MISSOURI DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION

OFFICE OF CHILDHOOD

SCHOOL AGE INSPECTION REPORT

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Facility Information

Facility Name
YMCA-FOUR RIVERS BRANCH-AUGUSTA ELEMENTARY

Facility DVN
001481927

Phone
(636) 266-9724

Physical Address
5541 LOCUST ST
AUGUSTA
MO 63332

Owner
GATEWAY REGION YOUNG MEN'S CHRISTIAN ASSOCIATION

Mailing Address
400 GRAND AVE
WASHINGTON
MO 63090-1204

Provider/Director
PENNOCK, DALLAS JORDAN

E-mail Address
dallas.pennock@gwrymca.org

Incorporated
Incorporated

Child Care Specialist
DEBBIE ASHLOCK

Age Range
5 YEARS - 12 YEARS

Capacity
20

Facility Type
SCHOOL AGE

Limitations
AFTER SCHOOL CARE ONLY

Inspection Information

Date
11/28/2018

Arrival Time
3:40 PM

Departure Time
5:06 PM

Notice
UNANNOUNCED

Inspection Type
COMPLIANCE MONITORING

Inspection ID
2345239859

Document	Document-Date
DIAGRAM/INDOOR	11/04/2015
DIAGRAM/OUTDOOR	11/04/2015
ARTICLES OF INCORPORATION	07/09/2016
CERTIFICATE OF GOOD STANDING	07/09/2016
JOB RESPONSIBILITIES	07/06/2016
DAILY SCHEDULE	07/06/2016
SAMPLE WEEKLY MENU	07/06/2016
POLICIES	07/06/2016
CHILD CARE PRACTICES	07/06/2016
DISCIPLINE POLICIES	07/06/2016
SAMPLE FORMS	07/06/2016
REGISTERING FICTITIOUS NAMES	08/01/2016
LOCAL FIRE DEPARTMENT NOTIFICATION	07/06/2016
DIRECTOR'S JOB RESPONSIBILITIES	07/06/2016
DISASTER AND EMERGENCY PREPAREDNESS PLAN	07/16/2016
DIRECTOR'S QUALIFICATIONS	12/11/2017
STAFF SHEET	04/11/2018
EQUIPMENT LIST	04/11/2018
APPLICATION	02/05/2018
LINES OF ADMINISTRATIVE AUTHORITY	08/26/2016

Inspection determined facility to be in compliance with licensing rules.

Open Violations: 1

NOTE

The licensee is responsible for compliance with all licensing rules, including but not limited to the rules listed on this compliance report form.

Attendance at Time of Inspection

Total Staff 2

Total Children 2

Staff	Child	Class Age	Note
2	2	SCHOOL AGE	with Jodi Reed and Cindy Semonis Melissa Mueller is the variance approved director for this si


19 CSR 30-62.032 Organization and Administration Compliance
19 CSR 30-62.042 Initial Licensing Information Compliance
19 CSR 30-62.052 License Renewal Compliance
19 CSR 30-62.082 Physical Requirements of Group Day Care Homes and Day Care Centers Compliance
19 CSR 30-62.090 Disaster and Emergency Preparedness Compliance
19 CSR 30-62.092 Furniture, Equipment and Materials Compliance
19 CSR 30-62.102 Personnel Violation
19 CSR 30-62.112 Staff/Child Ratios Compliance
19 CSR 30-62.122 Medical Examination Reports Compliance
19 CSR 30-62.132 Admission Policies and Procedures Compliance
19 CSR 30-62.172 Emergency School Closings Compliance
19 CSR 30-62.182 Child Care Program Compliance
19 CSR 30-62.192 Health Care Compliance
19 CSR 30-62.202 Nutrition and Food Service Compliance
19 CSR 30-62.212 Transportation and Field Trips Compliance
19 CSR 30-62.222 Records and Reports Compliance
RSMo 210.003 Immunizations of children required, when, exceptions--duties of administrator, report--notification of parents, when. Compliance
RSMo 210.1080 Background checks required--definitions--procedures—ineligible for employment, when--exemption, when--emergency rules. Compliance