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

General: Based on interview, with staff-in-charge, the surveyor discovered that staff-in-charge was unable to provide documentation of completed staff meetings; therefore, the surveyor could not determine if recurring staff meetings were conducted and documented.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on review of documentation, the surveyor discovered that the personnel file of one (1) staff (DOH: 06/30/25) did not contain documentation of education in the form of a high school diploma, GED, or Commonwealth Child Care Credential. During interview with staff-in-charge, the surveyor was not provided any additional documentation to review. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 10 of 33 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 discovered the following: 1. The personnel file for one (1) staff member (DOH: 03/28/24) contained a negative tuberculin result that was no longer current after 04/27/25; therefore, the child-care center failed to show proof that the employee was free of active tuberculosis or provide a copy of a negative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. 2. The personnel file for one (1) staff member (DOH: 06/30/25) did not contain a statement from a health professional that the individual is free of active tuberculosis or a copy of negative tuberculin results. 3. The personnel file for one (1) staff member (DOH: 07/09/25) did not contain a statement from a health professional that the individual is free of active tuberculosis or a copy of negative tuberculin results. During interview with staff-in-charge, the surveyor was not provided any additional documentation to review. Therefore, the child care center failed to show proof that the employees were free of active tuberculosis or provide a copy of a negative tuberculin result.

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. Cobwebs containing dead insects located throughout the front entrance of the child care center. 2. The urinal located in the restroom between the School-Age Classroom and One-Year-Old Classroom would not flush and was not operational. During interview with staff-in-charge, she stated that the urinal would go in and out of working; however, it has currently not been operational for about six (6) weeks, Therefore, the surveyor was able to determine that the child care center failed to keep the premises clean and 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 8. Kitchen Requirements.

General: Based on observation, the surveyor was unable to locate a thermometer in the refrigerator located in the Kitchen; therefore, the surveyor was not able to determine if the refrigerator was maintained at forty (40) degrees Fahrenheit or below.

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 observed an Evacuation Planning Form for Child Care Emergency/Disaster Preparedness form with a documented completion date of 11/15/24, and a submission date for review of 01/02/25. Upon review if the form, the surveyor found that it was blank and contained no required information. Therefore, the child care center failed to maintain a completed evacuation plan.

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 only documented fire drill attendance sheets available for review were for the months of February, March, April, May, June and July; however, five (5) out of the six (6) documents available to review, the year in which these drills were conducted was not indicated, and the surveyor was unable to determine if the required monthly drills were conducted within the 2025 calendar year. 2. The only documented earthquake, tornado and lockdown drill attendance sheets available for review were for the months of February, May and July; however, the year in which these drills were conducted was not indicated, and the surveyor was unable to determine if the quarterly required drills documented were conducted within the 2025 calendar year. 3. There was no documentation of quarterly shelter-in-place drills. 4. An emergency drill documentation sheet for the 2025 calendar year reflected written documentation that the fire drills had been completed for the months of January and February of 2025. However, there was no documentation of quarterly earthquake, tornado, lockdown or shelter-in-place had been documented. Staff-in-charge stated that the drills had been completed but did not know why the documentation was not filled out in its entirety. Therefore, the surveyor was able to determine that child care center failed to maintain written records of monthly fire drills and quarterly practiced earthquake and tornado drills. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 31 of 33 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 3. General Requirements.

General: Based on review of documentation, the surveyor discovered the following: 1. The only documented fire drill attendance sheets available for review were for the months of February, March, April, May, June and July; however, five (5) out of the six (6) documents available to review, the year in which these drills were conducted was not indicated, and the surveyor was unable to determine if the required monthly drills were conducted within the 2025 calendar year. 2. The only documented earthquake, tornado and lockdown drill attendance sheets available for review were for the months of February, May and July; however, the year in which these drills were conducted was not indicated, and the surveyor was unable to determine if the quarterly required drills documented were conducted within the 2025 calendar year. 3. There was no documentation of quarterly shelter-in-place drills. 4. An emergency drill documentation sheet for the 2025 calendar year reflected written documentation that the fire drills had been completed for the months of January and February of 2025. However, there was no documentation of quarterly earthquake, tornado, lockdown or shelter-in-place had been documented. Staff-in-charge stated that the drills had been completed but did not know why the documentation was not filled out in its entirety. Therefore, the surveyor was able to determine that child care center failed to maintain written records of monthly fire drills and quarterly practiced earthquake and tornado drills.

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on interview and review of documentation, and review of the KARES roster printed the date of the inspection, the surveyor found one (1) staff (DOH: 06/25/24) whose fingerprints were taken on 11/07/24 and whose eligibility determination date was listed as 11/08/24; therefore, this staff member was hired prior to fingerprints being taken and eligibility being determined. During interview, staff-in-charge stated she thought this staff member just had to have a check of the Child Abuse/Neglect registry and Sex Offender registry done prior to employment as this staff was under eighteen (18) years old, and that she had the fingerprints run as soon as she found out in November 2024 that this was a new requirement for staff under eighteen (18) years old. Supervision In Compliance Staffing Requirements In Compliance General Administration Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation and interview, the surveyor found a protective cover was missing on the top of the electric outlet near the sink in the restroom beside the School Age Classroom; therefore, the health, safety and comfort of the children was compromised. Staff-in-charge stated she would replace this missing outlet cover. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 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 interview and review of documentation, the surveyor found: 1.One (1) staff (DOH: 05/03/18) file contained an evaluation dated for 01/15/20. Staff-in-charge stated she was unable to locate a more recent written evaluation for review; therefore, the surveyor was unable to determine if this staff member had a written performance evaluation completed annually as required. 2. One (1) staff (DOH: 08/31/23) file did not contain an evaluation. Staff-in-charge stated she could not locate an annual written performance evaluation for this staff; therefore, the surveyor could not determine if the staff’s evaluation was completed annually. Employee 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 11. Staff Requirements.

General: Based on interview and review of documentation, the surveyor found one (1) staff (DOH: 09/01/23) file contained a tuberculin (TB) skin test that was no longer current, the TB skin test was dated for 05/27/17. During interview, staff-in-charge stated this employee had a bad reaction to a past TB skin test and could no longer have those done. Programming In Compliance Premises Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation and interview, the surveyor found the urinal in the restroom beside the School Age Classroom did not flush; therefore, the urinal was not kept in good repair. During interview, staff-in-charge stated she would contact a plumber to fix the urinal. Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance 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 13. Toys and Furnishings.

General: Based on observation, the surveyor found the plastic picnic table on the playground contained broken areas with sharp edges along the seat, as well as a screw inside a broken area of the seat which was accessible to children; therefore, this outdoor equipment was not free from sharp points, was not safe for children, and was not in good repair. Transportation In Compliance Kitchen Requirements In Compliance Food Service In Compliance Meal Planning/Center Provides Meals In Compliance Meal Planning/Center Does Not Provide Meals In Compliance Children's Records In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 4 Inspection Report Written Documentation Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on interview and review of documentation, the surveyor found a written Emergency Preparedness Plan dated for 08/15/22. During interview, staff-in-charge stated she could not locate a more recent dated Emergency Preparedness Plan; therefore, the surveyor was unable to determine if a plan had been updated and filed annually as required.

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 found: 1. One (1) staff (DOH: 05/03/18) file contained a professional development plan dated for 01/15/20. Staff-in-charge stated she could not find a more recent professional development plan for this staff. 2. One (1) staff (DOH: 08/31/23) file contained no written professional development plan; therefore, the surveyor was unable to determine if an annual development plan was completed. Staff-in-charge stated she could not locate a written professional development plan for the surveyor to review. 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 11. Status of Employment.

General: Based on review of documentation, the surveyor found the following: 1. A staff’s (DOH: 06/29/22) file contained documentation of a background check submitted through the Kentucky Applicant Registry and Employment System (KARES) that verified an eligibility date of 09/11/18. Based on review of KARES, the surveyor found that the staff person was not listed as a current employee at the child-care center. During interview, staff-in-charge stated that she was not aware the staff person was not listed on the child-care centers KARES report. During the surveyor’s visit, staff-in-charge started a new application on KARES to add the staff person to the child-care centers report and it stated a new application must be submitted. Staff-in-charge submitted the application during the visit and found that the staff person needs new fingerprints. Based on review of the Applicant History Report on KARES, the surveyor found that the staff person had a separation date of 05/23/22 recorded and no new applications had been submitted since that date. Staff-in-charge stated that she had printed the Employment Authorization Form when the staff person was hired that showed the staff person was eligible. The surveyor observed the staff person working alone with children on the day of the visit, 04/21/23. 2. A staff’s (DOH: 10/11/22) file contained documentation of a background check submitted through the Kentucky Applicant Registry and Employment System (KARES) that verified an eligibility date of 08/29/18. Based on review of KARES, the surveyor found that the staff person was not listed as a current employee at the child-care center. During interview, staff-in-charge stated that she was not aware the staff person was not listed on the child-care centers KARES report. During the surveyor’s visit, staff-in-charge started a new application on KARES to add the staff person to the child-care centers report and it stated a new application must be submitted. Staff-in-charge submitted the application during the visit and found that the staff person needs new fingerprints. Based on review of the Applicant History Report on KARES, the surveyor found that the staff person had a separation date of 08/19/22 recorded and no new applications had been submitted since that date. Staff-in-charge stated that she had printed the Employment Authorization Form when the staff person was hired that showed the staff person was eligible. The surveyor did not observe the staff person working alone with children. Staff-in-charge stated that the staff person has not worked alone with children. Supervision In Compliance Staffing Requirements In Compliance General Administration In Compliance Director Requirements In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 4 Inspection Report 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: 01/06/23) file did not contain verification of a High School Diploma, GED or Commonwealth Child Care Credential. Through interview with staff-in-charge, the surveyor learned that the educational verification was not available for review for the staff mentioned. Programming In Compliance Premises Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the surveyor found the following: 1. A small cream purse placed behind a desk and beside a desk chair in the Preschool Classroom. The purse was observed to be accessible to the children. The surveyor observed the children and staff in the Preschool Classroom to be on the playground when the purse was found. Staff-in-charge stated that the staff person had just came back from break. Staff-in-charge was observed to move the purse to make it inaccessible to the children. 2. A clear spray bottle that had "water" and "bleach" written on it was observed to be placed on top of two (2) sets of three (3) drawer plastic shelves that were stacked in the restroom located beside the School Age Classroom and One Year Old Classroom. Through interview with staff-in-charge, the surveyor learned that the school age children utilize the restroom. The spray bottle was observed to be accessible to the children.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the surveyor found the following: 1. The toilet seat moved easily and was not tightly secured to the toilet in the girls' restroom located by the Two Year Old Classroom and Preschool Classrooms; therefore, the toilet was not kept in good repair. 2.The silver pipe coming out of the wall and attached to the urinal located in the restroom beside the School Age Classroom was observed to be loose; therefore, the urinal was not kept in good repair. Hygienic Practices In Compliance First Aid/Medication In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 4 Inspection Report Outdoor Play Area Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation of the playground, the surveyor found the following: 1. The large base to a ball goal was observed hanging over the playground side of the fence by the child-care center building. 2. A slab of uneven concrete was observed to be located near the child-care center building; therefore, the concrete created a tripping hazard for the children. 3. Three (3) long wooden boards were observed placed on the ground beside the side fence roll on the playground. 4. One (1) hole was observed in the bottom of the siding on the child-care center building and one (1) hole toward the middle of the siding. The bottom hole contained a jagged edge. Therefore, the playground was not safe from foreseeable hazards.

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on observation, the surveyor found that the protective surface around a wooden play structure with two (2) slides was depleted; therefore, the wooden play structure did not have an adquate fall zone. The surveyor observed grass coming through parts of the protective surface. 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 13. Toys and Furnishings.

General: Based on observation, the surveyor found the following: 1. One (1) red tricycle located on the playground that was missing two (2) pedals; therefore, the tricycle was not in good repair. 2. A small red metal playhouse located on the playground that contained a loose bench seat. The seat was observed to no longer be bolted on one (1) end; therefore, the playhouse was not in good repair. 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

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: 03/13/23) file contained an immunization certificate that was no longer current as of 03/30/23. 2. A child’s (DOE: 07/26/21) file contained an immunization certificate that was no longer current as of 09/07/21.

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. The following children’s (DOE: 03/13/23, 07/11/22, 10/04/21 and 07/26/21) files did not contain the name of the child’s preferred hospital or contact telephone number. 2. The following children’s (DOE: 07/12/22 and 02/06/23) files did not contain the contact telephone numbers for the child’s preferred family physician and hospital. 3. A child’s (DOE: 02/08/17) file did not contain the contact telephone number for the child’s preferred hospital. 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 found that the written evacuation plan was last updated on approximately 08/07/18; therefore, the plan needs to be updated. Through interview with staff-in-charge, the surveyor learned that the up-to-date emergency preparedness plan was not available for review.

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 no documentation of a fire drill conducted during the month of March 2023. During interview, staff-in-charge stated that the fire drill had been conducted; however, she was unable to locate the documentation. 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 10. Director Requirements and Responsibilities.

General: Based on review of documentation, the surveyor found the following: 1. A staff’s (DOH: 12/27/12) file contained an annual written performance evaluation dated 2021 only; therefore, the surveyor was unable to determine that the evalutation was completed annually. 2. A staff’s (DOH: 03/16/09) file contained an annual written performance evaluation with no date; therefore, the surveyor was unable to determine that the evaluation was completed annually. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 5 Inspection Report Employee 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 11. Staff Requirements.

General: Based on review of ECE-TRIS, the surveyor found the following: 1. A staff (DOH: 10/25/21) obtained six (6) hours of cabinet-approved orientation training on 02/03/22; therefore, the training was not completed within the first three (3) months of employment. 2. A staff (DOH: 05/03/18) completed one and one-half (1 ½) hours of cabinet-approved pediatric abusive head trauma training on 07/24/17; therefore, the training was not completed within the last five (5) years. 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, the surveyor found that the lesson plan posted in the One Year Old Classroom was dated for 07/18/22 - 07/22/22; therefore, the lesson plan was not current. 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.

Based on observation, the surveyor found one (1) clear spray bottle that had “Bleach Water” written on the front of the bottle. Through interview with staff, the surveyor learned that the School Age children utilize the restroom. The items mentioned appeared to be within reach of the children.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the surveyor found a small cut out/hole in the wall located between two (2) restrooms by the Office area and the drywall was ripped/torn; therefore, the wall was not in good repair. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 5 Inspection Report

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on observation, the surveyor found the following: 1. The toilet seat moved easily and was not tightly secured to the toilet in the restroom located in front of the walk way beside the Office; therefore, the toilet was not kept in good repair. 2.The silver pipe on the urinal located in the restroom beside the School Age Classroom was observed to be loose; therefore, the urinal was not kept in good repair. Hygienic Practices Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the surveyor found debris on the diaper changing table underneath the diaper changing pad and a rip/tear in the diaper changing pad in the restroom located beside the School Age Classroom; therefore, the diaper changing surface was not kept clean or free of holes, rips, tears, or other damage. First Aid/Medication In Compliance Outdoor Play Area Not In Compliance

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on observation, the surveyor found the following: 1. A large ball goal that was turned over with the base of the ball goal standing upright located on the playground. The ball goal was observed to be wobbly when pushed on. 2. A slab of uneven concrete located on the grassy portion of the playground; therefore, the concrete created a tripping hazard for the children. 3. A plastic bag containing mulch placed on the ground beside the side fence roll on the playground. 4. Three (3) long wooden boards placed on the ground beside the side fence roll on the 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 grass coming through the protective surface around a climbing structure on the playground; therefore, climbing structure did not have an adequate fall zone. Equipment In Compliance Transportation In Compliance Kitchen Requirements In Compliance Food Service In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 5 Inspection Report 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 the following: 1. A child’s (DOE: 08/13/21) file did not contain the name or contact telephone number for the child's preferred hospital. 2. A child’s (DOE: 11/01/18) file did not contain the name or contact telephone number for the child's preferred hosptial. 3. A child’s (DOE: 12/20/15) file did not contain a contact telephone number for the child’s preferred hospital. 4. A child’s (DOE: 08/19/21) file did not contain the name or contact telephone number for the child's preferred hospital. 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 found that the written evacuation plan was last updated on 08/07/18; therefore, the plan needs to be updated.

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 staff’s (DOH: 03/16/09) file contained a professional development plan dated 01/22/20; therefore, the plan was not completed annually. 2. A staff’s (DOH: 05/03/18) file contained a professional development plan dated 01/15/20; therefore, the plan was not completed annually.

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. No documentation of fire drills conducted during the months of January, February, March, April, May and June of 2022. During interview, staff-in-charge stated that the fire drills were conducted and recorded; however, she was unable to locate the documentation. 2. No documentation of earthquake, tornado, or lock down drills conducted during the first quarter of 2022. During interview, staff-in-charge stated that an earthquake, tornado, and lock down drill was conducted and recorded for the first quarter of 2022; however, she was unable to locate the documentation. Posted Documentation In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 4 of 5 Inspection Report 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 10. Director Requirements and Responsibilities.

General: Based on review of documentation, the surveyor was presented with the following: 1. The staff member's (DOH:9/26/19) file did not contain an evaluation. 2. The staff member's (DOH:1/2/19) file did not contain an evaluation. 3. The staff member's (DOH:4/24/18) file did not contain an evaluation. 4. The staff member's (DOH:11/13/19) file did not contain an evaluation. Staff stated that she would make sure all staff have evaluations in their file. Employee Records In Compliance 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, the surveyor found the following: 1. In the Two Year Old Classroom, the lesson plan posted was dated July 13th-17th. 2. In the Preschool 2 Classroom, there was not a lesson plan posted. Staff stated that she would make sure lesson plans are up-to-date and are posted in all classrooms. 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 10. Toilet, Diapering, and Toiletry Requirements.

General: Based on observation, the surveyor found a yellow substance in the toilet bowl located in the boys restroom. Staff stated she would make sure staff checks the restroom after each use. Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Food Service/Food Program In Compliance Food Service In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3 Inspection Report 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 was presented with a child's (DOE:9/25/19) file that did not list a family physician or a contact number for the physician. Staff stated that she would have the guardian list the family physician's name and contact number in the child’s file. Written Documentation Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the surveyor was presented with the following: 1. The staff member's (DOH:9/26/19) file did not contain a Professional Development Plan. 2. The staff member's (DOH:1/2/19) file did not contain a Professional Development Plan. 3. The staff member's (DOH:4/24/18) file did not contain a Professional Development Plan. 4. The staff member's (DOH:11/13/19) file did not contain a Professional Development Plan. During interview, staff stated that she would make sure all staff have a Professional Development Plan in their file. Posted Documentation In Compliance Animals In Compliance Emergency Regulation In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, the surveyor found the following: (1.) Staff’s (DOH: 4/24/18) file did not contain a completed Criminal Records Check or a completed CAN Check. Staff confirmed through interview that the Criminal Records Check and CAN Check forms were mailed in; however, staff could not provide copies of the mailed Background Check or CAN Check stating copies of the forms were not made prior to the forms being mailed. Staff reported the results of the CAN Check and Background Check had not been received by the child care center. According to staff, the staff person has not worked alone with children. (2.) Staff’s (DOH: 8/25/2020) file did not contain a completed CAN Check. Staff stated a CAN Check had not been submitted for the staff. The surveyor observed the staff person working alone in the One Year Classroom with five (5) children. Supervision In Compliance Staffing Requirements In Compliance General Administration In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 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 observation, the surveyor found a staff (DOH: 8/25/2020) working alone in the One Year Classroom with five (5) children. The surveyor found the staff’s file did not have a completed CAN Check. Staff confirmed a CAN Check had not been submitted for the staff. 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 the following: (1.) Staff’s (DOH: 4/24/18) file did not contain a high school diploma, GED, or Commonwealth Child Care Credential. Staff confirmed through interview that the documentation was not obtained for the staff’s file. (2.) Staff’s (DOH: 8/25/2020) file did not contain a high school diploma, GED, or Commonwealth Child Care Credential. Staff confirmed through interview that the documentation was not obtained for the staff’s file. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Food Service/Food Program In Compliance Food Service In Compliance Children's Records In Compliance Written Documentation In Compliance Posted Documentation In Compliance Animals In Compliance Emergency Regulation In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation presented to surveyor for review, an employee (DOH: 04/23/19) record did not contain proof of education as required by regulations. During interview, the director stated that the staff person attended school outside the United States and the information has been requested for some time. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation provided to the surveyor, the following issues were found: 1. A staff member’s (DOH: 12/20/18) record presented for review did not contain evidence of the employee completing six (6) hours of cabinet-approved orientation. 2. A staff member’s (DOH: 01/04/16) record presented for review did not contain evidence of the employee completing six (6) hours of cabinet-approved orientation. 3. A staff member (DOH: 01/04/2016) has not completed the one and one half (1 ½) hours of pediatric abusive head trauma training. 4. A staff member (DOH: 10/12/09) has not completed the required fifteen (15) hours of cabinet approved training during the training year of 01/04/2018 – 01/03/2019. A review of ECE-TRIS found that the staff member has completed zero (0) hours of cabinet approved training. A review of the staff member’s file found training hours for the previous training period did not meet the fifteen (15) hours of training. During interview, the director stated she would have employee training updated as soon as possible. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation In Compliance 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: recordkeeping. Open / not marked corrected.

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

General: Based on review of documentation provided to the surveyor, a child’s (DOE: 10/22/17) file contained immunization certificate that was no longer current as of 05/10/19. Written Documentation In Compliance Posted Documentation In Compliance Animals In Compliance

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

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

General: Based on observation during a tour of the childcare center, the surveyor found that a staff person was on her cell phone for approximately five to seven (5-7) minutes while supervising the toddler-age children. Staffing Requirements In Compliance General Administration In Compliance Director Requirements 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 10. Director Requirements and Responsibilities.

General: Based on review of documentation, the surveyor found that a staff’s (DOH: 05/24/10) file contained a written performance evaluation dated 02/07/17. Therefore, the written performance evaluation was not completed annually. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 6 Inspection Report Employee 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, the surveyor found that a staff's (DOH: 07/25/17) file contained a criminal records check indicating a felony charge. Consultation with the Adair County Circuit Court Clerk on 04/13/18, found that the charge was amended to a lower charge which is a Class D felony. The individual was ordered to complete a diversion program. The clerk stated that the staff person is currently on probation that will be completed in December 2019. The staff person was alone with the children.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation contained in a staff’s (DOH: 05/24/10) file, the surveyor found the copy of a negative tuberculin result that was no longer current as of 03/15/18.

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 Type l childcare center does not have two (2) qualified substitute staff in the case of need. The two (2) individuals identified as substitute staff do not meet qualification due to lack of annual training hours and current negative tuberculin result.

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: 03/09/09) completed only fourteen (14) hours of cabinet-approved early care and education annual training during the review period of 03/09/17 and 03/08/18. 2. A staff (DOH: 03/28/16) completed only five (5) hours of cabinet-approved early care and education annual training during the review period of 03/28/17 and 03/27/18. 3. A staff (DOH: 05/13/15) completed only twelve (12) hours of cabinet-approved early care and education annual training during the review period of 05/13/16 and 05/12/17. 4. A staff (DOH: 01/04/15) completed only fourteen (14) hours of cabinet-approved early care and education annual training during the review period of 01/04/17 and 01/03/18. 5. A staff (DOH: 01/02/13) completed only fourteen (14) hours of cabinet-approved early care and education annual training during the review period of 01/02/17 and 01/01/18. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 6 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, the surveyor heard a staff person use a harsh tone when telling the children to “Get in your chair now, get over here now, hush, this is the last time I am going to tell you to lay down and go to sleep”. The staff threatened to take a child’s toy if she did not lay down and go to sleep.

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 found that an infant was sleeping in a swing located in the Infant Room. Through interview with staff and review of documentation, the surveyor learned that a health professional had not recommended that the child have an alternate sleep position.

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 a tour of the Infant Room, the surveyor found that an infant was sleeping in a crib. The child’s face was on a folded and loose receiving blanket located at the foot of the crib.

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 heard a staff person use a harsh tone repeatedly telling the children to "lay down and go to sleep”. The staff person did not allow the children to play quietly or offer an alternate activity.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 9. Food and Meal Requirements.

General: Based on observation, the surveyor heard a staff person in the Toddler Room tell a child that they would receive a sucker if they laid down on their cot to take a nap. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 6 Inspection Report Premises Not In Compliance

Open Not marked corrected in the state record

Category: nutrition. Open / not marked corrected.

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

General: Based on observation during a tour of the childcare center, the surveyor found the following: 1. A staff’s purse was placed on the floor beside the teacher’s desk located in the classroom for the two-year-old children. The purse was accessible to the children. 2. A staff’s purse was observed on an approximate three (3) feet high shelf in the Toddler Classroom. The purse handle was dangling down within reach of the children; therefore, the purse was accessible to the children. 3. An empty plastic bag was observed on top of a plastic stack bin located in the classroom for the two-year-old children. The empty plastic bag was within reach of the children. 4. A fire extinguisher was observed on the floor located in the Preschool Room. The fire extinguisher was within reach of the children. 5. An air freshener was plugged into an electrical outlet located in the Preschool Room. The air fresher was within reach of the children. 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, the surveyor found that an unlocked first aid kit was on an approximate two and one-half to three (2 ½ -3) foot high table located between the Preschool Room and the classroom for the two-year-old children. The first aid kit was within reach and accessible to the children. Outdoor Play Area In Compliance Equipment 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 6. Sleeping and Napping Requirements.

General: Based on observation, the surveyor found that multiple mats had tears in the vinyl covering that exposed the interior foam padding. The mats were used by the children at nap time in the Preschool Room and in the classroom for the two-year-old children. Transportation Not Applicable Food Service/Food Program In Compliance Food Service In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 4 of 6 Inspection Report 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: 04/25/17) file contained an immunization certificate that was no longer current as of 02/13/18. 2. A child’s (DOE: 05/01/17) file contained an immunization certificate that was no longer current as of 02/21/18. 3. A child’s (DOE: 07/08/15) file contained an immunization certificate that was no longer current as of 03/17/18.

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 contained in ten (10) children’s files, the surveyor found the following: 1. Three (3) files did not contain information to enable a person in charge to identify or contact the preferred hospital. 2. Three (3) files did not contain information to enable a person in charge to contact the preferred hospital. 3. One (1) file did not contain information to enable a person in charge to contact the family physician. 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 found that the Emergency Preparedness Plan was dated December 2016. An updated, reviewed or revised copy of the plan was not presented to the surveyor for review. Posted 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 8. General.

General: Based on review of documentation, the surveyor found that the completed Statement of Deficiency and Plan of Correction was not posted for the current licensure year. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 5 of 6 Inspection Report Animals Not Applicable

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation and interview, the following were found: 1. An employee (DOH: 5/24/10) file presented for review contained an employee performance evaluation dated January 2016 which had not been updated annually as required. 2. A substitute (DOH: 1/4/15) file presented for review did not contain an employee performance evaluation. 3. An employee (DOH: 5/13/15) file presented for review contained an employee performance evaluation dated January 2016 which had not been updated annually as required. 4. An employee (DOH: 8/7/15) file presented for review contained an employee performance evaluation dated January 2016 which had not been updated annually as required. 5. A substitute (DOH: 11/2/15) file presented for review contained an employee performance evaluation dated January 2016 which had not been updated annually as required. The director stated that she thought everyone's evaluation had been updated with the exception of one (1) substitute's (DOH: 1/4/15) who was on maternity leave. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 6 Inspection Report Employee Records Not In Compliance

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on review of documentation and interview, the surveyor found that the file for a substitute staff (DOH: 1/4/15) did not contain record of an annual performance evaluation. The director stated that the substitute has been on maternity leave.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, review of ECE-TRIS, and interview, the following were found: 1. A staff (DOH: 3/9/09) had obtained only twelve (12) hours of cabinet-approved early care and education annual training for 3/9/15 - 3/8/16. 2. A substitute (DOH: 11/2/15) file did not contain documentation of Pediatric Abusive Head Trauma Training, the training was not documented in ECE-TRIS; therefore, it had not been completed within the first year of employment. 3. A substitute (DOH: 11/2/15) file contained record of the substitute completing six (6) hours of cabinet-approved orientation on 2/24/16. Review of ECE-TRIS confirmed that orientation was completed on 2/24/16; therefore, orientation was not completed within three (3) months of the substitute's date of hire. Upon interview, the director was not aware of the descrepencies in relation to training. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 6 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, the surveyor found that the Lesson Plan posted in the School-age Classroom was dated for 1/30/17 - 2/3/17; therefore, it was not a current Lesson Plan. Upon interview, the Director confirmed that children would be present in the School-age Classroom that afternoon. 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 an unlocked storage closet in the Two's Classroom contained loose trash bags, a broom/dust pan sitting on the floor, and a staff member's can of Coca Cola. Upon interview, the staff member stated that the closet remains unlocked; therefore, the items were accessible to children.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation and interview, the surveyor found a gap of approximately a half (1/2) inch to one (1) inch between the double doors in the Pre-school Classroom that was not protected, thus allowing cold air, possibly rain, and vermin to enter the building. Upon interview, the Director stated that she was aware of the the issue. 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 4. Premises Requirements.

General: Based on observation and interview, the following were found: 1. The School-age Room contained various areas where the paint was peeling away from the wall. Upon interview, the director acknowledged she was aware of the peeling paint. 2. There were multiple ceiling tiles in the School-age Room that contained brown stains that appeared to be the result of a leak. The Director stated she was not aware of there ever being a leak in the School-age Room. 3. The floor vent underneath the window in the One's Classroom was broken and cracked creating sharp edges accessible to the children. Staff stated that they were not aware of the damaged floor vent or how long it had been damaged.

Open Not marked corrected in the state record

Category: physical safety. 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 ventilation fan located in the restroom at the end of the hallway contained a thick coating of dust, thus preventing it from effectively ventilating the restroom. Upon interview, the director was not aware of the dust accumulation on the ventilation fan. 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 mat located in the Two's Classroom contained a tear; therefore, it could not be properly sanitized. Upon interview, the director was not aware of the tear in the diaper changing mat. 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 and interview, the surveyor found that the playground was not free from litter or rubbish as there was a significant amount of litter along the inside border of the playground fence. The director stated they have had an issue with litter and rubbish blowing onto the playground from outside the fence. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 4 of 6 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 and interview, the surveyor found the following: 1. The black top was visible through the mulch under the yellow slide. 2. The school bus climber did not have a protective surface under it as it was sitting on a black top surface. 3. The back of the school bus climber was up against the fence; therefore, it did not have a fall zone equal to the height of the equipment. 4. The tractor climber did not have a protective surface under it as it was sitting on a black top surface. Upon interview, the Director was not aware of the issues relating to the protective surface or lack of appropriate fall zone. 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 11. Toys and Furnishings.

General: Based on observation and interview, the surveyor found that a child size vinyl chair located in the Pre-school Classroom contained multiple small tears in the vinyl; therefore, it was not in good repair. Staff stated they were aware of the chair's condition.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation and interview, the surveyor found that two (2) tricycles located on the playground were missing the plastic pedals leaving only the metal peg exposed; therefore, the tricycles were not in good repair. Upon interview, the director was not aware of the missing pedals. Transportation Not Applicable 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 2:110 · 922 KAR 2:110. Section 3. Records.

General: Based on review of documentation and interview, the following was found: 1. An employee (DOH: 3/16/09) file presented for review did not contain a professional development plan. 2. An employee (DOH: 3/9/09) file presented for review contained the most recent professional development plan dated January 2016; therefore, the plan had not been updated annually as required. 3. An employee (DOH: 3/1/12) file presented for review contained the most recent professional development plan dated January 2016; therefore, the plan had not been updated annually as required. 4. A substitute (DOH: 1/4/15) file presented for review did not contain a professional development plan. 5. An employee (DOH: 5/13/15) file presented for review contained the most recent professional development plan dated January 2016; therefore, the plan had not been updated annually as required. 6. A substitute (DOH: 11/2/15) file presented for review contained the most recent professional development plan dated January 2016; therefore, the plan had not been updated annually as required. The director stated she thought everyone was up to date in regards to the professional development plans with the exception of one substitute (DOH: 1/4/15) who was on maternity leave. Posted Documentation Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110. Section 2. General.

General: Based on observation and interview, the surveyor found that the Children's/Parent's Rights were not posted in the center. Upon interview, the director stated she thought they were posted but she could not locate where they were posted during the survey. Animals In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation the surveyor found the following; 1. While a child was being fed in a high chair, the child was not harnessed using the chairs safety straps. 2. The children’s coats and backpacks were hanging on pegs in the hallway and found to be touching, this could result in cross contamination.

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 contained in one (1) staff members (DOH:11/2/15) file, the surveyor found no evidence that a criminal record background check has been completed. Based on interview with the Director, the surveyor was informed that the background check has been submitted but it has not yet been received. The Director reports that the staff member has not been alone with the children. The staff member has been employed longer than ninety (90) calendar days.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation contained in one (1) staff members (DOH:5/13/15) file, the surveyor found no evidence of a current negative tuberculin skin test.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation contained in two (2) staff (DOH: 1/2/13) & (DOH: 1/6/15) files, the surveyor found that both are lacking a total number of fifteen (15) training hours in the last year based on their hire dates. 345 - Driver Requirements Not Applicable 922 KAR 2:120. Section 12. Transportation. (18) A driver of a vehicle transporting a child for a center shall: (a) Be at least twenty-one (21) years old; (b) Complete: 1. The background checks as described in 922 KAR 2:110; and 2. An annual check of the: a. Kentucky driver history records in accordance with KRS 186.018; or b. Driver history records through the state transportation agency that issued the driver’s license; (c) Hold a current driver’s license which has not been suspended or revoked during the last five (5) years; and (d) Not caused an accident which resulted in the death of a person. Programming

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on observation the surveyor found the following; 1. A plunger placed near the toilet in the upstairs boys' bathroom. The plunger is accessible to children. 2. A vacuum cleaner placed behind the door of the upstairs boys' bathroom. The vacuum cleaner is accessible to children.

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 there to be an unknown brown substance on the toilet seat and on the wall of the upstairs girls' bathroom.

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 toilet seats to be unsecure in both the upstairs boys' and girls' bathrooms. Hygienic Practices

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. The fencing around the central air unit did not completely enclose the unit. There is a gap of approximately 1-2 ft. between the end of the fence and a brick wall. The unit is located outside in an area where children play and this poses a risk of injury to a child. 2. A gap of approximately 1-1 ½ ft. between the fence and a brick wall located outside in an area where children play. The gap is large enough for a child to climb through or become stuck. 3. The gate’s top right hinge is not attached to the fence post that is located outside on the playground.

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 found the sheet on a mattress in a crib in the infant room to be soiled with a wet substance.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the surveyor found that the food service permit posted was out of date as of 12/31/15. Based on an interview with the Owner and Director, the surveyor was informed that a new food service permit has been issued but it has been temporarily misplaced.

Open Not marked corrected in the state record

Category: nutrition. Open / not marked corrected.

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

General: Based on observation the surveyor found there to be no thermometer in the refrigerator. Therefore, the temperature of the freezer could not be verified as being forty (40) degrees Fahrenheit or below.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation the surveyor found the thermometer in the kitchen freezer to be broken. The surveyor could not verify that the frozen foods were kept at a temperature of zero degrees Fahrenheit or below.

Open Not marked corrected in the state record

Category: nutrition. Open / not marked corrected.

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

General: Based on review of documentation, one (1) child's file did not contain the name or phone number of the family physcian or the preferred hospital information.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, the surveyor found no verification that two (2) of the staff's (DOH: 03/16/09 and 01/29/14) written annual performance evaluations had been completed. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 5 of 26 Web site: http://chfs.ky.gov/ Inspection Report

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on observation during a tour of the Infant Room, the surveyor found the following; 1. A four-month-old child had been placed in a bouncy seat that was then placed in a crib creating a safety hazard to the infant. 2. Two (2) infant children were observed to be sleeping in their cribs while wearing bibs, creating a safety hazard. 3. The surveyor observed that six (6) of the children's coats were hanging on pegs in the cubbies located in the Preschool Room. The coats were touching, creating the risk for cross contamination. 4. The surveyor observed that nine (9) of the children's coats were touching in the School-age Room, creating a risk for cross contamination. 5.The following items were observed to have been stored in the Preschool Room located beside the restroom that is used by the school-age children: Mop, bucket, vaccuum cleaner and a dust pan. These items were accessible to the children.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, the surveyor found the following: 1. A staff's (DOH: 01/02/13) file contained a copy of a negative tuberculin result that was no longer current as of 10/29/14. 2. A staff's (DOH: 03/01/13) file contained a copy of a negative tuberculin result that was no longer current as of 02/16/14.

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 a tour of the Infant Room, the surveyor found a pink-colored plastic ball in the crib where an infant was napping.

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. The surveyor observed that paint was peeling from the stairway railing that leads to the classrooms located on the lower level of the child care center. 2. The surveyor observed a thick layer of dust on the ceiling vents located in both of the restrooms that are used by the children. 3. The surveyor observed a thick layer of dust on the wall vent located under the diaper changing table in the Infant Room.

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 during a tour of the child care center, the surveyor found the following: 1. There was an approximate six (6) inch hole in the wall located near the stair in the School-age Room. 2. An extended section of the carpeting located in the School-age Room was frayed with ragged edges. 3. The paint was extensively marred as if tape had been peeled off of the walls located in the classroom for the two- and three-year-old children. 4. A broken floor vent cover was observed in Restroom #1.

Open Not marked corrected in the state record

Category: physical safety. 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 that the toilet seat was not securely attached to the toilet bowl located in Restroom #2. Hygienic Practices

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. The playground has an asphalt surface over which mulch has been placed. A climbing structure with a slide did not have a fall zone or protective surface. 2. The protective surface at the base of a slide had worn away exposing the underlying asphalt surface.

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 a tour of the playground, the surveyor found the following: 1. The top of the fence was not secured to the rail located beside the heating and air unit allowing for an approximate eighteen to twenty (18-20) inch gap. 2. The bracket on the top rail of the gate was not attached to the fence post which prevented the gate from opening properly.

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 a tour of the Preschool Room, the surveyor found a tear in the vinyl covering on a mat that is used by the children.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the surveyor found the following: 1. During a tour of the Toddler Room, the surveyor observed that a wooden table had a plastic laminate-type coating that was peeling and accessible to the children. 2. A metal bracket is used to secure together two (2) units of a sectional sofa located in the School-age Room. One (1) end of the metal bracket had detached and was jutting outward creating a safety hazard to the children.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, the surveyor found the following: 1. Ten(10) of the children’s files did not contain information to enable a person in charge to contact their preferred hospital. 2. Ten (10) of the children’s files were reviewed of which six (6) did not contain information to enable a person in charge to identify their preferred hospital. 3. Ten (10) of the children’s files were reviewed of which one (1) did not contain information to enable a person in charge to contact the child’s physician. 4. Ten (10) of the children’s files were reviewed of which one (1) did not contain information to enable a person in charge to identify or contact the child’s physician.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, a plan of correction was received from the provider on 2/14/14 as a result of the relicensure survey conducted on 1/24/14. However, a follow-up visit was conducted at the center on 2/27/14 and the following regulatory violations were found uncorrected: 1) A three feet (3') tall, free-standing heater/fan and a three feet (3') tall shelf in the Infant Room were unsecured and wobbly. The heater/fan and the shelf were accessible to mobile infants in the room. 2) A four feet (4') tall shelf and a two feet (2') tall shelf in the One's Room were unsecured and tipped easily. 3) An unsecured television was on a four and one-half feet (4 1/2') tall shelf in the Preschool Room. 4) A three feet (3') tall cubby was unsecured and tipped easily in the Preschool Room. 5) An unsecured television was on a three feet (3') tall shelf in the School Age Room. 6) An electric outlet plate was missing on an electric outlet in the Overflow Room. In addition, the following regulatory violation was not issued during the relicensure survey conducted on 1/24/14 but was found during the follow-up inspection: A corner of an electric outlet plate was broken off and two (2) outlets were uncovered in the School Age Room.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, staff evaluations were not presented for review. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 5 of 28 Web site: http://chfs.ky.gov/ Inspection Report

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on observation, the following were found: 1) A four feet (4') tall shelf and a two feet (2') tall shelf in the One's Room were unsecured and tipped easily. 2) A three feet (3') tall tower heater and a three feet (3') tall shelf in the Infant Room were unsecured and wobbly. 3) A ten-month-old infant was seated in a high chair and safety straps were not used to secure the child. 4) A six-week-old infant was sleeping on a boppy pillow in a crib in the Infant Room. Staff stated that the infant's parent verbally requested that the infant sleep on the boppy pillow but that written documentation of this request was not provided by the parent. 5) Plastic sleeves containing documentation of crib compliance were secured to the top, and hung below the rails, of two (2) cribs in the Infant Room. The cribs were assigned to individual infants who were currently enrolled and attended the center. 6) An unsecured television was on a four and one-half feet (4 1/2') tall shelf in the Preschool Room. 7) A three feet (3') tall cubby was unsecured and tipped easily in the Preschool Room. 8) A toilet brush was beside a toilet in the Preschool Restroom. 9) A child's mat was placed below a wall shelf at nap time. An unsecured desk telephone was on the shelf and the phone cord hung below the shelf to within approximately two feet (2') of the floor and within a child's reach. 10) A staff member placed sheets and covers on the children's mats prior to nap time in the Preschool Room. The staff member smoothed and arranged the sheet with her shoe on one (1) child's mat and she stepped on two (2) other children's sheet and blanket covered mats. 11) Two (2) mouse traps were located on the floor in the hot water closet. The closet was accessed via a door in the School Age Restroom and was secured by a hook and eye latch. However, the eye section had pulled away from the wooden door frame allowing the door to remain ajar by approximately two inches (2"). 12) An unsecured television was on a three feet (3') tall shelf in the School Age Room. 13) A bottle of Louisiana Hot Sauce was on a three feet (3') tall shelf in the Preschool Room. 14) An aerosol can of WD-40 was on a wall shelf in the hallway outside the director's office. 15) An electric outlet plate and a cover were missing on an electric outlet in the Overflow Room. 16) A tissue box containing debris including a tumb tack was on a cart in the School Age Room.

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 following was found: 1) A criminal records check was not presented for review for a staff member (date of hire - 3/1/2013). Staff stated during interview that this individual is a teacher and that she works alone with the preschool age children. 2) A criminal records check was not presented for review for a substitute staff member. A date of hire was also not provided. Staff stated during interview that this individual was employed through the school co-op program. Staff were unaware if this individual has resided outside of the Commonwealth of Kentucky in the last five (5) years.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, the following was found: 1) The personnel file for one (1) substitute staff member did not include a beginning date of employment. Staff stated during interview that it was unknown when this individual began employment. 2. A crininal records check, a child abuse or neglect check and a criminal records check from any previous state of residence were not presented for review for a volunteer. Staff stated during interview that they were unaware if this individual has resided outside of the Commonwealth of Kentucky in the last five years but that this individual has had no unsupervised contact with a child in care. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 7 of 28 Web site: http://chfs.ky.gov/ Inspection Report

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, a statement from a health professional that a staff member is free of active tuberculosis or a copy of negative tuberculin results was not presented for review for a staff member.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, evidence of fifteen (15) hours of cabinet-approved early care and education training obtained from 5/24/12 through 5/24/13 was not presented for review for a staff member (date of hire - 5/24/10). . 345 - Driver Requirements Not Applicable 922 KAR 2:120. Section 12. Transportation. (18) A driver of a vehicle transporting a child for a center shall: (a) Be at least twenty-one (21) years old; (b) Complete: 1. The background checks as described in 922 KAR 2:110; and 2. An annual check of the: a. Kentucky driver history records in accordance with KRS 186.018; or b. Driver history records through the state transportation agency that issued the driver’s license; (c) Hold a current driver’s license which has not been suspended or revoked during the last five (5) years; and (d) Not caused an accident which resulted in the death of a person. Programming

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on observation, a loose blanket was placed over a six-week-old infant who was sleeping in a crib in the Infant Room.

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 following was found: 1) P.A.W.S. Antimicrobial hand wipes and Q-Tips First Aid antibiotic cream were in an unlocked storage cabinet in the School Age Room. The preschool and school age children were in the School Age Room during the inspection. 2) A box of 20 Mule Team Borax Powder, a bottle of Sta-Flo liquid starch, an aerosol can of Sport 30 SPF sunscreen, a container of Bloodworms freeze dried fish food containing an allergy alert label, a bottle of Betta Safe water conditioner and an aerosol can of Conditioning Sheen were in an unlocked storage cabinet in the School Age Room. 3) Three (3) pairs of scissors (not safety scissors) and a screw driver were in an unlocked storage cabinet in the School Age Room. 4) A small appliance battery was on a cart in the School Age Room. 5) A rat tail comb with a metal pick and two (2) hair brushes containing a large amount of hair were on top of a storage cabinet in the School Age Room. 6) A bottle of hand sanitizer was on a shelf in the School Age Room. 7) An aerosol can of sunscreen, a bottle of sunscreen lotion and two (2) used combs were in an unlocked storage cabinet in the Preschool Room. Children were in the Preschool Room during the inspection. 8) Liquid laundry detergent, a gallon of liquid bleach, a toilet bowl plunger, mops and brooms were in an unlocked laundry closet located in the Preschool Room. 9) A bottle of hand sanitizer in which glitter had been added was in an unlocked cabinet in the Preschool Room.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the following was found: 1) Two (2) tables in the School Age Room were soiled and stained. The preschool children's lunch plates were placed on one (1) of the tables in order to assemble the required food components prior to serving the children's lunch. 2) Doors, trim, walls, vents and light fixture plates throughout the center were soiled. 3) Carpet installed on metal posts in the downstairs classrooms had come loose from the poles along the seams and the edges of the seams were frayed. 4) Carpeting on the floors in the downstairs classrooms was frayed in several areas. 5) The paint and plaster were chipped on the walls throughout the center. 6) Soil was in the crevices of plastic storage crates that were being used as cubbies for the children in the Preschool Room. 7) The exterior surfaces of the waste receptacle in the Preschool Restroom were soiled.

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, light bulbs that were not shatter proof were installed in an unshielded light fixture in the School Age Restroom.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the following was found: 1) Several water stained/circled ceiling tiles were in the Preschool Room. 2) A section of baseboard trim was loose along one (1) wall in the Preschool Room.

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on observation, the School Age Restroom was not equipped with toilet paper.

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 School Age Restroom was not equipped with a hand-drying blower or single use disposable hand drying material.

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 changing pads in the Infant and Toddler Rooms were in disrepair with holes and worn areas. Therefore, they could not be properly sanitized.

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 following was found: 1) A bottle of aspirin, a bottle of Tylenol Extra Strength caplets, Q-Tips First Aid antibiotic cream, and a strip of aluminum foil that was crumpled up and contained five (5) generic tums tablets were in an unlocked storage cabinet in the School Age Room. The preschool and school age children were in the School Age Room during the inspection. 2) A bottle of Tylenol Melts and a roll of Tums were in an unlocked storage cabinet in the Preschool Room. Children were in the Preschool Room during the inspection. 3) A bottle of Magnesium Citrate Oral Solution (saline laxative) was in an unlocked refrigerator in the Overflow Room. The Overflow Room and the Preschool Room were in one (1) large room and separated by five feet (5') tall shelves. Staff use the Overflow Room for storage of extra mats and for storage of milk for the preschool children's lunches. Staff were observed to access the Overflow room by pushing a shelf away to create an open area. Staff stated during interview that the room is currently not being used for child care but that it is being prepared for children's use beginning next week. Children were not observed in the room during the inspection. Outdoor Play Area

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, various paper and plastic debris was scattered on the playground and had gathered alongside the fence.

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, asphalt surfacing was exposed around, and at the bases of, three (3) slides and the play structures. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 17 of 28 Web site: http://chfs.ky.gov/ Inspection Report

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, a hole that measured approximately six inches by twelve inches (6" x 12") was located under and along the bottom of the fence at one (1) location on the playground.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the following was found: 1) Many children's coats, jackets and backpacks were stacked together and stored on only a few wall hooks and on the floor below the wall hooks in the School Age Room. 2) Seventeen (17) children were present in the Preschool Room and only twelve (12) storage crates were provided for storage of the children's personal belongings. As a result, some of the preschool children's personal belongings were stored in the School Age Room and on the floor. 725 - Playpens/Play Yards Not Applicable 922 KAR 2:120. Section 5. Infant and Toddler Play Requirements. (5) Playpens and play yards shall: (a) Meet federal standards as issued by the Consumer Product Safety Commission, including 16 C.F.R. 1221; (b) Be manufactured for commercial use; and (c) Not be used for sleeping or napping.

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, many two inch (2") thick mats throughout the center were in disrepair with tears and worn areas.

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, three (3) cribs were spaced two inches (2") apart rather than twelve inches (12") as required. Staff stated that the cribs are assigned to individual infants who are currently enrolled and attend the center.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the following was found on the playground: 1) The pedals on two (2) tricycles were missing. 2) The front section was missing, and the cab was not secured, on a fire engine ride toy.

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, there was no thermometer in a refrigerator in the Overflow Room that was used to store milk for the preschool children's lunches. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 22 of 28 Web site: http://chfs.ky.gov/ Inspection Report

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, there was no thermometer in a freezer used to store food for the children's meals. Therefore, it could not be determined that the food in the freezer was maintained at zero (0) degrees Fahrenheit or below as required.

Open Not marked corrected in the state record

Category: nutrition. Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 9. Food and Meal Requirements.

General: Based on observation, the following was found: 1) A half-full bottle of chocolate milk that was dated for use through 7/9/13 was in the refrigerator in the Overflow Room. 2) A bottle of ketchup and a bottle of mustard that had been opened and were warm to touch were on a cart in the School Age Room prior to lunch on the day of the visit. Both bottles contained the statement that they should be refrigerated after opening.

Open Not marked corrected in the state record

Category: nutrition. Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 9. Food and Meal Requirements.

General: Based on observation, a staff member used her bare hands to tear sliced bread in half and to place slices of lunch meat on the bread prior to placing the bread and meat on the preschool children's plates for lunch.

Open Not marked corrected in the state record

Category: nutrition. Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 9. Food and Meal Requirements.

General: Based on observation, two per cent (2%) low-fat milk was served to the preschool age children for lunch during the inspection.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, professional development plans were not presented for review.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, the lesson plan posted in the School Age Room was dated 1/13-17/14 which did not include the day of the inspection.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, the most recent written performance evaluations presented for surveyor review for four (4) staff members (DOH: 3/9/09, 8/24/09, 5/24/10, and 10/11/10) were dated 2011.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on review of documentation, the file presented for surveyor review for a staff member (DOH: 1/10/13) did not contain evidence of a high school diploma, GED, or Commonwealth Child Care Crendential. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 8 of 43 Web site: http://chfs.ky.gov/ Inspection Report

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110 - Section 5 (1)

General: Based on review of documentation, the most recent TB skin test result contained in the file presented for surveyor review for a staff member (DOH: 8/24/09) was dated 12/28/10 and was no longer current after 12/28/12. 128 - CPR/First Aid Coverage 922 KAR 2:110 - Section 5 (3) At least one (1) person on duty and present with the children shall be currently certified by a cabinet-approved training agency in the following skills: (a)Infant and child cardiopulmonary resuscitation; and (b) Infant and child first aid. 1) CPR In Compliance 2) First Aid In Compliance 131 - Adequate Substitute(s) 922 KAR 2:110 - Section 5 (6) Child-care centers shall have available in case of need: (a) One (1) qualified substitute staff person for a Type II child-care center; or (b) Two (2) qualified substitute staff persons for a Type I child-care center 1) Type I In Compliance 131 - Adequate Substitute(s) 922 KAR 2:110 - Section 5 (6) Child-care centers shall have available in case of need: (a) One (1) qualified substitute staff person for a Type II child-care center; or (b) Two (2) qualified substitute staff persons for a Type I child-care center 2) Type II Not Applicable 139 - Training 922 KAR 2:110 - Section 5 (14) A staff person with supervisory authority over a child shall complete the following: (a) Six (6) hours of cabinet-approved orientation within the first three (3) months of employment; (b) Nine (9) hours cabinet-approved child development training within the first year of employment; and (c) Fifteen (15) hours of cabinet-approved training during each subsequent year of employment. 1) Orientation In Compliance 2) 9 hours-first year In Compliance 139 - Training 922 KAR 2:110 - Section 5 (14) A staff person with supervisory authority over a child shall complete the following: (a) Six (6) hours of cabinet-approved orientation within the first three (3) months of employment; (b) Nine (9) hours cabinet-approved child development training within the first year of employment; and (c) Fifteen (15) hours of cabinet-approved training during each subsequent year of employment. 3) 15 hours annually Not In Compliance Findings: General: Based on review of documentation, a staff member (DOH: 8/24/09) completed only ten (10) hours of annual training from 8/24/11 to 8/24/12. 317 - Driver requirements Not Applicable 922 KAR 2:120 - Section 12 (18) A driver of a vehicle transporting a child for a center shall: (a) Be at least twenty one (21) years old; (b) Complete the background checks as described in 922 KAR 2:110; (c) Hold a current driver’s license which has not been suspended or revoked during the last five (5) years; (d) Not have had any convictions concerning vehicle operation in the past twelve (12) months; and (e) Not caused an accident which resulted in the death of a person. 1) Be 21 years old or over Not Applicable 2) Background checks Not Applicable 3) Drivers license Not Applicable 4) No convictions for vehicle operation Not Applicable 5) No accident causing death Not Applicable An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 9 of 43 Web site: http://chfs.ky.gov/ Inspection Report Programming 169 - Program of Activities Followed 922 KAR 2:120 - Section 2 (4) The child-care center shall provide a daily planned program of activities: (a) Posted in writing in a conspicuous location with each age group and followed; 1) Posted In Compliance 2) Followed In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120 - Section 6

1 Year Olds: Based on observation, the vinyl coverings on the corners of two (2) mats were torn. 294 - Toys/Equipment/Furniture 922 KAR 2:120 - Section 11 (1) All toys, equipment, and furniture contacted by a child shall be: (a) Kept clean and in good repair and (b) Free of peeling, flaking, or chalking paint. 1) Clean Not In Compliance Findings: 2 Year Olds: Based on observation, the cloth coverings on the arms and seat cushion of the adult chair were stained. 2) Good repair Not In Compliance Findings: School Age: Based on observation, the vinyl covering on a small soft chair was torn in numerous places. 1 Year Olds: Based on observation, the vinyl covering on the diapering mat had several tears. 294 - Toys/Equipment/Furniture 922 KAR 2:120 - Section 11 (1) All toys, equipment, and furniture contacted by a child shall be: (a) Kept clean and in good repair and (b) Free of peeling, flaking, or chalking paint. 3) Free from peeling, flaking, chalking paint In Compliance 295 - Indoor/outdoor Equipment 922 KAR 2:120 - Section 11 (2) Indoor and outdoor equipment shall: (a) Be clean, safe, and in good repair; (b) Meet the physical, developmental needs, and interests of children of different age groups; (c) Be free from sharp points or corners, splinters, protruding nails or bolts, loose or rusty parts, hazardous small parts, lead-based paint, poisonous material, and flaking or chalking paint; and (d) Be designed to guard against entrapment or situations that may cause strangulation. 1) Clean In Compliance 2) Safe In Compliance 3) Good repair In Compliance 4) Meets needs In Compliance 5) Free from harmful conditions In Compliance 6) Guard against entrapment/strangulation In Compliance 296 - Toys 922 KAR 2:120 - Section 11 (3) Toys shall be: (a) Used according to the manufacturer's safety specifications; (b) Durable; and (c) Without sharp points or edges. 1) Used according to manufacturers specifications In Compliance 2) Durable In Compliance An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 29 of 43 Web site: http://chfs.ky.gov/ Inspection Report 3) No sharp points/edges In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110 - Section 3

General: Based on review of documentation, the file presented for surveyor review for one (1) child (DOE: 10/3/12) did not contain an immunization certificate. 99 - Documentation for Off Premise Trip Not Applicable 922 KAR 2:110 - Section 3 The following records shall be maintained at the child-care center for five (5) years: (4) Permission forms for each trip off the premises signed by the parent; An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 39 of 43 Web site: http://chfs.ky.gov/ Inspection Report Written Documentation 93 - Policies and Procedures 922 KAR 2:110 - Section 2 (5) Program policies and procedures shall: (a) Be in writing; and (b) Include: 1. Staff policies; 2. Job descriptions; 3. An organization chart; 4. Chain of command; and 5. Other procedures necessary to ensure implementation of: a. KRS 199.898, Rights for children in child-care programs and their parents, custodians, or guardians - posting and distribution requirements; b. 922 KAR 2:090, Child-care center licensure; c. 922 KAR 2:120, Child-care center health and safety standards; and d. This administrative regulation. 1) Writing In Compliance 2) Staff Policies In Compliance 3) Job Description In Compliance 4) Organization Chart In Compliance 5) Chain of Command In Compliance 6) Other Procedures-a) Rights for Children b)922 KAR 2:090 c) 922 KAR 2:110 d)922 KAR 2:120 In Compliance 100 - Daily Attendance Records 922 KAR 2:110 - Section 3 (5) Daily attendance records documenting the arrival and departure time of each child; 1) Arrival Not In Compliance Findings: General: Based on review of documentation and interview, the following was found: (1) On 1/30/13, sixteen (16) children's arrival times at the center from school, preschool, or Head Start were not documented. (2) On 11/30/12, fourteen (14) children's arrival times at the center from school or Head Start were not documented. 2) Departure Not In Compliance Findings: General: Based on review of documentation and interview, the following was found: (1) Ten (10) children's departure times from the center to school on the date of the survey were not documented. Also, one (1) child was picked up by his grandfather prior to the surveyor's departure from the center and the child's departure time was not documented. (2) On 1/30/13, sixteen (16) children's departure times from the center to school, preschool, or Head Start were not documented. (3) Sixteen (16) children's departure times from the center to home were not documented on 1/30/13. (4) On 11/30/12, fourteen (14) children's departure times from the center to school or Head Start were not documented. (5) Six (6) children's departure times from the center to home were not documented on 11/30/12.

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110 - Section 3

General: Based on review of documentation and interview, the center did not have a written staff work schedule. 104 - Earthquake/Tornado Drills 922 KAR 2:110 - Section 3 (9) A written record of quarterly, practiced earthquake and tornado drills detailing the date, time, and children who participated; 1) Earthquake - conducted quarterly In Compliance 2) Earthquake - includes date In Compliance 4) Earthquake - includes children who participated In Compliance 5) Tornado - conducted quarterly In Compliance 6) Tornado - includes date In Compliance 7) Tornado - includes time In Compliance 8) Tornado - includes children who participated In Compliance An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 40 of 43 Web site: http://chfs.ky.gov/ Inspection Report 104 - Earthquake/Tornado Drills 922 KAR 2:110 - Section 3 (9) A written record of quarterly, practiced earthquake and tornado drills detailing the date, time, and children who participated; 3) Earthquake - includes time Not In Compliance Findings: General: Based on review of documentation, tornado and earthquake drills were conducted on the same day each month but only (1) time was documented on the log sheet. The director stated during interview that tornado drills were conducted first. Therefore, the time of each monthly earthquake drill was not documented as required. 105 - Fire Drills 922 KAR 2:110 - Section 3 (10) A written record of practiced fire drills conducted monthly detailing the date, time, and children who participated; 1) Date In Compliance 2) Time In Compliance 3) Children In Compliance 4) Conducted monthly 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 10

Infants: Based on observation, the diapering procedure was not posted. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 42 of 43 Web site: http://chfs.ky.gov/ Inspection Report Animals 319 - Animal Requirements Not Applicable 922 KAR 2:120 - Section 13 (1) Animals shall be: (a) Supervised by an adult if in the presence of a child in care; and (b) Certified as properly vaccinated against rabies. 1) Supervised Not Applicable 2) Vaccinated Not Applicable 321 - Prohibited Animals Not Applicable 922 KAR 2:120 - Section 13 (3) Except if used as planned program activity in the control of an animal specialist, an animal that is considered undomesticated, wild, or exotic shall not be allowed at a child-care center. 1) Undomesticated Not Applicable 2) Wild Not Applicable 3) Exotic Not Applicable C.O. 13 - Corporation/ LLC/ Partnership 922 KAR 2:090 - Section 4 (3) If the applicant for licensure is a: (a) Corporation or a limited liability company, the application shall include a current certificate of existence or authorization from the Secretary of State; or (b) Partnership, the application shall include a written statement from each partner that the partnership is current and viable. 1) Corporation/LLC statement Not Inspected 2) Partnership statement Not Inspected

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120 - Section 11

One year old Room: Based on interview, the staff in the one year old classroom stated that mouth contact toys were cleaned weekly by placing the toys in a bucket with hot, bleach water and then air dried. This is not the required toy sanitation procedure.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110 - Section 2

General: Based on observation, the surveyor found that the names of the children and their birthdates were posted in the Infant and Toddler classrooms.

Open Not marked corrected in the state record

Open / not marked corrected.

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

Infant Room: Based on observation, the surveyor found that an infant child was sleeping in a swing.

Open Not marked corrected in the state record

Open / not marked corrected.

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

One Year Old Room: Based on observation, the surveyor found the following health and safety issues: 1. The staff person placed the children's sippy cups that had been used for lunch in the sink on top of individual wash clothes that were being used to clean the children's hands and faces after they finished eating. This resulted in a risk of cross contamination. 2. When the children finished eating lunch, they began running around the table. The table was approximately two (2) feet away from a slide. A child ran around the table and tripped over the slide. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 11 of 40 Web site: http://chfs.ky.gov/ Inspection Report 191 - Inaccessible Items 922 KAR 2:120 - Section 3 (7) The following shall be inaccessible to a child in care: (a) Toxic cleaning supplies, poisons, and insecticides; (b) Knives and sharp objects; (c) Matches, cigarettes, lighters, and flammable liquids; (d) Plastic bags; (e) Litter and rubbish; (f) Bar soap; and (g) Personal belongings of staff. 1) Toxic cleaning supplies, poisons, and insecticides In Compliance 2) Knives and sharp objects In Compliance 3) Matches, cigarettes, lighters, and flammable liquids In Compliance 4) Plastic bags In Compliance 5) Litter and rubbish In Compliance 6) Bar soap In Compliance 7) Personal belongings of staff In Compliance 197 - Premises Requirements 922 KAR 2:120 - Section 4 Premises Requirements. (1) The premises shall be: (a) Suitable for the purpose intended; (b) Kept clean and in good repair; and (c) Equipped with a land-line telephone accessible to a room used by a child. 1) Suitable In Compliance 2) Clean In Compliance 3) Good repair In Compliance 4) Land-line phone accessible In Compliance 200 - Building Requirements 922 KAR 2:120 - Section 4 (4) The building shall be constructed to ensure the: (a) Building is: 1. Dry; 2. Adequately heated; 3. Ventilated; and 4. Well lit, including clean light fixtures: a. That are in good repair in all areas; and b. Shielded or have shattered proof bulbs installed; and 1) Dry In Compliance 2) Adequately heated In Compliance 3) Adequately ventilated In Compliance 4) Well Lit In Compliance 5) Clean Light Fixtures In Compliance 6) Lights good repair In Compliance 7) Shielded/shatter proof bulbs In Compliance 201 - Protected Items 922 KAR 2:120 - Section 4 (4) (b) Following are protected: 1. Windows; 2. Doors; 3. Stoves; 4. Heaters; 5. Furnaces; 6. Pipes; and 7. Stairs. 1) Windows In Compliance 2) Doors In Compliance 3) Stoves In Compliance An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 12 of 40 Web site: http://chfs.ky.gov/ Inspection Report 4) Heaters In Compliance 5) Furnaces In Compliance 6) Pipes In Compliance 7) Stairs In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.