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-MARTHASVILLE ELEMENTARY

Facility DVN
000978858

Phone
(636) 239-5704

Physical Address
800 E MAIN
MARTHASVILLE
MO 63357

Owner
GATEWAY REGION YOUNG MEN'S CHRISTIAN ASSOCIATION

Mailing Address
400 GRAND AVE
WASHINGTON
MO 63090

Provider/Director
MUELLER, MELISSA

E-mail Address
melissa.mueller@gwrymca.org

Incorporated
Incorporated

Child Care Specialist
JOY LYNN NICHOLS

Age Range
5 YEARS - 12 YEARS

Capacity
32

Facility Type
SCHOOL AGE

Limitations

Inspection Information

Date
12/02/2021

Arrival Time
9:15 AM

Departure Time
9:45 AM

Notice
ANNOUNCED

Inspection Type
COMPLIANCE MONITORING

Inspection ID
2413570505

Document	Document-Date
CERTIFICATE OF GOOD STANDING	12/14/2015
JOB RESPONSIBILITIES	11/09/2015
LINES OF ADMINISTRATIVE AUTHORITY	12/14/2015
SAMPLE FORMS	11/09/2015
SAMPLE WEEKLY MENU	11/09/2015
DAILY SCHEDULE	11/09/2015
DIRECTOR'S QUALIFICATIONS	12/01/2015
POLICIES	12/01/2015
REGISTERING FICTITIOUS NAMES	12/14/2015
DISCIPLINE POLICIES	12/01/2015
ARTICLES OF INCORPORATION	12/01/2015
DIRECTOR'S JOB RESPONSIBILITIES	12/01/2015
CHILD CARE PRACTICES	12/01/2015
APPLICATION	10/10/2019
STAFF SHEET	10/10/2019
LISTING OF CHILD CARE STAFF/HOUSEHOLD MEMBERS	11/30/2021
EQUIPMENT LIST	11/30/2021
ANNUAL DECLARATION	11/30/2021

Inspection determined facility to be in compliance with licensing rules.

Open Violations: NA

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 1

Staff	Child	Class Age	Note
1	0	NO CHILDREN IN ATTENDANCE	Melissa Mueller, facility director


5 CSR 25-500.032 Organization and Administration Compliance
5 CSR 25-500.042 Licensing Process Compliance
5 CSR 25-500.052 Annual Requirements Compliance
5 CSR 25-500.082 Physical Requirements of Group Day Care Homes and Day Care Centers Compliance
5 CSR 25-500.090 Disaster and Emergency Preparedness Compliance
5 CSR 25-500.092 Furniture, Equipment and Materials Compliance
5 CSR 25-500.102 Personnel Compliance
5 CSR 25-500.112 Staff/Child Ratios Compliance
5 CSR 25-500.122 Medical Examination Reports Compliance
5 CSR 25-500.132 Admission Policies and Procedures Compliance
5 CSR 25-500.172 Emergency School Closings Compliance
5 CSR 25-500.182 Child Care Program Compliance
5 CSR 25-500.192 Health Care Compliance
5 CSR 25-500.202 Nutrition and Food Service Compliance
5 CSR 25-500.212 Transportation and Field Trips Compliance
5 CSR 25-500.222 Records and Reports Compliance
5 CSR 25-600.020 General Requirements Compliance
5 CSR 25-600.040 Background Screening Findings Compliance
RSMo 210.115. Reports of abuse, neglect, and under age eighteen deaths — persons required to report — supervisors and administrators not to impede reporting — deaths required to be reported to the division or child fatality review panel, when — report made to another state, when. — Compliance
RSMo 210.211. License required - exceptions - written notice of licensure status, when. Compliance