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

General: Based on review of documentation, the surveyor found the following: 1. The child care center failed to document the monthly required fire drills for December 2024 through August 2025. 2. The child care center failed to document the quarterly required tornado drills for the first and second quarter of 2025. 3. The child care center failed to document the quarterly required earthquake drills for first and second quarter of 2025. 4. The child care center failed to document the quarterly required lockdown drills for first and second quarter of 2025. Therefore, the surveyor determined that the child care center failed to maintain written record of the monthly and quarterly required drills.

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 15. Statement of Deficiency and Corrective Action Plans.

A PLAN OF CORRECTION WAS DUE ON 10/10/2025 AND AS OF 11/13/2025, THE PLAN OF CORRECTION HAS NOT BEEN RECEIVED.

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 review of documentation, the surveyor was unable to locate documentation verifying that the child care center conducted recurring staff meetings within the past year, neither was documentation presented to the surveyor for staff meetings. Therefore, the child care center failed to maintain written records demonstrating compliance with the requirement to conduct, manage and document recurring staff meetings.

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, the surveyor found that one (1) child's (DOE: 07/01/25) file contained an immunization certificate that was no longer current as of 07/17/25.

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, the surveyor found that a child's (DOE: 08/01/25) file did not contain the contact telephone number for the child's preferred hospital and preferred family physician.

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 surveyor found the following: 1. The child care center failed to document the monthly required fire drills for December 2024 through August 2025. 2. The child care center failed to document the quarterly required tornado drills for the first and second quarter of 2025. 3. The child care center failed to document the quarterly required earthquake drills for first and second quarter of 2025. 4. The child care center failed to document the quarterly required lockdown drills for first and second quarter of 2025. Therefore, the surveyor was unable to determine if the following monthly and quarterly drills were conducted. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 31 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 4. Premises Requirements.

General: Based on observation, while performing the initial walk-through to obtain the classroom headcount, the surveyor entered the Nursery to find that the classroom was dark and not well lit. Staff reported that there were six (6) children napping in the Nursery. Although there was a small light source located in the back right corner of the room, the surveyor was unable to see the staff member and children until she turned on a flashlight. Therefore, the classroom was not well lit. During interview with staff in charge, she stated that she would place another light source in the classroom for naptime.

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 observation and interview, a staff’s (DOH: 04/10/25) file did not contain documentation of background checks submitted through KARES. During a review of the KARES report, the surveyor found that the staff member appeared under the child-care-centers separated employees; therefore, the staff member was hired prior to clearance for employment. The surveyor observed the staff person to be working alone in the Nursery at the child-care-center during the surveyor's visit on 04/24/25. During interview with staff-in-charge, the surveyor learned that the staff member was a previous employee and the staff-in-charge was unaware that the staff member was no longer under the child-care-centers list of current employees in KARES. Supervision 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 interview, staff-in-charge she stated that due to recent flooding, the staff had been replacing, updating, and painting damages sustained from the flood. Upon entering to the child-care-center, the surveyor could smell a strong odor of fresh paint throughout the center. Therefore, the health, safety and comfort of the children was compromised. Director Requirements Not 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 and interview, the surveyor found that a staff (DOH:04/10/2025) was listed as separated with a determination status of closed-fingerprints not taken on the child-care-center's KARES report. Upon further review of the staff person's individual KARES report, the surveyor found that the staff person's application has been closed on 12/23/23 due to an incomplete application. Through interview with staff, the surveyor was able to determine that the staff member had been employed at the child-care-center since 04/10/25. The staff member provided a written statement to the surveyor outlining her employment details. Through the interview and written statement, the staff member confirmed that she had provided care alone and maintained active supervisory/disciplinary control of the children enrolled during all her shifts at the child-care-center. Through interview with staff-in-charge, she stated that she was unaware that the staff member was not listed as a current employee on the child-care-center's KARES report. The surveyor observed the staff person to be working alone in the Nursery at the child-care-center during the surveyor's visit on 04/24/25. Therefore, the child-care-center failed to ensure that a caregiver was not left alone without having completed background checks.

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 observation, the surveyor was greeted and permitted into the child-care center by an adult individual. After the surveyor introduced herself to the individual, the individual informed the surveyor that she did not work at the child-care center. Based on review of the child care center's KARES report, the individual was not listed as a staff person and did not have a completed background check. During interview with the individual, the surveyor learned that the individual was at the child-care center for a job interview. The surveyor observed the individual walk into the School Age Classroom and sit down at a table where three (3) children were present at the table. There was a total of nine (9) children present in the classroom with one (1) staff member supervising the children. The surveyor observed the adult individual present in the School Age Classroom from 12:01 pm-12:12 pm. At 12:12 pm, the surveyor observed the individual to leave the School Age Classroom, without wearing shoes, and she walked into the Preschool Classroom where seven (7) children were present with one (1) staff person. The individual retrieved her shoes from a cubby located in the Preschool Classroom. The surveyor did not observe the individual to supervise or interact with any of the children within the child care center and did not witness the individual to be left alone with any children. However, the individual was permitted to be in the presence of children inside two (2) separate classroom while at the child care center and without have completed background checks. The surveyor over heard the individual saying that her ride would be at the child-care center soon. The surveyor did not witness the individual leave the child-care center; however, when the surveyor left the child-care center at 12:53 pm, the individual was no longer seen at the center. Staff-in-charge reported that the adult individual worked at the child-care center previously and was at the childcare center for a job interview. Staff-in-charge stated that the individual had been in the child-care center for approximately twenty (20) minutes but she had not been left alone with any of the children. The surveyor did not witness the individual alone with any child. Supervision In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 15. Statement of Deficiency and Corrective Action Plans.

A PLAN OF CORRECTION WAS DUE ON 02/14/2025 AND AS OF 03/18/2025, THE PLAN OF CORRECTION HAS NOT BEEN RECEIVED.

Open Not marked corrected in the state record

Open / not marked corrected.

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

Based on observation and interview with staff in the classroom, the surveyor learned the following: School Age Classroom: There were nine (9) children, ages five to eight (5-8) years old, being cared for in the classroom. Based on review of the diagram that DRCC has on file, the School Age Classroom has a measured capacity for six (6) children; therefore, the classroom was over room capacity by three (3) children. School Age Activity Classroom: There were six (6) children, ages seven to twelve (7-12) years old, being cared for in the classroom. Based on review of the diagram that DRCC's has on file, the School Age Activity Classroom has a measured capacity for five (5) children; therefore, the classroom was over room capacity by one (1) child.

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 sink located in the Ones/Twos Classroom did not contain hot or cold water; therefore, the surveyor was unable to determine if the hot water was a minimum temperature of ninety (90) degrees Fahrenheit and a maximum of 120 degrees Fahrenheit.

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 a trash can with no lid in the boys' restroom that contained exposed toilet paper that had fecal matter; therefore, the restroom was not kept clean and disinfected.

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 the following: 1. Based on review of ECE-TRIS, one (1) staff person (DOH: 08/30/24) completed one and one-half (1 ½) hours of cabinet-approved pediatric abusive head trauma training on 05/16/18; therefore, the training was not completed within the last five years. 2. Based on review of ECE-TRIS, one (1) staff person (DOH: 05/02/18) completed zero (0) hours of the required fifteen (15) hours of cabinet-approved early care and education training completed between 07/01/23 - 06/30/24. 3. Based on review of ECE-TRIS, one (1) staff person (DOH: 05/02/18) completed one and one-half (1.5) hours of the required fifteen (15) hours of cabinet-approved early care and education training completed between 07/01/23 - 06/30/24. 4. Based on review of ECE-TRIS, one (1) staff person (DOH: 08/12/24) completed zero (0) hours of the required fifteen (15) hours of cabinet-approved early care and education training completed between 02/06/24 - 06/30/24. The surveyor reviewed ECE-TRIS and found that the staff person had a first year start date of 02/06/23. 5. Based on review of ECE-TRIS, one (1) staff person (DOH: 08/30/24) completed zero (0) hours of the required fifteen (15) hours of cabinet-approved early care and education training completed between 07/01/23 - 06/30/24. The surveyor reviewed ECE-TRIS and found that the staff person had a first year start date of 11/06/2007. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 4 Inspection Report 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 an unlocked cabinet in the Preschool 1 Classroom that contained a bottle of bleach and a bottle of multi surface cleaner/peroxide. The surveyor observed both bottles to have labels that read, "Keep Out of Reach of Children." During interview with staff-in-charge, she stated that the classroom had not been used on the day that the surveyor had been visiting. The surveyor did not observe children to be present in the classroom on the day of visit.

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. There were chips on the floor in the Preschool 1 Classroom; therefore, the floor was not kept clean. During interview with staff-in-charge, she stated that the chips must have been left on the floor from snack the previous day. 2. There was a screw protruding out of the wall between the entrance of the Preschool 1 Classroom and the girls' restroom; therefore, the wall was not kept in good repair. During interview with staff-in-charge, she stated that a baby gate used to be attached to the wall and the gate had been removed recently.

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 seat moved easily and was not tightly secured to the toilet located in the boys' restroom. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 4 Inspection Report 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 a trash can with no lid in the girls' restroom that contained dirty diapers; therefore, the dirty diapers were not kept in a covered container.

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. The diaper changing pad located in the Preschool 2 Classroom contained a rip; therefore, the diaper changing surface was not free of holes, rips, tears, or other damage. 2. The diaper changing pad located in the Nursery contained a rip; therefore, the diaper changing surface was not free of holes, rips, tears, or other damage. 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 changing table that was between the Preschool 2 Classroom and the Cafeteria area that contained a bottle of Calmosptime Ointment and a tub of Butt Paste on the bottom shelf of the changing table area. Both items had labels that read, "Keep Out of Reach of Children." Both items were observed to be within reach of children; therefore, the child-care center failed to keep the diaper cream out of reach of children. 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 An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 4 Inspection Report Children's Records 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, the surveyor found the following: 1. A child's (DOE: 04/25/23) file did not contain the name or contact telephone numbers for the child’s preferred hospital and family physician or authorization by the parent for the child-care center to seek emergency medical care for the child in the parent’s absence. 2. A child’s (DOE: 08/30/24) file did not contain the contact telephone number for the child’s preferred hospital. 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 2:090 · 922 KAR 2:090. Section 15. Statement of Deficiency and Corrective Action Plans.

A PLAN OF CORRECTION WAS DUE ON 11/28/2024 AND AS OF 02/17/2025, THE PLAN OF CORRECTION HAS NOT BEEN RECEIVED. 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 interview with staff members, the surveyor learned that a parent and child discovered a knife with an approximately four (4) inch blade on the small playground the morning of 06/07/2024. No children had been on the playground that morning and the staff believe that the knife belonged to a mulch worker who was spreading mulch on the playground the previous day. Staff-in-charge reported that she would walk the playgrounds of the mornings.

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 interview with staff-in-charge, the surveyor requested the monitoring records related the Directed Plan of Correction (DPOC). The staff-in-charge called the director to ask where the monitoring records were located. The staff-in-charge handed the surveyor monitoring records for the following days 05/24/2024, 05/28/2024, and 05/29/2024. When interviewing the director via telephone, the director reported that she turned in the DPOC for the second monitoring visit on 05/24/2024 and did not understand that she was supposed to document what she monitored when walking through the child-care center; therefore, she started documenting on 05/24/2024. The surveyor read the Directed Plan of Correction: Section 4C: To assure ongoing compliance, the licensee, director, or staff-in-charge will monitor (and document) all areas where children are being cared for, multiple times throughout the day, each day, to assure that all children are being cared for and assure the health, safety, and comfort of each child in the center’s care. The director responded that she does not believe she received the Directed Plan of Correction and asked when she would have received the documentation. The director also reported that Child Care Aware has been helping her every two (2) weeks.

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

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

General: Based on interview with staff-in-charge, the surveyor discovered that the personnel file of one (1) staff (DOH: 03/15/24 First Year Hire Date: 10/19/23) did not contain documentation of education in the form of a high school diploma, GED, or Commonwealth Child Care Credential. Staff-in-charge stated that she had the documentation somewhere; however, the document was not presented during the surveyor's visit. Hygienic Practices In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Equipment Not In Compliance

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 surveyor discovered the following in the 1’s/2’s Classroom: 1. The distance between two (2) cribs was approximately nine and one half (9 1/2) inches apart. 2. The distance between two (2) cribs was approximately ten (10) inches apart. Therefore, the provider failed to ensure that the cribs were spaced twelve (12) inches apart to allow free and safe movement by a person. This deficiency was cited during a Renewal Inspection (#336243) conducted on 09/28/23. The provider’s plan of correction stated, “The director measured the cribs in the nursery to ensure that there was at least 12 inches between each crib.” The provider’s ongoing compliance stated, “The director and the nursery staff will ensure that the cribs remain at least 12 inches apart at all times by measuring the length in between daily.” Kitchen Requirements In Compliance Children's 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 9. Records.

General: Based on interview and review of documentation, the surveyor discovered the following: 1. Staff-in-charge stated that she did not have an immunization certificate for a child (DOE: Unknown). Staff-in-charge stated that she was having trouble getting the immunization exemption documentation for the child. 2. The file presented to the surveyor for a child (DOE: 02/27/24) did not contain an immunization certificate. A document had been placed in the file that listed some vaccinations; however, it did not indicate if the child was up to date on his immunizations. Therefore, the child-care center failed to maintain current immunization certificates for the children.

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 interview and review of documentation, the surveyor discovered the following: 1. The enrollment packet for a child (DOE: 03/27/24) did not contain the name or telephone number for the preferred hospital. 2. Upon request by the surveyor, no enrollment packet for a child (DOE: Unknown) was provided for review. Staff-in-charge stated that she could not find the child’s file. Therefore, the child-care center failed to maintain children's records.

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 observation and interview while performing the initial walk-through to obtain the classroom headcount, the surveyor discovered the following: 1. There were seven (7) children napping unsupervised in the 1’s/2’s Classroom; there was no staff present in the classroom. Therefore, the child-care center failed to provide adequate supervision, ensuring the children were within scope of vision and range of voice. After obtaining the headcount for the classroom, the surveyor discovered a staff member standing in the area outside of the 1’s/2’s Classroom, near the restrooms. The surveyor questioned the staff member who the teacher was for the 1’s/2’s Classroom, and the staff member indicated that she was the teacher for that classroom. When the surveyor arrived at the child-care center, the surveyor observed that same staff member pulled into the parking lot and exited the vehicle. After the staff member indicated that she was the teacher for the classroom, the surveyor questioned the staff member where she had been when the surveyor observed her pull into the parking lot. The staff member informed the surveyor that she had been at lunch. The staff member stated that she had been gone to lunch for “about thirty (30) minutes.” Staff stated that the seven (7) unattended children were all two (2) years old. 2. There were eight (8) children napping in the Preschool 2 Classroom. When the surveyor was performing the headcount in the Preschool 2 Classroom, the staff person that was standing outside of the 1’s/2’s Classroom was now present in the doorway of the Preschool 2 Classroom; she stated that she was now watching both classrooms of children. The distance between the two (2) classrooms was approximately eight (8) feet. The staff person could not visibly see the sleeping children in the 1’s/2’s Classroom due to the distance between the classrooms and the tall cubby shelving. Therefore, the child-care center failed to provide adequate supervision for all children, ensuring the children were within scope of vision and range of voice. Interview with staff revealed that the children ranged in age from two (2) years-old to five (5) years-old. The surveyor questioned the 1’s/2’s Classroom staff member who the teacher was for the Preschool 2 Classroom, and the staff member gave the name of the staff person who was responsible for supervising the children. The surveyor asked where that staff member was, and the 1’s /2’s Classroom staff stated that she thought the staff member had gone to lunch after she had returned from her lunch. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report Staffing Requirements Not In Compliance

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

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

General: Based on observation and interview while performing the initial walk-through to obtain the classroom headcount, the surveyor learned the following: One (1) staff person stated that she was supervising two (2) classrooms (1’s/2’s Classroom and Preschool 2 Classroom) of children. There were seven (7) children present in the 1’s/2’s Classroom. Staff stated the seven (7) children were all two (2) years old. There were eight (8) children present in the Preschool 2 Classroom. Staff stated that the eight (8) children were four- and five-year-old children. The staff member stated that she was responsible for supervising the fifteen (15) children in the classrooms; therefore, the staff-to-child ratio was exceeded by five (5) children. General Administration Not In Compliance

Open Not marked corrected in the state record

Category: ratio. Open / not marked corrected.

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

General: Based on observation and interview, the surveyor discovered the following: During the initial walk-through to obtain a headcount in the Nursery, the surveyor discovered one (1) child was sleeping in an infant bouncer seat. Staff stated that the child was fifteen (15) months old. According to the United States Consumer Product Safety Commission, the infant bouncer seat was intended for infants who have not developed the ability to sit up unassisted (approximately 0 to 6 months of age); therefore, the health, safety, and comfort of the child was compromised. The surveyor requested to review the child’s file; however, staff was unable to locate a file for the child. The surveyor questioned both staff members that were working in the Nursery if the child had documentation from a physician indicating that the child needed alternative sleeping accommodations and the staff indicated that they were not aware of any type of documentation. Director Requirements Not 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.

During initial interview with the director, the surveyor requested the monitoring records related the Directed Plan of Correction (DPOC). The director indicated that she had records; however, the director left prior to the conclusion of the surveyor’s visit and did not provide the documentation for review. The staff member who was left in charge after the director left indicated that she did not know where the documentation would be located. Therefore, the surveyor could not determine if the child-care center was monitoring the issues addressed in the DPOC to assure ongoing compliance. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3 Inspection Report Programming Not In Compliance

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

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

General: Based on observation, the surveyor discovered a child sleeping in an infant swing. A staff member stated that the child had been asleep for approximately one and one-half (1 1/2) hours. Upon review of the child’s file, the surveyor discovered that the child was nine (9) months old. The surveyor was unable to locate documentation in the child's file from a health professional indicating that the child required an alternate sleeping position. The surveyor questioned the two (2) staff that were observed working in the Nursery if they were aware of documentation indicating that the child required an alternate sleeping position; both staff denied being aware of any documentation.

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 during the initial walk-through of the Nursery to obtain a headcount, the surveyor discovered a loose blanket was placed over a child that was sleeping in a crib. Interview with the staff member revealed that the child had been in the crib for approximately one and one-half (1 1/2) hours. Review of the child’s file revealed that the infant was eight (8) months of age. 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 4. Premises Requirements.

General: Based on observation during the walk through to obtain a headcount, there were ten (10) children present in the School Age Classroom. Based on the child care center’s diagram from DRCC records, the classroom has a measured capacity for six (6) children. Therefore, the classroom capacity was exceeded by four (4) children and the child-care center failed to maintain thirty-five (35) square feet of space per child as required. Staff stated that normally the children would be split between the School Age Classroom and the School Age Activity Classroom to maintain the thirty-five (35) square feet of space per child.

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 surveyor discovered that the child care center’s liability insurance was no longer current after of 04/12/23.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 15. Statement of Deficiency and Corrective Action Plans.

A PLAN OF CORRECTION WAS DUE ON 12/27/2023 AND AS OF 01/23/2024, THE PLAN OF CORRECTION HAS NOT BEEN RECEIVED. Findings: A PLAN OF CORRECTION WAS DUE ON 02/06/2024 AND AS OF 02/07/2024, THE PLAN OF CORRECTION HAS NOT BEEN RECEIVED. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 5 Inspection Report

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 witnessed a staff member in the 1’s & 2’s room, change a child’s diaper and fail to wash her hands after changing the diaper; therefore, the staff failed to clean her hands with liquid soap and running water as required. First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment 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 13. Reports.

General: Based on observation, the surveyor discovered that the barriers used to create the classroom areas had been moved/removed resulting in the classroom sizes/spaces changing which reduced the overall capacity of the child-care center; therefore, the provider failed to report changes at the child-care center resulting in the reduction of the square footage of the child-care center’s premises. The surveyor updated the diagram and remeasured the rooms, to reflect the current space, which resulted in the capacity decreasing to fifty-seven (57). A staff member confirmed that the layout notated on the diagram no longer matched how the child-care center was set-up and the space being utilized on the date of the surveyor’s visit. The staff member was unsure how long the changes had been in effect.

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 noted that two (2) cribs were being used in the 1's/2's Room for the barrier wall for the classroom. The surveyor noted that the area under the cribs were large enough for children to crawl through and exit the room; therefore, the health, safety and comfort of the children were compromised. 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, with the staff-in-charge, the surveyor discovered that the personnel files for two (2) staff (DOH: 08/01/23 & 06/08/23) did not contain documentation of education in the form of a high school diploma, GED, or Commonwealth Child Care Credential.

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 discovered that the personnel file for two (2) staff members (DOH: 07/21/20 & 08/01/23) did not contain a negative tuberculin result; therefore, the child-care center failed to show proof that the employee was free of active tuberculosis or provide a copy of a negative tuberculin result. 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

Open / not marked corrected.

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

General: Based on observation, the surveyor discovered the following: 1. The ECE-TRIS Individual Training Record report for one (1) staff (DOH: 05/02/18) member did not have a date entered indicating that the staff member completed one and one- half (1 ½) hours of cabinet-approved pediatric abusive head trauma training (PAHT). The surveyor was unable to locate a PAHT certificate of completion while reviewing the staff member’s personnel file; therefore, the surveyor was unable to determine if the staff person completed the PAHT training every five years as required. 2. The ECE-TRIS Individual Training Record and the ECE-TRIS Required Training Hours Report for the timeframe of 07/01/22 thru 06/30/23, indicated that one (1) staff (DOH: 05/02/18) member had completed nine (9) hours of the fifteen (15) required hours of cabinet-approved early care and education training. 3. The ECE-TRIS Individual Training Record and the ECE-TRIS Required Training Hours Report for the timeframe of 07/01/22 thru 06/30/23, indicated that one (1) staff (DOH: 06/27/22 member; first year hire date 06/18/18) failed to complete any of the fifteen (15) required hours of cabinet-approved early care and education training. Therefore, the child-care center failed to ensure that training was completed as required. 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 4. Premises Requirements.

General: Based on observation, the surveyor discovered the following: School Age Classroom 1. Dirt/Debris on the gray rug. 2. Dirt/Debris on the alphabet rug. Therefore, the premises was not kept clean. Hygienic Practices 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 3. General Requirements.

General: Based on observation, the surveyor discovered the following: 1’s & 2’s Room 1. A staff member changed a child’s diaper and failed to wash the child’s hands after changing the diaper. Preschool Room 1. A staff member changed a child’s diaper and failed to wash the child’s hands after changing the diaper. Therefore, the staff members failed to clean the children’s hands with liquid soap and warm water as required. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 5 Inspection Report

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 surveyor discovered that two (2) cribs, located in the Nursery, were spaced at approximately seven (7) inches apart; therefore, the cribs were not spaced twelve (12) inches apart to allow free and safe movement by a person. Transportation Not Applicable 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 observed the following: 1. Dirt and debris in the refrigerator, in front of the bottom refrigerator drawers. 2. An unknown liquid substance on the refrigerator door shelf. Therefore, the kitchen area was not clean and sanitary. Food Service In Compliance Meal Planning/Center Provides Meals In Compliance Meal Planning/Center Does Not Provide Meals In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 4 of 5 Inspection Report 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 discovered that the file presented for review for a child (DOE: 04/19/23) did not contain the name or telephone number for the preferred hospital; therefore, the child-care center failed to maintain children's records. 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 5. Evacuation Plan.

General: Based on review of documentation, the surveyor discovered that the Emergency Preparedness Plan was not dated; therefore, the surveyor was unable to verify that the plan had been reviewed or revised within the past year. During interview with staff, staff could not confirm that the Emergency Preparedness Plan had been reviewed or submitted to the local emergency management by December 31st.

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 review of documentation, the surveyor discovered the following: 1. The personnel file for one (1) staff (DOH: 05/02/18) contained a written annual professional development plan that was not dated. 2. The personnel file one (1) staff (DOH: 05/02/18 ) did not contain a written annual professional development. Therefore, the surveyor was unable to determine if annual professional development plans were completed as required. 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 documentation, the surveyor found that a staff member (DOH: 08/14/23) was listed as "separated" on the child-care center’s KARES report. The staff member was previously eligible for hire with an eligibility date of 06/05/19. During interview, staff reported that the staff member worked at the child-care center on 08/14/23 due to staff calling in for sickness, and the staff member potentially worked on additional day(s), when needed. During interview with staff, the surveyor learned that the staff member worked at the child-care center a couple of years prior and had submitted to fingerprints at that time. Through interview with staff, the surveyor learned that on 08/14/23, the staff member worked inside the School Age Classroom with children with another staff member present; however, the other staff member left the classroom to go into the kitchen to fix lunch for the children. The other staff member was back and forth between the School Age Classroom and kitchen, leaving staff (DOH: 08/14/23) alone with children for an undetermined amount of time. The surveyor observed the kitchen to be located next door to the School Age Classroom. Supervision Not In Compliance

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, the surveyor learned that a three-year-old child was left unsupervised on the playground for an undetermined amount of time, approximately one (1) minute, up to five (5) minutes. On or about 06/19/23, one (1) staff member was caring for ten (10) children on the small playground. The children were from the Preschool Classroom. During interview, the surveyor learned that the staff member took the children inside the child care center at approximately 3:00 p.m. The staff member reported that she thought she had taken all of the children from the Preschool Classroom inside the building with her; however, a three-year-old child was found outside near a set of picnic tables on the big playground. The child was found by a parent. The parent took the child inside the child-care center. Through interview, the surveyor learned that the three-year-old child was crying "really bad" but had no injuries. Staff reported that it was the staff member's first day working and it was the three-year-old child's first day at the child-care center. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 4 Inspection Report General Administration Not In Compliance

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 13. Reports.

General: Based on interview with staff members, the surveyor found that an incident involving neglect of a three-year-old child was not reported to DRCC by the child-care center within twenty-four (24) hours from time of discovery. On or about 06/19/23, a three-year-old child was left unsupervised by a qualified staff member. The child was left unsupervised on the playground for an undetermined amount of time, approximately one (1) minute, up to five (5) minutes. During interview, staff-in-charge stated that by the time she asked her Child Care Aware Coach if she needed to report the incident to DRCC, it was too late.

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 interview, the surveyor found that on or about 06/19/23, a three-year-old child was left alone and unsupervised on the playground for an undetermined amount of time, approximately one (1) minute, up to five (5) minutes. It was reported that when the three-year-old child was found, she was crying “really bad.” Therefore, the health, safety, and comfort of the child was compromised. Director Requirements Not 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 review of documentation, the surveyor found that a staff member (DOH: 08/14/23) was listed as "separated" on the child-care center’s KARES report. The staff member was previously eligible for hire with an eligibility date of 06/05/19. During interview with staff, the surveyor learned that the staff member worked at the child-care center a couple of years prior and had submitted to fingerprints at that time. Through interview with staff, the surveyor learned that on 08/14/23, the staff member worked inside the School Age Classroom with children with another staff member present; however, the other staff member left the classroom to go into the kitchen to fix lunch for the children. The other staff member was back and forth between the School Age Classroom and kitchen; therefore, staff (DOH: 08/14/23) worked alone with children for an undetermined amount of time. 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 9. Records.

General: Based on interview with staff-in-charge, the surveyor was informed that a staff member (DOH: 08/14/23) had a personnel file; however, staff-in-charge stated that she was unable to locate the file on the day of the surveyor's visit. Therefore, the child-care center failed to maintain a current personnel file for the staff member to include the staff person’s address, proof of educational qualifications, compliance with tuberculosis screening, and results of background checks conducted. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 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, the surveyor was not presented with a personnel file for one (1) staff member (DOH: 08/14/23). Therefore, the surveyor was unable to determine that the staff member had educational documentation. Staff-in-charge stated that the staff member had a personnel file; however, she was unable to locate the file on the day of the surveyor’s visit.

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 three (3) staff members (DOH: 08/14/23, 08/14/23, and 06/15/23) did not have documentation of negative tuberculin results or a statement from a health professional stating that the individuals were free from active tuberculosis. During interview, staff-in-charge stated that the staff members had TB skin tests; however, she was unable to locate the documentation. One (1) of the staff (DOH: 08/14/23) mentioned did not have a personnel file located at the child care center for the surveyor to review.

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 documentation, the surveyor found that a staff member’s (DOH: 06/01/23) file did not contain documentation of a background check submitted through the Kentucky Applicant Registry and Employment System (KARES). The staff members file contained documentation from IdentoGO that stated, “Status as of 09/30/2022. Enrollment Received. Your enrollment has been received and is being process.” The document contained a UE ID and payment amount. The document did not contain a staff members name. Based on review of KARES, the surveyor found that the staff member was not listed as a current employee on the KARES report for the child-care center. Based on review of the Applicant History Report on KARES, the surveyor was unable to locate a background for the staff member using the staff members name and date of birth. Based on review of video footage provided by the child-care center, the surveyor observed the staff member working alone with children on the playground on 07/10/23. Supervision In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 4 Inspection Report Staffing 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 2. Child Care Services.

General: Based on review of video footage provided by the child-care center for the date of 07/10/23, the surveyor found the following: 1. The surveyor observed two (2) staff members on the playground with twelve (12) children at 3:46 p.m. The surveyor observed one (1) staff member to leave the playground through the gate at 3:46 p.m. leaving one (1) staff member on the playground with the twelve (12) children. Staff reported that the children ranged in age from one (1) to three (3) years of age; therefore, the staff-to-child ratio was exceeded by six (6) children. The surveyor observed the other staff member to return to the playground at 3:55 p.m. Through interview with staff, the surveyor learned that the staff member took a ten (10) minute break. 2. The surveyor observed two (2) staff members on the playground at 10:43 a.m. The surveyor observed one (1) staff member to go inside the child-care center building with who appeared to be a parent at 10:44 a.m. Through interview with staff, the surveyor learned that the one (1) staff member left on the playground was supervising fourteen (14) to twenty (20) children ranging in age from two (2) to five (5) years of age. Staff reported that another staff member who was supposed to be on the playground had taken a ten (10) minute break. Through interview with staff, the surveyor learned that a staff member did not come to the playground to assist with caring for children while the other staff member was on break. The surveyor observed the staff member return from break at 10:48 a.m. Staff reported that the staff and children went to the playground at approximately 10:30 a.m. Based on review of video footage, the surveyor observed sixteen (16) children on the playground with one (1) staff member; therefore, the staff-to-child ratio was exceeded by six (6) children. The surveyor observed one (1) staff member to line the children up at the door at 11:28 a.m. and observed fifteen (15) children at this time due to one (1) child leaving. Staff- in-charge reported the two (2) staff members were taking the children inside to change diapers. Staff-in-charge stated the other staff member on the playground went inside while the staff member on the playground lined the children up at the door and was standing at the diaper changing table to get ready to change diapers as the children came inside. 3. Through interview with staff, the surveyor learned that staff have witnessed one (1) staff member providing care for twelve (12) to twenty (20) children ranging in age from three (3) to five (5) years of age and one (1) staff member providing care for sixteen (16) to seventeen (17) children ranging in age from two (2) to five (5) years of age in the Preschool Classroom. General Administration Not In Compliance

Open Not marked corrected in the state record

Category: ratio. Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 15. Statement of Deficiency and Corrective Action Plans.

A PLAN OF CORRECTION WAS DUE ON 12/27/2023 AND AS OF 01/23/2024, THE PLAN OF CORRECTION HAS NOT BEEN RECEIVED. Findings: A PLAN OF CORRECTION WAS DUE ON 02/06/2024 AND AS OF 02/07/2024, THE PLAN OF CORRECTION HAS NOT BEEN RECEIVED. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 4 Inspection Report Director Requirements Not 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 review of documentation, the surveyor found that a staff member’s (DOH: 06/01/23) file did not contain documentation of a background check submitted through the Kentucky Applicant Registry and Employment System (KARES). The staff members file contained documentation from IdentoGO that stated, “Status as of 09/30/2022. Enrollment Received. Your enrollment has been received and is being process.” The document contained a UE ID and payment amount. The document did not contain a staff members name. Based on review of KARES, the surveyor found that the staff member was not listed a current employee on the KARES report for the child-care center. Based on review of the Applicant History Report on KARES, the surveyor was unable to locate a background for the staff member using the staff members name and date of birth. Based on review of video footage provided by the child-care center, the surveyor observed the staff member working alone with children on the playground on 07/10/23. Programming Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 5. Infant and Toddler Play Requirements.

General: Based on review of video footage provided by the child-care center for the date of 07/10/23, the surveyor observed twelve (12) children on the playground. Through interview with staff, the surveyor learned that the children ranged in age from one (1) to three (3) years old. Staff reported that one (1) of the children was a one-year-old child and had a transition plan; however, the plan was not signed by the parent. Staff-in-charge stated that the one-year-old child’s parent wanted the child to be moved to the Toddler Classroom.

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. Two (2) bottles of Germ-X and one (1) bottle of Clean N Fresh Instant Hand Sanitizer Antibacterial labeled "Keep Out of the Reach of Children" were placed on a shelf in the School Age Classroom located beside the kitchen. 2. A white mini refrigerator placed on a chrome wire shelf did not appear to be secured. The wire shelf appeared to be unsteady when pushed on. The Director stated that the wire shelf used to be bolted to the wall and she had moved the shelf out recently. 3. There was one (1) missing electrical outlet cover on an outlet located beside a bulletin board in the Preschool Classroom. 4. An uncovered white trash can located near a table with green chairs in the Preschool Classroom contained rubbish. 5. A bottle of Antibacterial Liquid Hand Wash Soap labeled "Keep Out of the Reach of Children Except Under Adult Supervision" was placed on the sink in the Two Year Old Classroom. 6. What appeared to be one (1) loose red and one (1) blue water line were located beside the sink in the Two Year Old Classroom. The lines were observed to be accessible to the children. 7. The surveyor observed children utilizing a large inflatable located on the playground. Through interview with staff, the surveyor learned that the children ranged in age from two to five years old. The Director stated that she did not obtain written parental consent for the children to use the inflatable. 8. The surveyor observed a slip and slide placed on the ground on the side playground. The surveyor observed children on the side playground; however, the surveyor did not observe children to utilize the slip and slide during the visit on 06/27/22. During interview, the Director stated that she had not obtained written parental consent for the children to use the slip and slide. 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 the files for the following staff (DOH: 03/14/22 and 06/27/22) 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 persons mentioned did not have an up-to-date TB skin test.

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: 07/21/20) obtained six (6) hours of cabinet-approved orientation training on 04/28/21; therefore, the training was not completed within the first three (3) months of employment. 2. A staff (DOH: 05/02/18) obtained zero (0) hours of the required fifteen (15) hours of cabinet-approved early care and education training for the review period 07/01/20 – 06/30/21. 3. A staff's (DOH: 03/14/22) file did not contain documentation of six (6) hours of cabinet-approved orientation training. Based on review of ECE-TRIS, the staff person had not completed six (6) hours of cabinet-approved orientation training; therefore, the training was not completed within the first three (3) months of employment. Programming In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 8 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, the surveyor found a purple bag that resembled a Bogg Bag that was open and appeared to contain a medicine bottle. This purple bag was placed on the bottom of a brown shelf located in an entry way beside the Office. The bottle appeared to be orange with a white lid. The surveyor observed an opening with no door leading from the entry way into the School Age Classroom. During interview, the Director stated that the bag belonged to a staff person and it was unknown if the bottle was a medicine bottle and what the bottle contained.

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 broken light switch plate which exposed a small gap to behind the plate was located near the exit door in the School Age Classroom next to the Infant Classroom; therefore, the wall plate was not in good repair. 2. There was an exposed gap in the wall around a white pipe coming out of the wall in the girls' restroom located by the Two Year Old Classroom; therefore, the wall was not in good repair. 3. A loose white half wall board was placed on the wall in front of the sink in the girls' restroom located by the Two Year Old Classroom that was exposing a gap in the top of the wall board and what appeared to be a nail; therefore, the wall was not in good repair. 4. There was an exposed hole/gap at the bottom corner in front of the sink in the girls' restroom located by the Two Year Old Classroom. The surveyor observed debris in the hole/gap. 5. A white wall board placed on the wall beside the toilet in the girls' restroom located by the Two Year Old Classroom was partially detached from the wall on the corner/side and exposed a gap when pulled on; therefore, the wall was not in good repair. 6. A white half wall board placed on the side of the sink in the girls' restroom located by the Two Year Old Classroom was detached and exposed a gap at the top of the wall board; therefore, the wall board was not in good repair. 7. There were exposed gaps in the wall around white pipes that led to the toilet in the girls' restroom located by the Two Year Old Classroom; therefore, the wall was not in good repair. 8. The faucet in the girls' restroom located by the Two Year Old Classroom was loose; therefore, the faucet 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 4. Premises Requirements.

General: Based on observation, the surveyor found the following: 1. Eleven (11) children were observed inside the Two Year Old Classroom upon the surveyor's arrival at the child-care center on 06/27/22. Based on review of documentation, the surveyor found that the Two Year Old Classroom is licensed for ten (10) children; therefore, there was not a minimum of thirty-five (35) square feet of space per child. 2. Nine (9) children were observed inside the School Age Classroom located next to the kitchen on 06/27/22. Based on review of documentation, the surveyor found that the School Age Classroom is licensed for six (6) children; therefore, there was not a minimum of thirty-five (35) square feet of space per child. Hygienic Practices Not 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 documentation, the surveyor found that a staff’s (DOH: 03/14/22) file did not contain documentation of background checks submitted through the Kentucky National Background Check Service. Based on review of the Kentucky National Background Check Service, the staff person's determination status showed "In Process" and the staff person had not submitted to fingerprints. During interview, staff-in-charge stated that the staff person was seventeen (17) years of age when she was hired. Staff-in- charge stated that she completed the Child Abuse/Neglect Background Check (CAN) on the staff person at that time. The staff's file contained a completed CAN check dated 06/02/22. The staff’s file did not contain a completed Criminal Records Background Check. The surveyor observed the staff person to work alone with children in the Two Year Old Classroom. Staff-in-charge stated that she would have the staff person to submit to fingerprints. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 8 Inspection Report Supervision Not In Compliance

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, the surveyor learned that nine (9) school age children attended Vacation Bible School at approximately 10:00 a.m. on 06/27/22. The surveyor observed the nine (9) children arrive back at the child-care center on 06/27/22 at approximately 11:50 a.m. Based on review of documentation, the surveyor found that the children ranged in age from five to ten years old. During review of permission slips provided by the Director for all nine (9) children, the surveyor found that the permission slips outlined the following: a) Dates as 06/27/22 - 07/02/22; b) Length of time as 10:00-12:00; c) The child's name; and d) The parent's name and signature. The permission slip stated that by filling out the form, it gave the bus permission to pick up/drop off the child at the child-care center. The Director stated that the church bus picked up the children and dropped the children off at the child- care center. The Director stated that no staff person from the child-care center went with the children and that the church members were responsible for the children; therefore, the children were not provided with adequate supervision at all times by a qualified staff person. The Director stated that she was not aware that a staff person needed to go with the children to the church. Staffing Requirements Not In Compliance

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

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

General: Based on observation, the surveyor found one (1) staff person providing care for six (6) children in the Infant Classroom. Staff stated that the children ranged in age from three months to one year old; therefore, the classroom exceeded the staff-to-child ratio by one (1) child. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 8 Inspection Report General Administration Not In Compliance

Open Not marked corrected in the state record

Category: ratio. 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 Two Year Old Classroom; therefore, the diaper changing surface was not kept clean. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 4 of 8 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 brown container that had "First Aid" written on the front of the container placed on a shelf above the sink in the girls' restroom located by the Two Year Old Classroom; therefore, the First Aid Kit was not stored out of reach of the children.

Open Not marked corrected in the state record

Category: health medication. 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 purple bag that resembled a Bogg Bag placed on the bottom of a brown shelf located in an entry way beside the office. The purple bag was open and appeared to contain a medicine bottle. The bottle appeared to be orange with a white lid. The surveyor observed an opening with no door leading from the entry way into the School Age Classroom. During interview, the Director stated that the bag belonged to a staff person and it was unknown if the bottle was a medicine bottle and what the bottle contained. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 5 of 8 Inspection Report 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 following: 1. Exposed yellow and orange extension cords were placed on the ground and led to a large inflatable on the side the playground. The cords were observed to be easily accessible to the children. 2. A double gate located on the side playground was not latched and had a gap in the middle where the gate should have been latched. The gate appeared to be pulled too far apart to latch properly. 3. A bottle of Palmolive Oxy Deep Grease Cutting Power labeled "Keep Out of the Reach of Children" was placed on the side playground. 4. A large ball goal turned over with a large black base was located on the side playground beside the fence. 5. Wooden thin poles were placed inside a large white container on the other side of the fence roll on the small playground. The poles were observed to stick up and over the fence. 6. The flat end of a rusty nail was sticking out from the back of a wooden fence post located behind a swing set on the small playground. 7. A gap was between a wooden fence post and a silver metal fence post located behind a swing set on the small playground.

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. The protective surface around a swing set with two (2) swings and one (1) slide located on the small playground was depleted and the swing set did not have an adequate fall zone. 2. A large inflatable was placed on top of a concrete slab on the side playground; therefore, the inflatable did not have an adequate fall zone. The surveyor observed children utilizing the inflatable on the day of the visit, 06/27/22. Through interview with staff, the surveyor learned that the children ranged in age from two to five years old.

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. Small tree branches were sticking through the bottom of the fence roll located behind a swing set on the small playground. The fence was observed to be pushed inward; therefore, the fence was not in good condition. 2. The chain link was observed to not be attached to the top metal pole on parts of the fence rolls along the front and back of the side playground. The fence pushed out slightly at the top when pushed on; therefore, the fence was not in good condition. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 6 of 8 Inspection Report Equipment 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 a large inflatable placed on top of a concrete slab located on the side playground that did not appear to be securely fastened to the ground. 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 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 review of documentation, the surveyor found that the following children's (DOE: 05/03/22, 05/03/22, and 05/03/22) files did not contain the name of each person who is designated in writing to pick-up the child. 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 review of documentation, the surveyor found the following: 1. The daily attendance record for 06/27/22 had twenty-four (24) children’s arrival times documented; however, twenty-six (26) children were present at the child-care center. During interview, the Director stated that two (2) children were not signed in on the daily attendance record. 2. Nine (9) school age children's departure times were not documented on the daily attendance record on 06/27/22. Through interview with the Director, the surveyor learned that nine (9) school age children departed the child-care center at approximately 10:00 a.m. to attend a Vacation Bible School until approximately 11:50 a.m. During interview, staff stated that they were not aware they had to sign the children out on the daily attendance record when the children left for Vacation Bible School. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 7 of 8 Inspection Report

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, the surveyor found the following: 1. A staff’s (DOH: 05/02/18) file contained a professional development plan dated 11/16/20; therefore, the plan was not completed annually. 2. A staff’s (DOH: 05/02/18) file contained a professional development plan dated 11/14/20 therefore, the plan was not completed annually. 3. A staff’s (DOH: 05/02/18) file contained a professional development plan with no date; therefore, the surveyor was unable to determine that the plan was completed annually. 4. A staff’s (DOH: 07/21/20) file contained a professional development plan with no date; therefore, the surveyor was unable to determine that the plan was completed annually. 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 13. Reports.

General: Based on review of documentation, the surveyor found that an incident involving a seven-year-old child that occurred on 11/22/21 was not reported to DRCC by the child- care center; therefore, the incident was not reported to the cabinet within twenty-four (24) hours from the time of discovery. Based on multiple interviews and review of documentation, the surveyor found that medical care was sought for the seven-year-old child and a report of child abuse/neglect was accepted by the cabinet, naming an employee as the alleged perpetrator. 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 8. General.

General: Based on review of video footage of an incident involving a staff person and seven-year-old child at the child-care center on 11/22/21, the surveyor observed the seven- year-old child to be under a table in the classroom. The surveyor observed the seven-year-old child to come out from under the table and the staff person sat the seven-year-old child down roughly on the floor against a wall and cross his legs. The surveyor observed a loud 'thud' when the child was sat down on the floor and against the wall. The surveyor also observed the staff person to raise her voice and talk aggressively to the seven-year-old child. Based on interview, the surveyor learned that the staff person pulled the seven-year-old by the foot to help bring him out from under the table while the seven-year-old child used his hands to push himself out from under the table. The health, safety, and comfort of the child was compromised. 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: 04/27/18) 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 confirmed that the staff person has not had a TB skin test.

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 presented, the surveyor found: 1. A staff’s (DOH: 06/21/2021) file presented for review did not contain a high school diploma, GED, or Commonwealth Child Care Credential. 2. A staff’s (DOH: 05/24/2021) file presented for review did not contain a high school diploma, GED, or Commonwealth Child Care Credential. During interview, staff confirmed the documents were not in the staff’s files. 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 presented, the surveyor found: 1. A staff’s (DOH: 05/24/2021) file did not contain a statement from a health professional that the individual is free of active tuberculosis or a copy of negative tuberculin result. Staff confirmed through interview that the staff’s file did not contain a negative tuberculin result or a copy of a negative tuberculin result. 2. A staff’s (DOH: 04/27/2018) file did not contain a current statement from a health professional that the individual is free of active tuberculosis or a copy of negative tuberculin result. The most current negative tuberculin result in the staff’s file was dated 04/06/2018; therefore, the result was not updated every two (2) years. Staff confirmed through interview that the staff’s file contained a negative tuberculin result that was not completed within the last two (2) years.

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 presented, the surveyor found: 1. There were no staff on duty and present with the children who are certified by a cabinet-approved training agency in infant and child cardiopulmonary resuscitation or infant and child first aid. 2. There were no staff on duty and present for school-age children who are certified by a cabinet- approved training agency in adult cardiopulmonary resuscitation and first aid. During interview, staff were aware that there were no staff present at child-care center who were certified in first aid or CPR.

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

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

General: Based on review of documentation presented, a staff (DOH: 6/21/2021) identified as a substitute does not meet the staff requirements of this administrative regulation. The staff’s proof of educational qualifications were not in the staff’s file. 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

Open / not marked corrected.

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

General: Based on review of documentation provided and a review of ECE-TRIS, the surveyor found the following: 1. A staff file (DOH: 05/02/2018) did not contain documentation of the staff’s completion of the fifteen (15) hours of cabinet-approved early care and education training for a time period of 07/01/2020 through 06/30/2021. A review of ECE-TRIS revealed that the staff obtained zero (0) of the required hours of annual training. 2. A staff member (DOH: 04/27/2018) completed the one and one-half (1 ½) hours of pediatric abusive head trauma training on 11/18/2015. A review of the staff member’s file and ECE-TRIS found no additional PAHT training; therefore, the PAHT training was not completed every five (5) years. 3. A staff member (DOH: 07/21/2020) obtained the six (6) hours of cabinet-approved orientation on 04/28/2021; therefore, the training was not obtained during the staff's first three (3) months of employment. 4. A staff member (DOH: 07/01/2020) obtained the six (6) hours of cabinet-approved orientation on 05/25/2021; therefore, the training was not obtained during the staff's first three (3) months of employment. 5. A staff member (DOH: 08/28/2020) obtained the six (6) hours of cabinet-approved orientation on 05/24/2021; therefore, the training was not obtained during the staff's first three (3) months of employment. 6. A staff member (DOH: 06/28/2021) did not obtain the six (6) hours of cabinet-approved orientation training within the first three (3) months of employment. 7. A staff member (DOH: 06/21/2021) did not obtain the six (6) hours of cabinet-approved orientation training within the first three (3) months of employment. 8. A staff member (DOH: 05/24/2021) did not obtain the six (6) hours of cabinet-approved orientation training within the first three (3) months of employment. During interview, staff stated they were not aware that the staff had not completed their trainings. 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 Kitchen Requirements In Compliance Food Service In Compliance Meal Planning/Center Provides Meals In Compliance Meal Planning/Center Does Not Provide Meals In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 4 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 presented, the surveyor found the following: 1. A child’s (DOE: 05/11/2018) did not contain contact information to enable a person in charge to contact their preferred hospital. 2. A child’s (DOE: 09/24/2020) did not contain contact information to enable a person in charge to contact their preferred hospital. The file did not contain the name of each person who is designated in writing to pick-up the child. The file did not contain the name and phone number of each person to be contacted in an emergency involving or impacting the child. 3. A child’s (DOE: 07/27/2020) did not contain contact information to enable a person in charge to contact their preferred hospital. 4. A child’s (DOE: 07/27/2020) did not contain contact information to enable a person in charge to contact their preferred hospital. 5. A child’s (DOE: 03/23/2018) did not contain contact information to enable a person in charge to contact their preferred hospital. 6. A child’s (DOE: 06/27/2018) did not contain contact information to enable a person in charge to contact their preferred hospital. 7. A child’s (DOE: 07/22/2021) did not contain contact information to enable a person in charge to contact their preferred hospital. 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 2:090 · 922 KAR 2:090. Section 13. Reports.

General: Based on interview, staff reported that the child-care center failed to report classroom closures related to COVID 19 exposure. Staff stated that she was not aware that the child-care center was required to report the classroom exposures and/or closures to DRCC.

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 documentation, the surveyor found the following: (1.) Staff’s (DOH: 7/1/2020) file did not contain a criminal records check. Staff confirmed through interview that the criminal records check was not completed on the staff. The surveyor observed the staff working alone with children in the School Age Classroom. (2.) Staff’s (DOH: 7/21/2020) file did not contain a criminal records check. Staff confirmed through interview that the criminal records check was not completed on the staff. The surveyor observed the staff working alone with children in the Twos Classroom. Supervision In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 5 Inspection Report Staffing 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 2. Child Care Services.

General: Based on observation, the surveyor found one (1) staff supervising eighteen (18) children in a classroom. The children were between the ages of six-years-old to nine- years-old. Based on the age of the youngest child, the staff-to-child ratio was over by three (3) children. General Administration In Compliance Director Requirements Not In Compliance

Open Not marked corrected in the state record

Category: ratio. Open / not marked corrected.

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

General: Based on review of documentation, the surveyor found the following: (1.) Staff’s (DOH: 4/17/18) file contained an annual written performance evaluation that was dated 11/2/18; therefore, the evaluation needs to be updated. (2.) Staff’s (DOH: 4/27/18) file contained an annual written performance evaluation that was dated 11/2/18; therefore, the evaluation needs to be updated. (3.) Staff’s (DOH: 5/2/18) file contained an annual written performance evaluation that was dated 11/2/18; therefore, the evaluation needs to be updated.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on review of documentation, the surveyor found the following: (1.) Staff’s (DOH: 7/1/2020) file did not contain a criminal records check. Staff confirmed through interview that the criminal records check was not completed on the staff. The surveyor observed the staff working alone with children in the School Age Classroom. (2.) Staff’s (DOH: 7/21/2020) file did not contain a criminal records check. Staff confirmed through interview that the criminal records check was not completed on the staff. The surveyor observed the staff working alone with children in the Twos Classroom. Employee Records In Compliance Programming In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 5 Inspection Report 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 4. Premises Requirements.

General: Based on observation, the surveyor found the following: (1.) A square rug, blue in color, located in the Nursery contained several dark stains; therefore, the rug was not kept clean. (2.) A round rug located in the Twos Classroom contained debris; therefore, the rug was not kept clean.

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 one (1) staff with eighteen (18) children in a classroom that has an approved capacity for six (6) children. The children ranged in age of six-years-old to nine-years-old.

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, the surveyor found the following in the boy’s restroom: (1.) A puddle of water was observed underneath the urinal. (2.) Several pieces of dirty toilet paper were observed on the floor between the toilet and the wall; therefore, the restroom was not clean. 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 10. Toilet, Diapering, and Toiletry Requirements.

General: Based on observation, the surveyor found the staff in the Ones Classroom did not disinfect the diapering surface after diapering a child. A staff member reported the staff forgot to complete this step in the diaper changing process. 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 merry-go-round had one (1) wooden plank raised where the children stand on the merry-go-round, creating a safety hazard for the children. (2.) Wooden edging surrounding pea gravel was split at the end and contained sharp edges that created a potential safety hazard for the children. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 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 two (2) Little Tikes climbing structures with slides which did not have an adequate protective surface. Equipment In Compliance Transportation Not Applicable Food Service/Food Program In Compliance Food Service In Compliance Children's 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 9. Records.

General: Based on review of documentation, the surveyor found the following: (1.) A child’s (DOE: 7/13/2020) file did not contain the name of a preferred hospital. (2.) A child’s (DOE: 7/27/2020) file did not contain a preferred hospital’s telephone number. (3.) A child’s (DOE: 1/7/2020) file did not contain the name of a preferred hospital. (4.) A child’s (DOE: 10/29/2020) file did not contain the name of a preferred hospital. (5.) A child’s (DOE: 7/27/2020) file did not contain a preferred hospital’s telephone number. (6.) A child’s (DOE: 7/13/2020) file did not contain a preferred hospital’s telephone number. (7.) A child’s (DOE: 10/29/2020) file did not contain contact information regarding the child’s parents. (8.) A child’s (DOE: 10/29/2020) file did not contain the name of each person who is designated in writing to pick up the child. (9.) A child’s (DOE: 10/25/2020) file did not contain the name of each person who is designated in writing to pick up the child. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 4 of 5 Inspection Report 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 review of documentation, the surveyor found the following: (1.) Staff’s (DOH: 4/27/18) file contained a written annual plan for professional development that was dated 2/27/13; therefore, the plan needs to be updated. (2.) Staff’s (DOH: 4/27/18) file contained a written annual plan for professional development that was dated 9/11/19; therefore, the plan needs to be updated. (3.) Staff’s (DOH: 4/27/18) file contained a written annual plan for professional development that was dated 11/28/18; therefore, the plan needs to be updated. (4.) Staff’s (DOH: 5/2/18) file contained an annual written plan for professional development that was dated 9/11/19; therefore, the plan needs to be updated. Posted Documentation In Compliance Animals In Compliance Emergency Regulation Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:400 · 922 KAR 2:400E. Emergency Regulation.

General: Based on observation, the surveyor found that this requirement was not met as follows: (1.) There were eighteen (18) children present in the School Age Classroom. Based on interview, the children ranged in age from six-years-old to nine-years-old. Therefore, the classroom was over the group size by three (3) children. The deficiency was cited due to the following E-Reg: 922 KAR 2:400E Section 3. Social Distancing Requirements for Child Care Programs. (1) A child care center shall have a maximum group size of fifteen (15) children per group. (2.) Based on observation, the surveyor observed eighteen (18) school age children were not wearing facemasks. Therefore, the proper Personal Protective Equipment was not being utilized. Staff reported children refuse to wear the facemasks.

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 interview, the surveyor found that a child had been permitted in the center's kitchen with their parent who works at the center. Multiple staff and the parent of the child confirmed that the parent had taken the child to the kitchen with them when retrieving drinks for the all of the children..

Open Not marked corrected in the state record

Category: nutrition. Open / not marked corrected.

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

General: Based on observation and interview, the surveyor found the following: 1. A one-year-old child was sitting in a high chair in the preschool classroom watching television with two-year-old to five-year-old children. Staff stated that the child was one (1) year old. The one's teacher left four (4) other one-year-old children unattended in the one's classroom when she went to the preschool classroom to retrieve the one-year-old that had been watching television. 2. The one's teacher stepped outside of the classroom to sweep and clean high chairs and left five (5) one-year-old children unattended in the one's classroom. Staff stated that they thought it was okay for the teacher to step outside the classroom barrier and leave the children inside as long as the teacher could still see and hear all of the children. However, the staff's attention was devoted to the task of sweeping the floor and not on supervising the children inside the classroom. Staffing Requirements In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 6 Inspection Report General Administration Not In Compliance

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 12. Reports.

General: Based on observation, interview, and review of previous inspections conducted at the center, the surveyor found that the preschool classroom has been divided up so that there is now a separate one's classroom, two's classroom, and preschool classroom. At time of previous inspection in July 2018 and August 2018 there was only a large classroom for preschool and one (1) smaller classroom for one's and two's. A new classroom space for one's has been added without it being properly inspected and measured prior to being utilized. Staff stated they did not realize a change of space needed to be reported since the space was already licensed and just being divided differently. Director Requirements Not 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 and interview, the surveyor found that a television electrical wire was dandling down behind a shelf utilized to store toys in the school age classroom. The wire was accessible to the children and creates a risk to the children. Staff was aware of the wire being accessible but stated they had not thought of it as being a safety risk. 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 and interview, the surveyor found that a staff file (DOH: 6/30/19) did not contain documentation of education in the form of a high school diploma, GED, or Commonwealth Childcare Credential. Staff-in-Charge stated that the staff member was supposed to bring a new copy because the first copy provided had been lost. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 6 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 review of ECE-TRIS, the following were found: 1. A staff file (DOH: 4/27/18) did not contain fifteen (15) hours of annual training. Review of ECE-TRIS, revealed that only six and a half (6.5) hours of annual training had been completed for 4/27/18 - 4/26/19. 2. A staff file (DOH: 4/27/18) did not contain fifteen (15) hours of annual training. Review of ECE-TRIS, revealed that only one (1) hour of annual training had been completed for 4/27/18 - 4/26/19. 3. A staff file (DOH: 5/2/18) did not contain fifteen (15) hours of annual training. Review of ECE-TRIS, revealed that only seven and a half (7.5) hours of annual training had been completed for 5/2/18 - 5/1/19. 4. A staff file (DOH: 4/27/18) did not contain documentation of completing Pediatric Abusive Head Trauma (PAHT) training. Review of ECE-TRIS, revealed that PAHT had not been completed. 5. A staff file (DOH: 6/12/18) did not contain documentation of completing Pediatric Abusive Head Trauma (PAHT) training. Review of ECE-TRIS, revealed that PAHT had not been completed. 6. A staff file (DOH: 3/25/19) did not contain documentation of completion of six (6) hours of orientation training. Review of ECE-TRIS, revealed that orientation had not been completed. Based on interview, staff were not aware of the deficiencies in training. 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 2. Child Care Services.

General: Based on observation and interview, the surveyor found that the two-year-old children and preschool age children were watching Scooby Doo on the television upon the surveyor entering the facility. Staff stated that the children watch television while washing hands and preparing for lunch each day. Staff stated that the children are supposed to be watching Caillou which is on the lesson plan. Review of the current lesson plan revealed that Caillou or television time were not included on the lesson plan. Therefore, the TV time was not used as an educational tool.

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 and interview, the surveyor found that the two-year-old children and preschool age children were watching Scooby Doo on the television. Staff stated that the children watch television while washing hands and preparing for lunch each day. Staff explained that the children are supposed to be watching Caillou instead of Scooby Doo as it is usually included in the lesson plan. Review of the current lesson plan revealed that Caillou or television time were not included as part of the planned program. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 6 Inspection Report

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 5. Infant and Toddler Play Requirements.

General: Based on observation and interview, the surveyor found that two (2) one-year-old children were combined with four (4) two-year-old children for the duration of the inspection, 11:40 a.m. - 1:40 p.m. Upon interview, staff stated the one-year-old children would be turning two (2) year old soon and they were being transitioned to the two's classroom. Staff stated that a signed transition plan was on file for the one-year-old children. Staff stated they were not aware that one-year-old and two-year-old children could not be combined for more than one (1) hour per day. 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 and interview, the surveyor found that a small hand held broom and dust pan were on the bottom shelf of the changing table located outside the two's classroom. They were accessible to the children. Staff stated they were aware that the items were on the changing table.

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 and interview, the surveyor found the following: 1. There was one (1) light in the school age classroom that was not functioning. 2. A fluorescent light in the school age classroom contained two (2) non-shatter proof bulbs. There was not a cover over the bulbs. Staff stated they did not realize the bulbs needed to be shatter proof or covered. 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 10. Toilet, Diapering, and Toiletry Requirements.

General: Based on observation and interview, the surveyor found that the diaper changing pad located in the nursery had a small tear in the vinyl covering preventing it from being properly sanitized. Staff reported that the diaper changing mat had been replaced within the past two (2) weeks. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 4 of 6 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 and interview, the surveyor found the following: 1. A tube of triple anti-biotic cream was in a white basket on top of the cubbies in the school age classroom, where it was accessible to children. Staff stated the cream belonged to them and they had forgot to lock it back up. 2. A bottle of prescription medication was stored in an unlocked cabinet in the kitchen. Staff was aware of the medication not being locked up. 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 and interview, the surveyor found that the playground had styrofoan cups, a Gatorade bottle, and food wrappers scattered around the playground area. The playground was not clean. Staff stated that the items had been left outside when the children came back inside.

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 and interview, the surveyor found that the protective surface of mulch had been depleted and had thick areas of grass growing through it. Staff stated the mulch had been replenished approximatley a month ago but they did not lay a plastic barrier down first. 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 5 of 6 Inspection Report 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 review of documentation and interview, the following were found: 1. A staff file (DOH: 4/27/18) did not contain a professional development plan. 2. A staff file (DOH: 4/27/18) did not contain a professional development plan. 3. A staff file (DOH: 6/12/18) did not contain a professional development plan. 4. A staff file (DOH: 5/2/18) did not contain a professional development plan. Staff-in-Charge confirmed the professional development plans had not been completed.

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 review of documentation and interview, the following were found: 1. There was not a monthly fire drill documented for August of 2019. Staff stated they had failed to document the drill but it had been conducted the last Friday in August. 2. There were no quarterly earthquake or tornado drills documented for the April - June 2019. Staff reported the drills were conducted along with the monthly fire drills but they had failed to document them.

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on review of documentation and interview, the following were found: 1. The surveyor could not confirm if a fire drill was conducted in August of 2019 as there was not a fire drill documented for that month. Staff stated that drill was conducted on the last Friday in August. 2. The surveyor could not confirm that an earthquake or tornado drill was conducted for the April - June 2019 quarter. Staff stated that the drills had been conducted but not documented. 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 9. Records.

General: Based on review of documentation and interview, the surveyor found that a tornado drill had not been documented for April - June 2018. Upon interview, the Director stated that the tornado drill was conducted on 5/31/18; however, they must have failed to document it. 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 11. Staff Requirements.

General: Based on review of documentation, review of ECE-TRIS, and interview, the surveyor found that a staff file (DOH: 4/27/18) did not contain documentation of the completion of six (6) hours of cabinet-approved orientation training. Review of ECE-TRIS, revealed that the staff member had not yet completed orientation; therefore, orientation has not been completed within the required time frame. Upon interview, the Director stated that she is aware that the staff member had not yet completed orientation training. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report 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 2. Child Care Services.

General: Based on observation and interview, a current lesson plan was not posted in the Preschool Classroom. The lesson plan posted was dated for 7/16 - 7/20/18. Staff reported that they had not completed an updated lesson plan yet. 2. The lesson plan posted in the School Age Classroom for 7/23 - 7/27/18 only had the plans for Monday completed. Staff stated that she had not finished updating the lesson plan yet. Premises In Compliance Hygienic Practices In Compliance First Aid/Medication Not In Compliance

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 observation and interview, the surveyor observed a box of Montelukast had been placed on top of the refrigerator in the Nursery Classroom. The medication had been prescribed to a child (DOE: 3/23/18). Staff stated that they had been administering the medication to the child daily. Staff also stated that she had not seen written consent to administer the medication to the child. Upon interview with the Director, it was confirmed that written permission for the center staff to administer medication had not been obtained.

Open Not marked corrected in the state record

Category: ratio. Open / not marked corrected.

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

General: Based on observation and interview, the surveyor observed a box of Montelukast had been placed on top of the refrigerator in the Nursery Classroom. The medication was not stored in a locked place. The medication had been prescribed to a child (DOE: 3/23/18). Staff stated that they had been administering the medication to the child daily; therefore, they kept it on the refrigerator. Outdoor Play Area In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3 Inspection Report Equipment In Compliance Transportation Not Applicable Food Service/Food Program In Compliance Food Service In Compliance Children's Records 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 and interview, the following were found: 1. A child's file (DOE: 3/26/18) contained an immunization certificate that was no longer current. The immunization certificate should have been updated by 6/14/18. 2. A child's file (DOE: 3/23/18) contained an immunization certificate that was no longer current. The immunization certificate should have been updated by 3/30/18. The Director stated that she was not aware that immunization certificates on file were not current. 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 and interview, the surveyor found that there were thirty (30) children present at the time of the inspection; however, there were only twenty-three (23) children signed in. Upon interview, the Director stated that she was aware that not all of the children had been signed in.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.