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Alleghany Highlands YMCA West Early Learning Center
515 E. Pine Street
Covington, VA 24426
(540) 965-9622

Current Inspector: Monique Anderson (540) 309-2397

Inspection Date: Sept. 6, 2019

Complaint Related: No

Areas Reviewed:
22VAC40-191 Background Checks (22VAC40-191)
63.2(17) License & Registration Procedures

An unannounced renewal inspection was made on 9/6/19. There were 51 children present in six groupings with 12 staff supervising and two administrative staff present in addition. Five children's records and six staff records were reviewed. Five Board officer and agent records were reviewed.
Two prescription daily medications were observed.

The inspector arrived at the center at 10:50 am and departed at 5:30 pm. The inspection was completed on 9/9/19 and emailed to the program administration on that date.

Standard #: 22VAC40-185-240-B
Description: Based on review of policies and procedures and interview, the center failed to ensure that the required policies and procedures required to be given to the staff in writing were policies and procedures that could be located in writing.

1. After review of all policies and procedures given to the inspector for review, the administrative staff was asked for the policies required by this Standard. The staff person could not locate the required policies and procedures in writing.

2. The policies and procedures required by this Standard are related to supervision of children, supervision of children on field trips, and other supervision related polices/procedures.

Plan of Correction: Staff in administration will add the policies and procedures required by the Standard to the staff policies and procedures.

Standard #: 22VAC40-185-250-C
Description: Based on observation and interview, the center failed to ensure that a notice regarding the presence and location of asbestos containing materials and advising that the asbestos inspection report and management plan are available for review was posted.

1. The center was found to have asbestos as determined by a previously posted notice observed by the inspector at previous inspections and this notice being observed in a book of various forms at the center. The notice in the book was dated April 2011 and stated the location of the asbestos as well as the location of the management plan. This notice was not posted at the center.

2. The site coordinator was asked about this notice and stated that it had been taken down recently.

Plan of Correction: This will be posted at the site.

Standard #: 22VAC40-185-270-A
Description: Based on observation and interview, the center failed to ensure that areas and equipment of the center, inside and outside, were maintained in a clean, safe and operable condition. Unsafe conditions shall include, but not be limited to, splintered, cracked or otherwise deteriorating wood; chipped or peeling paint; visible cracks, bending or warping, rusting or breakage of any equipment; head entrapment hazards; and protruding nails, bolts or other components that could entangle clothing or snag skin.

1. There was a hole in the wall approximately three feet from floor level in the toddler classroom that was approximately 3 inches by one inch. The sheet rock had a hole in it and sheet rock was exposed and jagged edges were also exposed.

2. According to the site coordinator, a maintenance request had been made a couple weeks ago.

Plan of Correction: The site director will follow up with maintenance to ensure it is fixed promptly.

Standard #: 22VAC40-185-340-D
Description: Based on observation and record review, the center failed to ensure that in each grouping of children at least one staff member who meets the qualifications of a program leader or program director was regularly present.

1. The toddler classroom with seven children ages 13 months up to two years of age did not have a program lead qualified staff person in the class on the date of the inspection. Staff #1 and staff #4 were present in the classroom during the inspection.

Plan of Correction: The site administrator will ensure that a program lead is present in each grouping.

Standard #: 22VAC40-185-340-F
Description: Based on observation, the center failed to ensure that children under 10 years of age were always within actual sight supervision.

1. There were two groups of children observed during nap where two or more children in each group were out of sight supervision. The children were laying on cots or mats and were behind barriers such as shelving units. The staff were observed to be sitting on the floor or in child size chairs and were not able to see the children who were resting. All of the children were under the age of four years old (two toddler age and three preschool age).

Plan of Correction: Site administration will remind staff of sight supervision during rest time.

Standard #: 22VAC40-185-420-E-1
Description: Based on observation and interview, the center failed to ensure that for each infant, a daily record with all required information was kept.

1. The daily record for infants was observed. There was no place to document the description of bowel movements on the form. There were three infants who had bowel movements on the date of the inspection as documented on the diapering log but the descriptions were not provided.

2. The infant staff was asked about the documentation of the description of bowel movements and stated that there was a new form provided by the center administration that did not have a space for this information. The staff provided the inspector the previous form that had this information on it.

3. There was no space on the infant daily communication log to document the time the infants spent on their stomachs or developmental milestones. The previous form, as provided by the infant staff, had a space to document this information.

Plan of Correction: The administration will adjust the form to address all required information.

Standard #: 22VAC40-185-500-A
Description: Based on observation, the center failed to ensure that staff washed their hands as required.

1. Staff #1 was observed to change the diapers of six toddler children. The staff person did not wash their hands after each diaper change. The staff person did use gloves with each diaper change and changed gloves after each diaper change.

Plan of Correction: This was corrected as the staff person washed their hands after the last diaper change. Administration will review diaper changing procedures with staff.

Standard #: 22VAC40-185-500-B
Description: Based on observation, the center failed to ensure that diapering procedures were followed as required.

1. There were six toddler children observed to be diapered by staff #1. The diapering surface was not cleaned and sanitized after each change. Staff #1 was observed to clean the surface with soap and water only; no sanitizing of the surface was done in between each diaper change.

2. Staff #1 was observed to use their hand to open the lid to the diaper disposal system on approximately five occasions. The staff person used their hand to open it to throw away paper towels after cleaning the surface with the staff person's gloves on in which were used during the diaper change. The staff person was observed to use their hand to open the lid to the diaper disposal system once to dispose of a soiled diaper. The Standards require that the diaper disposal system is foot operated or used in such a way that neither the staff member's hand nor the soiled diaper touches an exterior surface of the storage system during disposal.

Plan of Correction: This was corrected as the staff person sanitized the diaper changing pad after all diaper changes were complete. Administration will review diaper changing procedures with staff.

Standard #: 22VAC40-80-120-E-2
Description: Based on observation, the center failed to ensure that the findings from the most recent inspection were posted.

1. The last inspection was completed 7/25/19 and resulted in a violation of the Standards. The "Violation Notice" which would display the most recent findings was not displayed. The "Violation Notice" from the April 2018 inspection was posted. There have been four inspections at the facility since April 2018.

Plan of Correction: The "Violation Notice" from today's inspection will be posted.


A compliance history is in no way a rating for a facility.

The online compliance history includes only information after July 1, 2003. In addition, the online compliance history includes information regarding adverse actions that may be the subject of a pending appeal. An adverse action is not final until a provider has exhausted or waived all due process rights. For compliance history prior to July 1, 2003, or information regarding the status of pending adverse actions, please contact the Licensing Inspector listed in the facility's information. The Virginia Department of Social Services (VDSS) is not responsible for any errors in or omissions from the compliance history information.

Virginia Quality is a voluntary quality rating and improvement system for early care and education facilities serving children ages birth through pre-K. To find programs participating in Virginia Quality, click here.

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