in the care of a staff member or independent contractor who has current MAT certification. There was no one on site with current MAT training until 3:45 pm. There was a child in care (child 2) who has emergency medications prescribed.”

8VAC20-780-60-A-8

“Each center shall maintain and keep at the center a separate record for each child enrolled which shall contain the following information: *A written care plan for each child with a diagnosed food allergy, 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. There was no written allergy care plan on file for child 1 who has a diagnosed food allergy. Child 1 was in care during the inspection.”

8VAC20-780-245-J-3

“Any child for whom emergency medications (such as albuterol, glucagon, and epinephrine auto injector) have been prescribed shall always be in the care of a staff member or independent contractor who has current MAT certification. There was no one on site with current MAT training until 3:45 pm. There was a child in care (child 2) who has emergency medications prescribed.”

8VAC20-780-60-A-8

“Each center shall maintain and keep at the center a separate record for each child enrolled which shall contain the following information: *A written care plan for each child with a diagnosed food allergy, 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. There was no written allergy care plan on file for child 1 who has a diagnosed food allergy. Child 1 was in care during the inspection.”

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 the time of parent notification. 3 of 6 injury reports reviewed lacked documentation of the time the parent was notified of the injury.”

8VAC20-780-350-B-5

“Repeat Violation The staff-to-children ratios are required whenever children are in care. School age eligible up to 9 years: 1:18 There was only 1 staff with a group of 20 children, ages 5 years - 8 years, with staff 2 from approximately 2:30 pm until approximately 2:45 pm.”

8VAC20-780-240-A

“The Virginia Department of Education-sponsored orientation course shall be completed within 90 calendar days of employment. Staff 1 has not completed The Virginia Department of Education sponsored orientation course. Staff 1 has been employed for more than 20 months.”

8VAC20-780-70

“Repeat Violation Staff records shall contain documentation that two or more references as to character and reputation as well as competency were checked before employment. There were no reference checks on file for staff 1. Staff 1 has been employed more than 20 months.”

22.1-289.035-B-3

“Repeat Violation The child day center failed to obtain a copy of the results of a search of the central registry maintained pursuant to ? 63.2-1515 for any founded complaint of child abuse or neglect against him. Staff 1 lacks documentation of the results of a central registry check. Staff 1 has been employed more than 20 months and was caring for children during the inspection.”

8VAC20-780-245-A

“Staff shall complete annually a minimum of 16 hours of training appropriate to the age of children in care. There is no written documentation to demonstrate that staff 1 has completed 16 hours of annual training in 2023.”

8VAC20-790-600-F

“Staff who work directly with children shall annually attend the department's health and safety update course. Staff 1 has not completed the annual health and safety update course. Staff 1 has been employed for 33 months.”

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 the time of parent notification. 3 of 6 injury reports reviewed lacked documentation of the time the parent was notified of the injury.”

8VAC20-780-350-B-5

“Repeat Violation The staff-to-children ratios are required whenever children are in care. School age eligible up to 9 years: 1:18 There was only 1 staff with a group of 20 children, ages 5 years - 8 years, with staff 2 from approximately 2:30 pm until approximately 2:45 pm.”

8VAC20-780-240-A

“The Virginia Department of Education-sponsored orientation course shall be completed within 90 calendar days of employment. Staff 1 has not completed The Virginia Department of Education sponsored orientation course. Staff 1 has been employed for more than 20 months.”

8VAC20-780-70

“Repeat Violation Staff records shall contain documentation that two or more references as to character and reputation as well as competency were checked before employment. There were no reference checks on file for staff 1. Staff 1 has been employed more than 20 months.”

22.1-289.035-B-3

“Repeat Violation The child day center failed to obtain a copy of the results of a search of the central registry maintained pursuant to ? 63.2-1515 for any founded complaint of child abuse or neglect against him. Staff 1 lacks documentation of the results of a central registry check. Staff 1 has been employed more than 20 months and was caring for children during the inspection.”

8VAC20-780-245-A

“Staff shall complete annually a minimum of 16 hours of training appropriate to the age of children in care. There is no written documentation to demonstrate that staff 1 has completed 16 hours of annual training in 2023.”

8VAC20-790-600-F

“Staff who work directly with children shall annually attend the department's health and safety update course. Staff 1 has not completed the annual health and safety update course. Staff 1 has been employed for 33 months.”

8VAC20-770-60-C-2

“Based on record review and interview, the center failed to ensure that staff have a central registry finding within 30 days of employment. Evidence: 1. There was no central registry finding on file for staff 1 who was observed caring for children during the on-site inspection on 04/16/2024. 2. Administrative staff confirmed that a central registry finding was not on file for staff 1. a. Administrative staff stated that staff 1 had an approximate hire date of 45 days prior to the staff record review completed on 04/26/2024. b. Administrative staff further stated they were unsure if a central registry check had been requested for staff 1.”

8VAC20-780-560-J

“Based on observation, the center failed to ensure that tables shall be sanitized after each use for feeding. *The definition of sanitized means that the surface of the item is sprayed with the disinfectant solution and allowed to air dry on the surface for a minimum of two minutes. Evidence: 1. Staff 1 was observed using the same cloth towel to immediately wipe the tables down after application of the disinfectant spray.”

8VAC20-780-340-A

“Based on staff interviews, record review and observation the center failed to ensure that when staff are supervising children, they shall always ensure their care and protection. Evidence: 1. Staff 2 stated that she was by herself with more than 18 children when child 1, age 7 years, sustained a serious injury requiring outside medical attention. Child 1 fell in the gym on 02/07/2024 at approximately 3:00 pm. The required staff-to-child ratio for children ages 5 - 8 years is 1:18. a. Staff 4 confirmed that staff 2 was alone in the gym with more than 18 children when child 1 was injured. b. Staff 3 stated that staff 1 was actually alone with 39 children based on record review for this date. 2. The lack of sufficient staff resulted in staff 1 not being able to redirect child 1 when he was engaging in an unsafe activity. a. Staff 2 stated that child 1, and several other children, were running in the gym when child 1 tripped and fell hitting his head on the door. This injury required 7 stitches. b. Staff 2 stated she had asked child 1 to stop running however, she was not able to provide direct intervention due to the number of children she was responsible for during this time.”

8VAC20-780-350-B-5

“Based on observation, record review and staff interviews the center failed to maintain the required staff-to-children ratios whenever children are in care. *School age eligible up to 9 years- ratio 1:18 (staff: children) Evidence: 1. During the on-site inspection on 04/16/2024 staff 2 was observed alone, on the outdoor play area, with 26 children ages 5 years - 8 years at 4:10 pm. a. Staff 2 stated that there was not a second staff present and that she had been the only staff supervising this group of children since 3:30 pm. b. Staff 2 stated that "it was normal" for her to be alone with more than 18 children which is the required staff-to-child ratio for this age group. 2. Additional interviews with staff 2 and staff 3 indicated that staff 1 was alone, in the gymnasium, with 39 children, ages 5 - 8 years, on 02/07/2024 at approximately 3:00 pm. a. A review of written attendance records, by staff 3, confirmed that staff 2 was alone with 39 children, ages 5 - 8 years, on 02/07/2024.”

8VAC20-770-60-B

“Based on record review and staff interview, the center failed to ensure that staff are not employed until the facility has the person's completed sworn statement or affirmation. Evidence: 1. There was no sworn statement or affirmation on file for staff 1 who was observed caring for children during the on-site inspection on 04/16/2024. a. Staff 1 has an approximate hire date of 45 days prior to the 04/16/2024 inspection according to administrative staff. 2. Administrative staff confirmed that a completed sworn statement or affirmation was not available for staff 1.”

8VAC20-780-540-C

“Based on observation and interview, the center failed to ensure that the required first aid kit contained all of the required elements. Evidence: 1. The facility first aid kit lacked band-aids, assorted types. 2. Center staff stated they could not locate band-aids in any of the first aid kits available during the on-site inspection on 04/16/2024.”

8VAC20-780-70

“Based on record review and interview, the center failed to ensure that staff records contain all of the required elements. Evidence: 1. The name, address and telephone number for a designated emergency contact was not maintained on site for staff 1 who was working in the after school program during the 04/16/2024 on-site inspection. 2. The employment file for staff 1 lacked documentation of a hire date, job title and completion of orientation training. a. Administrative staff stated that staff 1 began work approximately 45 days prior to the inspection.”