591-1-1-.25(7) · Rule 591-1-1-.25(7) requires that doors to rooms not approved for child care, other than the kitchen doors, be latched or locked so children cannot wander into those areas. Except in School- age Centers, interior Center door locks shall permit Personnel to open the locked room from outside of the room in an emergency.

During a Licensing Study conducted on February 3, 2022 ; It was determined based on observation that the gate to the office area was not latched and was accessed by a child on this date.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.21(3) · Rule 591-1-1-.21(3) requires that the Center conduct drills for fire, tornado and other emergency situations. The fire drills will be conducted monthly and tornado and other emergency situation drills will be conducted every six months. The Center shall maintain documentation of the dates and times of these drills for two years.

During a Licensing Study conducted on February 3, 2022 ; It was determined based on a review of records that center failed to provide documentation of emergency drills.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.21(3) · Rule 591-1-1-.21(3) requires that the Center conduct drills for fire, tornado and other emergency situations. The fire drills will be conducted monthly and tornado and other emergency situation drills will be conducted every six months. The Center shall maintain documentation of the dates and times of these drills for two years.

During an Incident Investigation & Follow Up conducted on July 25, 2022 ; It was determined based on a review of records that center failed to provide documentation of emergency drills for 2021.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.25(11) · Rule 591-1-1-.25(11) requires that floor coverings be tight, smooth, free of odors and washable or cleanable.

During a Licensing Study conducted on February 3, 2022 ; It was determined based on observation that the laminate floors in classrooms A and C were torn.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.25(11) · Rule 591-1-1-.25(11) requires that floor coverings be tight, smooth, free of odors and washable or cleanable.

During an Incident Investigation & Follow Up conducted on July 25, 2022 ; It was determined based on observation that the laminate flooring in classroom C contained an "L" shaped tear. Further, the floors in classroom A and classroom C could be felt to ripple underfoot when walked upon.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.25(13) · Rule 591-1-1-.25(13) requires that potentially hazardous equipment, materials and supplies be stored in a locked area inaccessible to children.

During a Licensing Study conducted on February 3, 2022 ; It was determined based on observation that a stapler, Sharpie markers, a tape dispenser with a serrated edge, and hand sanitizer were on the table in classroom A. Further, a package of baby wipes and a hole punch were accessible to children in classroom A.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.25(13) · Rule 591-1-1-.25(13) requires that potentially hazardous equipment, materials and supplies be stored in a locked area inaccessible to children.

During an Incident Investigation & Follow Up conducted on July 25, 2022 ; It was determined based on observation that correction fluid, "Sharpie" markers, and a tape dispenser with a serrated edge were on a table accessible to the children present for care in classroom A.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.25(3) · Rule 591-1-1-.25(3) requires the Center and surrounding premises to be kept clean, free of debris and in good repair. Hygienic measures such as, but not limited to, screened windows and proper waste disposal procedures shall be utilized to minimize the presence of rodents, flies, roaches and other vermin at the Center.

During a Licensing Study conducted on February 3, 2022 ; It was determined based on observation that the vents in the bathrooms, the paper towel dispenser in boys' bathroom, the doll house on the shelf between classrooms A and B were covered in dust; the windows in classroom C had accumulated dirt in the sills.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.25(3) · Rule 591-1-1-.25(3) requires the Center and surrounding premises to be kept clean, free of debris and in good repair. Hygienic measures such as, but not limited to, screened windows and proper waste disposal procedures shall be utilized to minimize the presence of rodents, flies, roaches and other vermin at the Center.

During an Incident Investigation & Follow Up conducted on July 25, 2022 ; It was determined based on observation that the left toilet in the girls' restroom was not working and the warm water faucet was broken in the boys restroom located in classroom A.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.25(7) · Rule 591-1-1-.25(7) requires that doors to rooms not approved for child care, other than the kitchen doors, be latched or locked so children cannot wander into those areas. Except in School- age Centers, interior Center door locks shall permit Personnel to open the locked room from outside of the room in an emergency.

During an Incident Investigation & Follow Up conducted on July 25, 2022 ; It was determined based on observation that the gate to the office area located in classroom A did not did not contain a latch preventing children from entering the office area. Children did not access the office area during the visit.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.25(8) · Rule 591-1-1-.25(8) requires protective caps on all unused electrical outlets within children's reach and requires that electrical outlets in use be made inaccessible to children.

During a Licensing Study conducted on February 3, 2022 ; It was determined based on observation that both receptacles in the boys' bathroom and a receptacle in Classroom A were not covered with protective caps.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.25(8) · Rule 591-1-1-.25(8) requires protective caps on all unused electrical outlets within children's reach and requires that electrical outlets in use be made inaccessible to children.

During an Incident Investigation & Follow Up conducted on July 25, 2022 ; It was determined based on observation that both receptacles in the boys' restroom and a receptacle located on the right-side of the exit door to the playground area located in classroom A were not covered with protective caps.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.26(4) · Rule 591-1-1-.26(4) requires that playgrounds be protected from traffic or other hazards by a (4) four foot high fence or other barrier approved by this Department. Fencing material shall not present a hazard to children and shall be maintained so as to prevent children from leaving the playground area by any means other than through an approved access route. Fence gates shall be kept closed except when persons are entering or exiting the area.

During a Licensing Study conducted on February 3, 2022 ; It was determined based on observation and measurement that the fence on the left measured approximately three feet, eight inches, in the back left corner it measured approximately three feet, two inches. Additionally, there was rust observed on the fence, the top rail of the fence was separated at the back; and there were exposed, sharp prongs by the gate on the right, front section and at the back.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.26(4) · Rule 591-1-1-.26(4) requires that playgrounds be protected from traffic or other hazards by a (4) four foot high fence or other barrier approved by this Department. Fencing material shall not present a hazard to children and shall be maintained so as to prevent children from leaving the playground area by any means other than through an approved access route. Fence gates shall be kept closed except when persons are entering or exiting the area.

During an Incident Investigation & Follow Up conducted on July 25, 2022 ; It was determined based on observation that the back fence measured approximately three feet eight inches in height on the playground PG. Further observation revealed that the top rail was not attached to the wire mesh on the back side of the fence.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.26(6) · Rule 591-1-1-.26(6) requires that playground equipment provide an opportunity for the children to engage in a variety of experiences and shall be age-appropriate. For example, toddlers shall not be permitted to swing in swings designed for School-age Children. The outdoor equipment shall be free of lead-based paint, sharp corners and shall be regularly maintained in such a way as to be free of rust and splinters that could pose significant safety hazard to the children. All equipment shall be arranged so as not to obstruct supervision of children.

During a Licensing Study conducted on February 3, 2022 ; It was determined based on observation that the structure over the sandbox had a protruding nail and splintered wood, the yellow train had peeling paint and splintered wood, and the basketball goal had rust on the pole.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.26(6) · Rule 591-1-1-.26(6) requires that playground equipment provide an opportunity for the children to engage in a variety of experiences and shall be age-appropriate. For example, toddlers shall not be permitted to swing in swings designed for School-age Children. The outdoor equipment shall be free of lead-based paint, sharp corners and shall be regularly maintained in such a way as to be free of rust and splinters that could pose significant safety hazard to the children. All equipment shall be arranged so as not to obstruct supervision of children.

During an Incident Investigation & Follow Up conducted on July 25, 2022 ; It was determined based on observation that the wooden structure covering the sandbox contained a protruding nail and splintered wood located on preschool playground. Furthermore, the yellow train contained peeling paint and splintered wood located on the preschool playground. The orange chair and basketball goal contained rust and the white and green activity table contained bent legs on the preschool playground. The gray plastic picnic table top was observed to be cracked creating a potential pinching hazard located on the preschool playground.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.31(2)(c) · Rule 591-1-1-.31(2)(c) requires the Center to maintain a copy and/or written verification of the credential or degree awarded to the lead teacher that is required by these rules in the lead teacher's file, to make the document available for inspection and to provide the document to Department staff upon request.

During a Licensing Study conducted on February 3, 2022 ; It was determined based on review of records that there was no evidence of documentation of credentials or degrees for any of the lead teachers.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.31(2)(c) · Rule 591-1-1-.31(2)(c) requires the Center to maintain a copy and/or written verification of the credential or degree awarded to the lead teacher that is required by these rules in the lead teacher's file, to make the document available for inspection and to provide the document to Department staff upon request.

During an Incident Investigation & Follow Up conducted on July 25, 2022 ; It was determined based on review of records that staff #4, date of hire August 1, 2008, staff #5, date of hire September 1, 1990, and staff #8, date of hire January 17, /2022 did not have evidence of a credential or degree required for a lead teacher.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.30(1)(a)3 · Rule 591-1-1-.30(1)(a)3 requires that each crib shall have only an individual, tight-fitting sheet which is changed daily or more often as needed and prior to a change of occupant.

During a Licensing Study conducted on February 3, 2022 ; It was determined based on observation that crib sheets were loose enough that the consultant was able to pull approximately two inches of fabric away from the mattress. Per the center staff statement, crib sheets were changed every other day.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.30(1)(a)3 · Rule 591-1-1-.30(1)(a)3 requires that each crib shall have only an individual, tight-fitting sheet which is changed daily or more often as needed and prior to a change of occupant.

During an Incident Investigation & Follow Up conducted on July 25, 2022 ; It was determined based on observation that the crib sheet in the first right crib was not changed prior to changing the occupant of the crib in classroom C.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.30(4). · Rule 591-1-1-.30(4). requires that if cots and mats are stored in the children's activity room or area, they shall be stored to prevent children's access to them and to allow maximum use of play space. When storage is available and used for the storage of cots and mats that allows the cots, mats and any bedding to be stored without touching any other cots, mats or bedding, the bedding may be left on the cot or mat. When such storage is not available for the cots and mats, each child¶s bedding shall be kept separate from other children¶s bedding and stored in containers marked for individual use, such as, but not limited to, bins, cubbies, or bags.

During a Licensing Study conducted on February 3, 2022 ; It was determined based on observation that the cots stored in the girls' bathroom had bedding touching other mats and bedding.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.30(4). · Rule 591-1-1-.30(4). requires that if cots and mats are stored in the children's activity room or area, they shall be stored to prevent children's access to them and to allow maximum use of play space. When storage is available and used for the storage of cots and mats that allows the cots, mats and any bedding to be stored without touching any other cots, mats or bedding, the bedding may be left on the cot or mat. When such storage is not available for the cots and mats, each child¶s bedding shall be kept separate from other children¶s bedding and stored in containers marked for individual use, such as, but not limited to, bins, cubbies, or bags.

During an Incident Investigation & Follow Up conducted on July 25, 2022 ; It was determined based on observation that the cots stored in the girls' bathroom in classroom A had bedding touching other mats and bedding.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.32(2) · Rule 591-1-1-.32(2) requires the Center maintain Staff:child ratios in mixed-age groups based on the age of the youngest group of children that includes more than twenty percent of the total number of children in the mixed-age group.

During a Licensing Study conducted on February 3, 2022 ; It was determined based on observation that Classroom C had six infants and one one-year-old child with with one staff person in the room. The required ratio for the group was one adult to six children. In Classroom B, one staff person was in the room with four one-year-old children and seven two-year-old children. The required ratio for the younger group was one person with eight children.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.32(2) · Rule 591-1-1-.32(2) requires the Center maintain Staff:child ratios in mixed-age groups based on the age of the youngest group of children that includes more than twenty percent of the total number of children in the mixed-age group.

During an Incident Investigation & Follow Up conducted on July 25, 2022 ; It was determined based on observation that a ratio of 1:11 one-year-old (three) and two-year-old (eight) children were observed in classroom B. A ratio of 2:11 was required. Further, a ratio of 1:27 (five three-year-olds, eight four-year- olds, five five-year-olds, and nine six to ten year old children) was observed in classroom A. A ratio of 2:27 was required.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.21(1)(p) · Rule 591-1-1-.21(1)(p) requires the Center to have a written plan for handling emergencies, including but not limited to severe weather, loss of electrical power or water and death, serious injury or loss of a child, a threatening event, or natural disaster which may occur at the Center; to have in place procedures for evacuation, relocation, shelter-in-place, lock-down, communication and reunification with families, and continuity of operations. The plan must apply to all children in care and include specific accommodations for infants and toddlers, children with disabilities, and children with chronic medical conditions and shall include assurance that no Center Personnel will impede in any way the delivery of emergency care or services to a child by licensed or certified emergency health care professionals.

During a Licensing Study conducted on February 3, 2022 ; It was determined based on the review of records that there was no evidence of current emergency plans.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.21(1)(p) · Rule 591-1-1-.21(1)(p) requires the Center to have a written plan for handling emergencies, including but not limited to severe weather, loss of electrical power or water and death, serious injury or loss of a child, a threatening event, or natural disaster which may occur at the Center; to have in place procedures for evacuation, relocation, shelter-in-place, lock-down, communication and reunification with families, and continuity of operations. The plan must apply to all children in care and include specific accommodations for infants and toddlers, children with disabilities, and children with chronic medical conditions and shall include assurance that no Center Personnel will impede in any way the delivery of emergency care or services to a child by licensed or certified emergency health care professionals.

During an Incident Investigation & Follow Up conducted on July 25, 2022 ; It was determined based on the review of records that the written plan for handling emergencies did not contain procedures for relocation, shelter-in-place, lock-down, communication and reunification with families, and continuity of operations and did not include specific accommodations for infants and toddlers, children with disabilities, and children with chronic medical conditions.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.10(4) · Rule 591-1-1-.10(4) requires that if diapers are changed on a diaper changing surface, the surface shall be smooth, nonporous, and equipped with a guard or rails to prevent falls. Between each diaper change, the diaper changing surface shall be cleaned with a disinfectant and dried with a single-use disposable towel.

During a Licensing Study conducted on February 3, 2022 ; It was determined based on observation that the changing table had a quilted pad that was not smooth and was not disinfected after use.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.10(4) · Rule 591-1-1-.10(4) requires that if diapers are changed on a diaper changing surface, the surface shall be smooth, nonporous, and equipped with a guard or rails to prevent falls. Between each diaper change, the diaper changing surface shall be cleaned with a disinfectant and dried with a single-use disposable towel.

During an Incident Investigation & Follow Up conducted on July 25, 2022 ; It was determined based on observation that the changing table located between classrooms B and C was observed to have a torn quilted pad. Further observation revealed that the staff member did not disinfect the changing table after completing the diaper changing process.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.10(5) · Rule 591-1-1-.10(5) requires that Center Staff shall not leave infants or children unattended while being diapered or having their clothes changed on the diaper changing surface.

During a Licensing Study conducted on February 3, 2022 ; It was determined based on observation that a staff member in classroom C walked away from the changing table while a child was being changed.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.10(5) · Rule 591-1-1-.10(5) requires that Center Staff shall not leave infants or children unattended while being diapered or having their clothes changed on the diaper changing surface.

During an Incident Investigation & Follow Up conducted on July 25, 2022 ; It was determined based on observation that a staff member in classroom C did not keep a hand on a child on the changing table when they washed their hands during the diaper changing process. 16. A. Rule 591-1-1-.18(12) prohibits children from being in the kitchen except as part of a planned, supervised learning experience. During a Licensing Study conducted on February 3, 2022 ; It was determined based on observation that the door to the kitchen in classroom A was observed to be unlocked and thus not excluding the children from the kitchen. 16. B. Rule 591-1-1-.18(12) prohibits children from being in the kitchen except as part of a planned, supervised learning experience. During an Incident Investigation & Follow Up conducted on July 25, 2022 ; It was determined based on observation that the saloon-style doors to the kitchen do not extend to the floor and the kitchen was accessed by a child scooting beneath the doors on this date.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.18(2) · Rule 591-1-1-.18(2) requires the Center to have a designated space for food preparation separate from rooms used by children and in an area not used for diaper changing. The area shall be kept clean and free of accumulation of dust, dirt, food particles and grease deposits. Food preparation surface areas shall be nonporous with no unsealed cracks or seams.

During a Licensing Study conducted on February 3, 2022 ; It was determined based on observation that there were droppings in the cabinet under the sink in the kitchen, food stored in open containers and a half eaten pop-tart on the counter.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.18(2) · Rule 591-1-1-.18(2) requires the Center to have a designated space for food preparation separate from rooms used by children and in an area not used for diaper changing. The area shall be kept clean and free of accumulation of dust, dirt, food particles and grease deposits. Food preparation surface areas shall be nonporous with no unsealed cracks or seams.

During an Incident Investigation & Follow Up conducted on July 25, 2022 ; It was determined based on observation that roach droppings were observed in the cabinet underneath the sink located in the kitchen and an open bag of cereal was observed on the kitchen counter.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.26(9) · Rule 591-1-1-.26(9) requires the playground to be kept clean, free from litter and free of hazards, such as but not limited to rocks, exposed tree roots and exposed sharp edges of concrete.

During a Licensing Study conducted on February 3, 2022 ; It was determined based on observation that the playground had exposed tree roots, cracked concrete, two uncoiled hoses, and the bars used to anchor the gray, blue and red slide protruded from the ground to the extent that they posed a tripping hazard.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.26(9) · Rule 591-1-1-.26(9) requires the playground to be kept clean, free from litter and free of hazards, such as but not limited to rocks, exposed tree roots and exposed sharp edges of concrete.

During an Incident Investigation & Follow Up conducted on July 25, 2022 ; It was determined based on observation that exposed tree roots, standing water in a plastic tarp, and an uncoiled hose were observed on the preschool playground creating a potential tripping hazard. Further, the bars used to anchor the base of the gray, blue and red slide were observed to be protruding from the ground creating a potential tripping hazard.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.31(1)(c) · Rule 591-1-1-.31(1)(c) requires that a copy and/or written verification of the credential or degree awarded to the Director by the technical college, university, school or Department- approved trainer listed in 591-1-1-.31(1)(b)2.(i) through (xiii) be maintained by the Center in the Director's file and such documentation shall be available for inspection by Department staff upon request.

During a Licensing Study conducted on February 3, 2022 ; It was determined based on review of records that there was no evidence of documentation of credentials or degrees for the director.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.31(1)(c) · Rule 591-1-1-.31(1)(c) requires that a copy and/or written verification of the credential or degree awarded to the Director by the technical college, university, school or Department- approved trainer listed in 591-1-1-.31(1)(b)2.(i) through (xiii) be maintained by the Center in the Director's file and such documentation shall be available for inspection by Department staff upon request.

During an Incident Investigation & Follow Up conducted on July 25, 2022 ; It was determined based on review of records that there was no evidence of documentation of credentials or degrees for the director.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.17(10) · Rule 591-1-1-.17(10) requires that if used potty chairs be emptied in a flush toilet after each use, cleaned with a disinfectant and stored in the bathroom. If a sink is used, the sink shall also be disinfected.

During a Licensing Study conducted on February 3, 2022 ; It was determined based on observation that a potty chair in the boys' bathroom contained urine on this date.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.17(10) · Rule 591-1-1-.17(10) requires that if used potty chairs be emptied in a flush toilet after each use, cleaned with a disinfectant and stored in the bathroom. If a sink is used, the sink shall also be disinfected.

During an Incident Investigation & Follow Up conducted on July 25, 2022 ; It was determined based on observation that a potty chair in the boys' bathroom in classroom A contained residue and was not cleaned after each use.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.19(1) · Rule 591-1-1-.19(1) requires a Center to provide 35 square feet of usable space per child, which will determine the Center's License capacity.

During a Licensing Study conducted on February 3, 2022 ; It was determined based on observation and investigation that the center's capacity was limited to twenty-nine students and thirty-four students were present for care on this date.

Open Not marked corrected in the state record

Open / not marked corrected.

591-1-1-.19(1) · Rule 591-1-1-.19(1) requires a Center to provide 35 square feet of usable space per child, which will determine the Center's License capacity.

During an Incident Investigation & Follow Up conducted on July 25, 2022 ; It was determined based on observation that the center capacity exceeded classroom A-Front's licensed capacity of 18 when it was observed that staff members cared for 27 children in the classroom. Furthermore, the center exceeded their overall licensed capacity of 40 when it was observed that the staff members cared for approximately 43 children during the visit. Exhibit "A"

Open Not marked corrected in the state record

Open / not marked corrected.