922 KAR 2:120 · 922 KAR 2:120. Section 2. Child Care Services.

General: Based on observation during the inspection, the Infant/Toddler room and the Young Preschool 1 room were very dark; requiring the use of a flashlight to see the children and staff. Therefore, the children were not within the scope of vision. The staff in-charge acknowledged the deficiency.

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 8. General.

General: Based on observation during the inspection, the following was found: Woman’s Bathroom 1) A plunger was sitting on the floor adjacent to the toilet. Men’s Bathroom 1) A plunger was sitting on the floor adjacent to the toilet.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 4. Premises Requirements.

General: Based on review of documentation and interview, the fire marshal report that was presented for review was dated 02/27/23. The staff in-charge stated that the fire marshal had made a visit recently, but he/she did not present documentation of the recent inspection.

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 10. Director Requirements and Responsibilities.

General: Based on interview and review of documentation, current, annual, written performance evaluations were not presented for fourteen (14) staff members (DOH: 11.01.22; 08.21.18; 01.10.14; 05.17.24; 08.20.18; 05.16.23; 10.23.23; 03.07.22; 09.03.19; 11.01.21; 08.03.98; 11.19.13; 11.14.23; and 12.11.15).

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 11. Staff Requirements.

General: Based on interview and review of documentation, there was no verification of education presented for review for two (2) staff members (DOH: 09.10.25 and 12.23.24). Interview with the staff in charge revealed the staff member (DOH: 09.10.25) is currently enrolled in secondary education; however verification of such was not available at the time of the inspection.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 4. Premises Requirements.

General: Based on observation, a wall within the men’s bathroom contained chipping paint. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 16 of 32 Inspection Report

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 7. First Aid and Medicine.

General: Based on review of documentation and interview, an allergy care plan was not created for the enrolled children that had allergies listed within their file. The staff in-charge did not present an allergy care plan for the children.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 11. Staff Requirements.

General: Based on review of documentation and review of ECE-TRIS, the surveyor found the following: 1. One (1) staff (DOH: 10/23/23) completed six (6) hours of the fifteen (15) required hours of cabinet-approved early care and education training for the review period of 10/23/23- 10/23/24. 2. One (1) staff (DOH: 08/16/99) completed thirteen (13) and one-half (1/2) hours of the fifteen (15) required hours of cabinet-approved early care and education training for the review period of 07/01/23-06/30/24. 3. One (1) staff (DOH: 11/01/22) completed zero (0) hours of the required fifteen (15) hours of cabinet-approved early care and education training for the review period of 11/02/23- 06/30/24. 4. One (1) staff (DOH: 05/16/23) completed zero (0) hours of the required fifteen (15) hours of cabinet-approved early care and education training for the review period of 05/17/24- 06/30/24. Programming In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Premises In Compliance Hygienic Practices In Compliance First Aid/Medication Not In Compliance

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 7. First Aid and Medicine.

General: Based on observation, the surveyor found a tube of Desitin Daily Defense Cream in an unlocked cabinet beneath the diaper changing table in the Toddler Classroom (Room 102). Outdoor Play Area In Compliance Equipment In Compliance Transportation In Compliance Kitchen Requirements In Compliance Food Service In Compliance Meal Planning/Center Provides Meals In Compliance Meal Planning/Center Does Not Provide Meals In Compliance Children's Records In Compliance Written Documentation Not In Compliance

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 9. Records.

General: Based on review of documentation of the childcare center’s written fire, earthquake, tornado and lockdown drill logs the surveyor found the following: 1. On 1/24/24, the time for the fire, earthquake, tornado, and lockdown drills was documented as occurring at 9:15am. 2. On 05/24/24, the time for the fire, earthquake, tornado, and lockdown drills was documented as occurring at 9:30am. 3. On 08/27/24, the time for the earthquake and tornado drills was documented as occurring at 9:15am. 4. On 11/08/24, the time for the earthquake and tornado drills was documented as occurring at 9:00am. Therefore, the drills were not conducted separately as only one (1) time was documented for all the drills. Posted Documentation In Compliance Animals In Compliance

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

922 KAR 2:280 · 922 KAR 2:280. Section 5. Checks of Other States.

General: Based on review of documentation, the surveyor found that a staff’s (DOH: 11/01/22) file contained documentation of a background check submitted through the Kentucky Applicant Registry and Employment System (KARES) that verified the staff’s eligibility date as 10/27/22. The documentation verified that the staff person lived in the state of Colorado in the last five (5) years. The staff’s file did not contain a completed out of state Child Abuse/Neglect Background Check (CAN) or a check of the state’s sex offender registry. The surveyor observed the staff person working with a volunteer alone with children in Room 102 on the day of the surveyor's visit. Supervision In Compliance Staffing Requirements In Compliance General Administration Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 8. General.

General: Based on observation, the surveyor found a two-year-old child sleeping in the back right corner with a large pillow covering her face in Room 105. The child was observed to be holding the pillow down onto her face with both her hands. The classroom was observed to be dark and not well lit. The staff person was observed to be sitting beside the classroom door with the child lying beside a bookshelf. This is a potential hazard to the child; therefore, the health, safety and comfort of the child was compromised. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 5 Inspection Report Director Requirements In Compliance Employee Records Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 11. Staff Requirements.

General: Based on review of documentation, the surveyor found that a staff’s (DOH: 05/18/20) file did not contain documentation of a current TB skin test or a statement from a health professional stating that the adult was free from active tuberculosis. During interview, staff-in-charge stated that the staff had an updated TB skin test; however, the documentation was not at the child-care center during the surveyor's visit.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 7. First Aid and Medicine.

General: Based on review of documentation and ECE-TRIS, the surveyor found that the following staff (DOH: 08/03/98, 08/16/99, 12/03/03, 11/19/13, 01/10/14, 06/19/15, 08/20/18, 08/21/18 and 11/01/21 ) had not completed the required cabinet approved training in first aid and cardiopulmonary resuscitation (CPR). Programming Not In Compliance

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 6. Sleeping and Napping Requirements.

General: Based on observation, the surveyor entered Room 103 at 11:46 a.m. to observe an eleven-month-old child sleeping in a crib with a loose blanket. During interview, a staff confirmed that the child had been sleeping for approximately five (5) minutes. Premises Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 3. General Requirements.

General: Based on observation, the surveyor found a clear spray bottle and a bucket of cleaning wipes in the elevator that leads to the upstairs classrooms. During interview, staff-in- charge stated that the cleaner was a multi-purpose cleaner and the wipes were disinfectant wipes. Staff-in-charge stated that the cleaning supplies belonged to the church and that children are supervised by staff when using the elevator. Staff-in-charge stated that she would make sure that the items mentioned were made inaccessible to the children.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 4. Premises Requirements.

General: Based on observation, the surveyor found the windowsill had a buildup of black dirt and debris in Room 304; therefore, the premises was not kept clean. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 5 Inspection Report

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 4. Premises Requirements.

General: Based on observation, the surveyor found that Room 102, Room 103 and Room 105 were dark during the surveyor's observations of the classrooms. While walking through the classrooms, the surveyor had to use a flashlight; therefore, the classroom were not well lit.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 12. Toilet, Diapering, and Toiletry Requirements.

General: Based on observation, the surveyor found that the hot water temperature in the restroom located in Room 101 measured seventy-eight (78) degrees Fahrenheit; therefore, the hot water temperature was not a minimum temperature of ninety (90) degrees Fahrenheit and a maximum of one-hundred twenty (120) degrees Fahrenheit. Hygienic Practices Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 12. Toilet, Diapering, and Toiletry Requirements.

General: Based on observation, the surveyor found debris on the diaper changing table underneath the diaper changing pad in the Room 104; therefore, the diaper changing surface was not kept clean. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 5 Inspection Report First Aid/Medication Not In Compliance

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 7. First Aid and Medicine.

General: Based on observation, the surveyor found a bottle of Destitin Baby Rash Cream that stated, "Keep out of Reach of Children" on the back label in Room 104 on the shelf of a cubby. The Destitin Diaper Rash Cream was observed to be within reach of children; therefore, the diaper rash cream was accessible to children. Outdoor Play Area Not In Compliance

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 4. Premises Requirements.

General: Based on observation, the surveyor found the back fence row had a large gap that that was six and one-half (6 1/2) inches long; therefore, the playground's fence was not in good repair. Equipment In Compliance Transportation In Compliance Kitchen Requirements Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 8. Kitchen Requirements.

General: Based on observation, the surveyor found that the temperature in the refrigerator in Room 103 has a temperature reading of approximately fifty (50) degrees Fahrenheit; therefore, the temperature of the refrigerator was not forty (40) degree Fahrenheit or below. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 4 of 5 Inspection Report Food Service Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 9. Food and Drink Requirements for All Child-Care Centers.

General: Based on observation, the surveyor found the following: 1. One (1) unopened gallon of Vitamin D Milk in the kitchen refrigerator that had a best by used by date of 06/14/23. 2. One (1) gallon of Vitamin D Milk that had been opened with a best by used date of 06/14/23. Therefore, the child-care center failed to keep the milk free from spoilage. During interview, staff-in-charge stated that the milk had not been served to children since 06/14/23 and that the unopened gallon of milk was being sent back to Kroger for a refund. Meal Planning/Center Provides Meals In Compliance Meal Planning/Center Does Not Provide Meals In Compliance Children's Records Not In Compliance

Open Not marked corrected in the state record

Category: nutrition. Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 9. Records.

General: Based on review of documentation, the surveyor found that a child’s (DOE: 12/20/22) file did not contain the name of the child’s preferred hospital or contact telephone number. Written Documentation In Compliance Posted Documentation In Compliance Animals In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:280 · 922 KAR 2:280. Section 3. Implementation and Enforcement.

General: Based on review of the Kentucky National Background Check Service, the surveyor found that a staff’s (DOH: 11/01/21) employment status was listed as “Provisional” and the determination status was listed as “Closed-Fingerprints not Taken.” The surveyor found that the staff person submitted to fingerprints on 05/04/18 and the fingerprints were rejected by the FBI on 05/09/18. The surveyor found that the staff person submitted to fingerprints again on 05/17/18 and the fingerprints were rejected by the FBI on 05/24/18. The surveyor found that the staff person was provisionally hired on 11/01/21 and a Final Registry Results letter was generated on 11/01/21. The staff’s file contained an employment authorization form showing that the staff person was eligible for employment. During interview, staff-in-charge stated that the staff person had submitted to fingerprints and she was not aware that a new application was needed. Staff-in-charge checked KARES during the surveyor’s visit on 08/15/22 and pulled up the employment authorization form that verified the staff person as being eligible for employment. Staff-in-charge stated that the staff person had not worked alone with children. The surveyor did not observe the staff person working alone with children. Supervision In Compliance Staffing Requirements In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report General Administration Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 8. General.

General: Based on observation, the surveyor found the following: 1. A power strip and several loose cords were placed on the floor beside a brown shelf in Classroom 306. The cords and power strip were observed to be accessible to the children. Staff-in-charge stated that the classroom was not currently being utilized by children. 2. A container of Aquaphor that stated "Keep Out of the Reach of Children" on the label and one (1) roll of white garbage bags were placed in an unlocked cabinet underneath the diaper changing table in the Infant Classroom 101. 3. One (1) roll of white garbage bags was placed in an unlocked cabinet underneath the diaper changing table in the Infant Classroom 103. 4. A brown box that appeared to be a cassette player that contained a loose cord was located in an unlocked cabinet on a brown shelf in the Two Year Old Classroom 105. 5. White tape was placed around an electrical outlet that appeared to be holding the outlet in place in the Gym. 6. The door to a breaker box did not close properly and was observed to be partially open and was located on the wall beside the entry/exit door into the Gym. Director Requirements In Compliance Employee Records In Compliance Programming In Compliance Premises Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 3. General Requirements.

General: Based on observation, the surveyor found a clear spray bottle that stated "Zep Professional Cleaner" on the front of the bottle in the elevator that leads to the upstairs classrooms. During interview, staff-in-charge stated that the bottle may have contained a cleaning agent and that the spray bottle belonged to the Church. Staff-in-charge stated that the children are supervised by staff persons when they take the elevator to the upstairs classrooms. Staff-in-charge stated that she would make the item mentioned inaccessible to the children.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 4. Premises Requirements.

General: Based on observation, the surveyor found the following: 1. Peeling paint was on the wall behind the faucet in the restroom located between the Three Year Old Classroom 107 and Four Year Old Classroom 106; therefore, the wall was not in good repair. 2. What appeared to be peeling white caulk exposing a black residue underneath on the wall was behind the faucet in the restroom located between the Infant Classroom 103 and and Toddler Classroom 102; therefore, the wall was not in good repair. 3. Peeling paint was on the wall beside the toilet in the boys' restroom located upstairs; therefore, the wall was not in good repair.

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 12. Toilet, Diapering, and Toiletry Requirements.

General: Based on observation, the surveyor found the following: 1. A yellow substance was on the bottom base of both sides of the toilet located in the restroom between the Three Year Old Classroom 107 and Four Year Old Classroom 106; therefore, the toilet was not kept in clean condition. 2. There was what appeared to be dust/debris on the bottom base of both sides of the toilet located in the restroom between the Infant Classroom 103 and Toddler Classroom 102; therefore, the toilet was not kept in clean condition. 3. A yellow substance was on the bottom base of the toilet located in the boys' restroom upstairs; therefore, the toilet was not kept in clean condition. Hygienic Practices In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3 Inspection Report First Aid/Medication In Compliance Outdoor Play Area Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 4. Premises Requirements.

General: Based on observation, the surveyor found the following: 1. Two (2) holes in the white fence roll along the back of the playground contained jagged edges. 2. Part of a tree stump that was protruding upward was located beside the white fence roll along the side of the playground. Equipment In Compliance Transportation In Compliance Kitchen Requirements In Compliance Food Service In Compliance Meal Planning/Center Provides Meals In Compliance Meal Planning/Center Does Not Provide Meals In Compliance Children's Records In Compliance Written Documentation In Compliance Posted Documentation In Compliance Animals In Compliance

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 8. General.

General: Based on observation, the surveyor found the following: 1. A yellow package of Wet Ones was located on the bottom shelf in the Preschool Two Classroom 307. The Wet Ones container had a label that read to "Keep Out of the Reach of Children"; however, the container was accessible to the children. 2. A loose television cord dangling down the wall from a television that was hanging on the wall located in the Two Year Old Classroom 105. The dangling cord was accessible to the children. Director Requirements In Compliance Employee Records Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 11. Staff Requirements.

General: Based on review of documentation, the surveyor found that a staff's (DOH: 09/03/19) file did not contain documentation of a current TB skin test or a statement from a health professional stating that the staff person was free from active tuberculosis. The staff's file did contain a negative TB skin test dated for 08/19/19; however, the results were no longer current. During interview, staff-in-charge stated that she was unsure if the staff person had a current TB skin test. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 4 Inspection Report

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 11. Staff Requirements.

General: Based on review of documentation, and ECE-TRIS, the surveyor found the following: 1. A staff (DOH: 09/22/17) completed one and one-half (1 ½) hours of cabinet-approved pediatric abusive head trauma training on 11/04/15; therefore, the training was not completed within the last five years. 2. A staff (DOH: 06/19/15) completed one and one-half (1 ½) hours of cabinet-approved pediatric abusive head trauma training on 06/06/16; therefore, the training was not completed within the last five years. 3. A staff (DOH: 09/03/19) completed one and one-half (1 ½) hours of cabinet-approved pediatric abusive head trauma training on 10/15/13; therefore, the training was not completed within the last five years. Programming In Compliance Premises Not In Compliance

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 3. General Requirements.

General: Based on observation, the surveyor found the following: 1. Two (2) spray bottles that stated "bleach water" and one (1) spray bottle with a pink solution placed on a table beside the exit door in the School Age Classroom 305. 2. A white tub of what appeared to be sanitizing wipes and a spray bottle containing a cleaning agent placed inside the elevator. The items mentioned were observed to be within reach of the children. During interview, staff-in-charge stated the the children use the elevator to go to the third floor and that the cleaning supplies belong to the church. Staff-in-charge stated that the staff persons ensure the children do not access the cleaning supplies in the elevator. Staff-in-charge stated that she would make the cleaning items mentioned inaccessible to the children.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 4. Premises Requirements.

General: Based on observation, the surveyor found the following: 1. A blue square rug that contained stains in the Three Year Old Classroom 107; therefore, the rug was not kept clean. 2. A blue round rug that contained debris in the Two Year Old Classroom 105; therefore, the rug was not kept clean. 3. A round blue rug that contained debris in the Toddler Classroom 102; therefore, the rug was not kept clean. 4. A gray square rug that contained stains in the Toddler Classroom 102; therefore, the rug was not kept clean. 5. An oval blue rug that contained stains in the Infant Classroom 101; therefore, the rug was not kept clean. 6. Three (3) blue rocking chairs that contained stains; therefore, the rocking chairs were not kept clean. 7. A blue square rug that contained stains in the Three Year Old Classroom 106; therefore, the rug was not kept clean. 8. What appeared to be built up black corrosion underneath the faucet handle on the sink located in the restroom between the Toddler Classroom 104 and Two Year Old Classroom 105. 9. What appeared to be built up black corrosion underneath the faucet handle on the sink located in the restroom between the Toddler Classroom 102 and Infant Two Classroom 103. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 4 Inspection Report

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 12. Toilet, Diapering, and Toiletry Requirements.

General: Based on observation, the surveyor found that the toilet bowl and white hinges contained stains and both sides of the bottom base of the toilet contained what appeared to be built up brown rust in the restroom located between the Toddler Classroom 104 and Two Year Old Classroom 105. Hygienic Practices Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 12. Toilet, Diapering, and Toiletry Requirements.

General: Based on observation, the surveyor found the following: 1. White stains on a red diaper changing pad, debris and a pencil on the diaper changing table underneath the diaper changing pad in the Two Year Old Classroom 105; therefore, the diaper changing surface was not kept clean or free from other items. 2. Debris on the diaper changing table underneath the diaper changing pad in the Toddler Classroom 104; therefore, the diaper changing surface was not kept clean. First Aid/Medication In Compliance Outdoor Play Area Not In Compliance

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 4. Premises Requirements.

General: Based on observation, the surveyor found the following: 1. A large tree branch was on the ground under a tree on the playground. 2. A gap underneath the fence roll along the back of the playground. 3. A black bungee cord placed on the fence near the toy storage container on the playground. 4. A drain pipe that came out from the building and had a broken end and exposed a sharp edge located on the way to the playground. During interview, staff-in-charge stated that there were two (2) ways the staff walk the children to the playground; however, the children do walk by the drain pipe sometimes when going to the playground. Staff-in-charge stated that she would request to have the gap in the fence and drain pipe repaired. Equipment In Compliance Transportation In Compliance Kitchen Requirements In Compliance Food Service In Compliance Meal Planning/Center Provides Meals In Compliance Meal Planning/Center Does Not Provide Meals In Compliance Children's Records In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 4 Inspection Report Written Documentation Not In Compliance

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 9. Records.

General: Based on review of documentation, the surveyor found that a staff’s (DOH: 03/09/20) file did not contain a professional development plan; therefore, the surveyor was unable to determine if a professional development plan had been completed. Through interview with staff-in-charge, the surveyor learned that an up-to-date annual professional development plan was not available for review for the staff mentioned. Posted Documentation In Compliance Animals In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 11. Staff Requirements.

General: Based on review of documentation, the surveyor found a staff's (DOH: 10/12/2020) file did not contain a high school diploma, GED, or Commonwealth Child Care Credential. Staff confirmed the documentation had not been obtained for the staff's file. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Food Service/Food Program In Compliance Food Service In Compliance Children's Records In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Written Documentation In Compliance Posted Documentation In Compliance Animals In Compliance Emergency Regulation In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 10. Director Requirements and Responsibilities.

General: Based on observation during a tour of Room #103, the surveyor found that a staff was assisting a female child to wash her hands at a sink located in the restroom. The child was standing on a step in front of the sink. The staff person attempted to help the child down by holding both of the child’s hand and pulling the child up by both arms as she descended onto the floor; thus, placing the child for injury. Employee Records Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 11. Staff Requirements.

General: Based on observation and review of documentation, the surveyor found that a staff’s (DOH: 6/19/15) tuberculin result was no longer current as of 5/26/19. Through interview, the surveyor learned that a current tuberculin result or statement from a health professional that the individual is free of active tuberculosis was not available for review. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 11. Staff Requirements.

General: Based on review of documentation and ECE-TRIS, the surveyor found the following: 1. A staff (DOH: 6/19/15) completed only nine (9) hours of cabinet-approved early care and education annual training for the review period of 6/19/18 through 6/18/19. 2. No verification was found that a staff (DOH: 1/7/19) completed six (6) hours of cabinet-approved orientation training. 3. A staff (DOH: 8/21/18) completed six (6) hours of cabinet-approved orientation training on 12/17/18; however, the training was not completed within the first three (3) months of employment. Programming Not In Compliance

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 6. Sleeping and Napping Requirements.

General: Based on observation during a tour of Room #101, the surveyor found that an infant child was sleeping in a swing. Through interview, the surveyor learned that a health professional had not submitted a waiver indicating that the child needs an alternate sleeping position. Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Food Service/Food Program In Compliance Food Service In Compliance Children's Records In Compliance Written Documentation Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 9. Records.

General: Based on observation during a tour of Room #104, the surveyor found that four (4) two-year-old children were present. Review of the Daily Attendance Record found that the arrival times of only three (3) children were documented. Posted Documentation In Compliance Animals Not Applicable

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 11. Staff Requirements.

General: Based on review of documentation in personnel files and ECE-TRIS, the surveyor found that a staff (DOH: 07/08/15) had obtained only five (5) hours of cabinet-approved early care and education annual training. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Food Service/Food Program In Compliance Food Service In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Children's Records Not In Compliance

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 9. Records.

General: Based on review of documentation contained in a child’s (DOE: 01/09/17) file, the surveyor found that the immunization certificate was no longer current as of 05/04/18. Written Documentation In Compliance Posted Documentation In Compliance Animals In Compliance

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 2. Child Care Services.

General: Based on observation of the infant classroom, the minimum staff-to-child ratio was not met for at least five (5) minutes, i.e., on 3-31-17 at 1:05pm there were six (6) children, all under the age of one (1), and two (2) adults present in the infant classroom. Based on interview, it was found that one (1) adult in the classroom was a volunteer and the other adult was a staff member. The volunteer and staff member had been the only adults present in the classroom since 1:00pm. General Administration In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report Director Requirements Not In Compliance

Open Not marked corrected in the state record

Category: ratio. Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110. Section 4. Director Requirements and Responsibilities.

General: Based on observation of the infant classroom, the following was found: 1) One (1) child (DOE: 3-6-17) had a pacifier clip attached to their clothing while they were asleep in a crib. 2) Four (4) children (DOE: 1-3-17, 1-9-17, 2-6-17, and 3-6-17) had a crib mobile hanging above their individual crib. Employee Records Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 6. License Issuance.

General: Based on review of documentation of staff files, one (1) staff (DOH: 12-19-16) indicated on their child abuse and neglect background check that they had lived in the state of Pennsylvania within the last five (5) years. The staff file did not contain a completed out-of-state background check or a completed form for the background check to be ran. Based on interview, the director stated that a request has been sent to Pennsylvania for the background check to be completed; however, no written documentation was kept to show that it was submitted timely. The director further stated that this staff member has never been left alone with the children.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110. Section 5. Staff Requirements.

General: Based on review of documentation of staff files, three (3) staff (DOH: 8-24-16, 12-14-16, and 5-2-16) files did not contain proof of a high school diploma, GED or qualifying documentation from a comparable educational entity, or Commonwealth Child Care Credential as described in 922 KAR 2:250. Based on interview, the director stated that all three (3) staff have a high school diploma; however, she has not yet received a copy.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110. Section 5. Staff Requirements.

General: Based on review of documentation of ECE-TRIS and staff files, the following was found: 1) Staff with DOH: 8-16-99 completed twelve (12) of the required fifteen (15) hours of annual training for the training year 8-16-15 to 8-15-16. 2) Staff with DOH: 12-11-15 has not completed the required pediatric abusive head trauma training. Programming In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3 Inspection Report Premises Not In Compliance

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 3. General Requirements.

General: Based on observation of Room 107 (one (1) of the three-year-old classrooms), one (1) BIC lighter and one (1) bottle of hand sanitizer were found in an unlocked cabinet. Both items were within reach and accessible to the children in the classroom.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 4. Premises Requirements.

General: Based on observation, the following things were found: 1) There was one (1) stained ceiling tile located above the window of the toddler classroom. 2) There was one (1) stained ceiling tile located above the window of the infant classroom. Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Food Service In Compliance Children's Records Not In Compliance

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110. Section 3. Records.

General: Based on review of documentation, the following was found: 1) A child with DOE: 2-25-13 did not have a current immunization certificate for review, i.e., the immunization certificate present in the file was only current until 1-5-17. 2) One (1) child with DOE: 9-26-16 did not have a current immunization certificate for review, i.e., the immunization certificate present in the file was only current until 3-30-17. 3) A child with DOE: 9-26-16 did not have a current immunization certificate for review, i.e., the immunization certificate present in the file was only current until 2-20-17. Written Documentation In Compliance Posted Documentation In Compliance Animals In Compliance

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110. Section 5. Staff Requirements.

General: Based on review of documentation of staff files, one (1) staff member with a DOH: 10-15-15 did not have current TB verification, i.e., the TB paperwork was only current through 4-18-2014.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 6. License Issuance.

General: Based on review of documentation of staff files, one (1) staff member did not have an updated child abuse and neglect (CA/N) check to reflect their new hire date, i.e., staff member was rehired on 3-30-16 however the CA/N check in the file was submitted on 3-28-12 (original hire date was 3-29-12). Based on interview with the director, staff has never been left alone with children.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 3. General Requirements.

General: Based on observation of the girls restroom on the third floor, there was one (1) can of Lysol spray sitting on the counter next to the bathroom sink and it was accessible and within reach of children. Based on interview with the director, this restroom is used by the four-year-old classroom as well as the school-age classroom.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 10. Toilet, Diapering, and Toiletry Requirements.

General: Based on observation of the toilets in the child care center, the following were found: 1) There were feces left in the toilet that is used by the three (3) year old classrooms. 2) There was one (1) puddle of urine on the back of the toilet that is used by the two (2) year old classrooms. Hygienic Practices

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 6. Sleeping and Napping Requirements.

General: Based on observation, the mats used in the older three (3) year old classroom were stacked on top of each other with the children's bedding still on and there was no barrier in between them; therefore the sleeping and napping requirements were not met.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 5. Evacuation Plan.

General: Based on review of documentation, the child care center did not have an updated emergency prepardness plan, i.e., the most recent plan was dated October 2012.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110. Section 5. Staff Requirements.

General: Based on review of documentation, the following issues were found: 1) An employee (DOH 04/01/15) file presented for review did not contain evidence of educational qualification as required by regulations. 2) An employee (DOH 10/23/14) file presented for review did not contain evidence of educational qualification as required by regulations. 3) An employee (DOH 03/20/15) file presented for review did not contain evidence of educational qualification as required by regulations.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110. Section 5. Staff Requirements.

General: Based on review of documentation, the following issues were found: 1) An employee (DOH 02/17/09) record presented for review contained negative tuberculin verification dated 02/08/13 which was no longer current. 2) An employee (DOH 03/06/14) record presented for review contained negative tuberculin verification dated 02/08/13 which was no longer current. 3) An employee (DOH 04/08/13) record presented for review contained negative tuberculin verification dated 03/07/13 which was no longer current. 4) An employee (DOH 04/04/07) record presented for review contained negative tuberculin verification dated 02/08/13 which was no longer current. 5) An employee (DOH 04/01/15) record presented for review did not contain negative tuberculin verification as required by regulations.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110. Section 5. Staff Requirements.

General: Based on review of documentation, the following issues were found: 1) An employee (DOH 10/09/14) record did not contain evidence of the employee completing six (6) hours of cabinet-approved orientation as verified by ECE-TRIS and the file presented for review. 2) An employee (DOH 04/20/14) file contained only seven (7) hours of cabinet-approved training as verified by ECE-TRIS and the record presented for review. 345 - Driver Requirements Not Applicable 922 KAR 2:120. Section 12. Transportation. (18) A driver of a vehicle transporting a child for a center shall: (a) Be at least twenty-one (21) years old; (b) Complete: 1. The background checks as described in 922 KAR 2:110; and 2. An annual check of the: a. Kentucky driver history records in accordance with KRS 186.018; or b. Driver history records through the state transportation agency that issued the driver’s license; (c) Hold a current driver’s license which has not been suspended or revoked during the last five (5) years; and (d) Not caused an accident which resulted in the death of a person. Programming

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 11. Toys and Furnishings.

General: Based on interview, the toy sanitization process of mouthed toys did not include soaking toys in warm, soapy water and scrubbing with a brush to reach into crevices as required by regulations. First Aid/Medication

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110. Section 3. Records.

General: Based on review of documentation, a written record of quarterly practiced earthquake and tornado drills for 2015 was not presented during the DRCC inspection on 04/29/15. The most recent earthquake and tornado drill documentation presented was dated 12/02/14.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 3. General Requirements.

General: Based on review of documentation, the most recent earthquake and tornado drills were conducted on 12/02/14; therefore, earthquake and tornado drills were not being conducted on a quarterly basis. During an interview with the director, she stated that quarterly earthquake and tornado drills had not been conducted since December 2014. Posted Documentation

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110. Section 4. Director Requirements and Responsibilities.

General: Based on review of documentation, the following issues were found: 1) In the Infant's room, the posted daily lesson plan of activities was dated 04/20 - 04/24; therefore, lesson plans were not up-to-date as required by regulations. 2) In the older Three's room, daily lesson plans and daily schedules were not posted as required by regulations.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110. Section 6. Reports.

General: Based on interviews, the child care center failed to report an incident of child abuse or neglect to the cabinet pursuant to KRS 620.030. The child care center staff observed an abrasion/bruise on a toddler child's buttock during a diaper change on 04/21/15 and did not report the incident as required by regulations. The abrasion/bruise on the child's buttock was reported to the Department for Community Based Services by another source other than the child care center staff and was accepted for investigation. Director Requirements

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110. Section 4. Director Requirements and Responsibilities.

General: Based on interviews, the comfort of toddler-age children in the Creeper's room was compromised when staff wrapped masking and/or duct tape around their shoes to cover the laces or velcro closures. Employee Records

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 3. General Requirements.

General: Based on observation in Preschool Rooms 106 and 107 during nap time, children were napping on mats that were spaced around the rooms with some of the mats being located behind shelves and not visible to staff in the rooms.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 6. Sleeping and Napping Requirements.

General: Based on observation, two (2) cribs in the Infant Room were spaced end-to-end and approximately three inches (3") apart rather than twelve inches (12") as required.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 2. Child Care Services.

General: Based on interview, it was learned that a preschool age child was in the restroom stall using the toilet while another preschool age child was washing his hands at the sink. The staff person left the restroom doorway to walk down the hallway approximately ten (10) feet to check on five (5) other children. When the staff person returned to the restroom three to four (3-4) minutes later, the child who was washing his hands had entered the restroom stall and stuck his finger in the other child's butt. Staffing Requirements

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110. Reports.

General: Based on interview, it was learned that staff had concerns about a preschool age child's behavior within the past few months, and did not report to DCBS or law enforcement as required. The behavior included the following: on one (1) occassion, the child placed his penis on the rim of the toilet and hit his penis with the toilet lid; on another occasion staff found the child drinking from the toilet after he had urinated in it; within the past three (3) weeks, the child was found licking the rim of the toilet. Staff stated that the child beats his head on the floor or wall and then cries because he had hurt himself. Director Requirements

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110. Section 4. Director Requirements and Responsibilities.

General: Based on interview, it was learned that within the past three (3) weeks, a staff person has placed a preschool child between her legs and wrapped her arms around him to restrain him.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 6. License Issuance.

General: Based on review of documentation, the child care center failed to provide documentation for submitting a timely criminal records check for one (1) employee (DOH: 5-19-12), pursuant to KRS 199.896(19).

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110. Section 5. Staff Requirements.

General: Based on review of documentation, the child care center failed to maintain a current statement from a health professional for one (1) volunteer (DOH:10-13-10) stating that the individual is free of active tuberculosis or a copy of negative tuberculin results.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120 - Section 3

Infant Room: Based on observation, there were two (2) blankets folded in the crib beside a sleeping child.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110 - Section 4 (1)

Four-Year-Old Room: Based on observation, there was a toilet plunger in the floor of the boys' bathroom shared by both the Four-Year-Old and School Age Rooms. Three-Year-Old Room #2: Based on observation, a toilet plunger was located in the floor beside the toilet in the bathroom that is shared by both Three-Year-Old Rooms. Two-Year-Old Room #1: Based on observation, there were a broom and dust pan in the bathroom shared by both Two-Year-Old Rooms accessible to the children. 191 - Inaccessible Items 922 KAR 2:120 - Section 3 (7) The following shall be inaccessible to a child in care: (a) Toxic cleaning supplies, poisons, and insecticides; (b) Knives and sharp objects; (c) Matches, cigarettes, lighters, and flammable liquids; (d) Plastic bags; (e) Litter and rubbish; (f) Bar soap; and (g) Personal belongings of staff. 1) Toxic cleaning supplies, poisons, and insecticides In Compliance 2) Knives and sharp objects In Compliance 3) Matches, cigarettes, lighters, and flammable liquids In Compliance 4) Plastic bags In Compliance 5) Litter and rubbish In Compliance 6) Bar soap In Compliance 7) Personal belongings of staff In Compliance An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 11 of 40 Web site: http://chfs.ky.gov/ Inspection Report 197 - Premises Requirements 922 KAR 2:120 - Section 4 Premises Requirements. (1) The premises shall be: (a) Suitable for the purpose intended; (b) Kept clean and in good repair; and (c) Equipped with a land-line telephone accessible to a room used by a child. 1) Suitable In Compliance 2) Clean In Compliance 3) Good repair In Compliance 4) Land-line phone accessible In Compliance 200 - Building Requirements 922 KAR 2:120 - Section 4 (4) The building shall be constructed to ensure the: (a) Building is: 1. Dry; 2. Adequately heated; 3. Ventilated; and 4. Well lit, including clean light fixtures: a. That are in good repair in all areas; and b. Shielded or have shattered proof bulbs installed; and 1) Dry In Compliance 2) Adequately heated In Compliance 3) Adequately ventilated In Compliance 4) Well Lit In Compliance 5) Clean Light Fixtures In Compliance 6) Lights good repair In Compliance 7) Shielded/shatter proof bulbs In Compliance 201 - Protected Items 922 KAR 2:120 - Section 4 (4) (b) Following are protected: 1. Windows; 2. Doors; 3. Stoves; 4. Heaters; 5. Furnaces; 6. Pipes; and 7. Stairs. 1) Windows In Compliance 2) Doors In Compliance 3) Stoves In Compliance 4) Heaters In Compliance 5) Furnaces In Compliance 6) Pipes In Compliance 7) Stairs In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.