MISSOURI DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION

OFFICE OF CHILDHOOD

SCHOOL AGE INSPECTION REPORT

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Facility Information

Facility Name
Y-CLUB @ THOMAS JEFFERSON MIDDLE SCHOOL

Facility DVN
002782878

Phone
(573) 659-3250

Physical Address
1201 FAIRGROUNDS RD
JEFFERSON CITY
MO 65109-5445

Owner
JEFFERSON CITY AREA YOUNG MEN'S CHRISTIAN ASSOCIATION

Mailing Address
PO BOX 104176
JEFFERSON CITY
MO 65110-4176

Provider/Director
WILLIAMS, DESTINY

E-mail Address
jkever@jcymca.org

Incorporated
Incorporated

Child Care Specialist
LAUREN R RAYWARNKE

Age Range
11 YEARS - 14 YEARS

Capacity
60

Facility Type
SCHOOL AGE

Limitations
BEFORE SCHOOL CARE ONLY

Inspection Information

Date
10/27/2022

Arrival Time
7:15 AM

Departure Time
7:50 AM

Notice
UNANNOUNCED

Inspection Type
COMPLIANCE MONITORING

Inspection ID
2433963633

Document	Document-Date
APPLICATION	07/30/2019
ARTICLES OF INCORPORATION	07/15/2019
REGISTERING FICTITIOUS NAMES	07/25/2019
CERTIFICATE OF GOOD STANDING	07/25/2019
DISCIPLINE POLICIES	07/25/2019
DISASTER AND EMERGENCY PREPAREDNESS PLAN	07/25/2019
DAILY SCHEDULE	07/25/2019
LINES OF ADMINISTRATIVE AUTHORITY	07/25/2019
SAMPLE FORMS	07/25/2019
POLICIES	07/25/2019
STAFF SHEET	08/13/2019
LOCAL FIRE DEPARTMENT NOTIFICATION	08/13/2019
JOB RESPONSIBILITIES	08/13/2019
CHILD CARE PRACTICES	08/13/2019
DIRECTOR'S JOB RESPONSIBILITIES	08/13/2019
CERTIFICATE OF INCORPORATION	07/25/2019
DIRECTOR'S QUALIFICATIONS	08/26/2019
EQUIPMENT LIST	03/18/2022
ANNUAL DECLARATION	03/18/2022
LISTING OF CHILD CARE STAFF/HOUSEHOLD MEMBERS	03/18/2022

Inspection determined facility to be in compliance with licensing rules.

Open Violations: 3

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 3

Total Children 15

Staff	Child	Class Age	Note
3	15	SCHOOL AGE	D.H., D.W. and D.G. with 15 children ages 12 through 14 year's old.

Compliance List
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 Violation
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 Violation
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