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

General: Based on observation, interview and review of documentation, the surveyor found the following: At approximately 3:11 pm, the surveyor entered the cafeteria and observed thirty-five (35) children and one (1) staff member. The staff member stated that the children were ages five- to ten-years-old. She stated that there are typically three (3) additional staff members, and she did not know why they had not arrived. Based on a review of attendance on the staff member’s tablet, the surveyor found that there had been forty-four (44) children present at 3:00 pm. At approximately 3:15 pm, the number of children had dropped to thirty-one (31). The staff member notified her manager about the situation. At approximately, 3:20 pm, a second staff member arrived and escorted several children to the restroom. In short, the staff member in charge, was over-ratio and group size for twenty (20) minutes.

922 KAR 2:120 · Correction status not published

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

General: Based on observation and interview, the surveyor found the following: At approximately 3:19 pm, eight (8) children walked out of the cafeteria. The staff member in charge stated that three (3) children ages ten years old, were taking five (5) of the younger children to the restroom. The surveyor noted that the restroom is located down the hall and not within sight of the staff member in charge. At approximately, 3:20 pm, a second staff member arrived and immediately escorted more children to the restroom. Therefore, the eight (8) children were out of sight for approximately one (1) minute before the second staff member arrived. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Staffing Requirements Not In Compliance

922 KAR 2:120 · Correction status not published

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

General: Based on observation, for approximately ten (10) minutes there was forty-one (41) children. ages five (5) to ten (10) years old, with two (2) staff members in the Cafeteria. In those ten (10) minutes, one (1) staff member took two (2) children to the bathroom and left one (1) staff member alone with thirty-nine (39) children.

922 KAR 2:120 · Correction status not published

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

General: Based on review of documentation, a staff member (DOH: 08/25/23) did not have evidence of an annual evaluation on file in the facility.

922 KAR 2:090 · Correction status not published

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

General: Based on review of documentation, a staff member (DOH:08/25/23) did not have evidence of completing fifteen (15) hours of early care and education training. A review of ECE-TRIS system verified this information.

922 KAR 2:090 · Correction status not published

922 KAR 2:090. Section 9. Records.

General: Based on review of documentation, a staff member (DOH: 08/25/23) did not have a current Professional Development Plan on file in the facility.

922 KAR 2:090 · Correction status not published

922 KAR 2:090. Section 9. Records.

General: Based on review of documentation, there was no written evidence of completed fire drill for the month of November 2024.

922 KAR 2:090. Section 9. Records.

General: Based on review of documentation, three (3) staff members files (DOH: 09/17/2020, 01/13/2022, and 11/23/2020) did not contain a 2023 professional development plan. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3 Inspection Report

922 KAR 2:090 · Correction status not published

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

General: Based on review of documentation, the following was found: 1.) Staff member (DOH: 09/17/2020) completed six (6) out of fifteen (15) hours of cabinet-approved early care and education training for the 7/1/22-6/30/2023 training year. 2.) Staff member (DOH: 11/10/2021) completed nine (9) hours of cabinet-approved early care and education training for the 11/10/22-6/30/2023 training year. 3.) Staff member (DOH: 01/13/2023) completed three (3) out of fifteen (15) hours of cabinet-approved early care and education training for the 1/13/2023-06/30/2023 training year. 4.) Staff member (DOH: 11/23/2020) completed ten (10) out of fifteen (15) hours of cabinet-approved early care and education training for the 07/01/2022-06/30/2023 training year. A review of ECE-TRIS supports these findings. 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 Kitchen Requirements In Compliance Food Service In Compliance Meal Planning/Center Provides Meals In Compliance Meal Planning/Center Does Not Provide Meals In Compliance Children's Records Not In Compliance

922 KAR 2:090 · Correction status not published

922 KAR 2:090. Section 9. Records.

General: Based on observation and review of documentation, a diagram with written instructions directing building occupants on the proper actions to take in an event of an emergency was not posted for public inspection. Animals Not Applicable

922 KAR 2:120. Section 10. Meal Planning Requirements for a Center that Provides Meals.

General: Based on observation, it was found that the facility did not serve two required components for the snack. The facility served a variety of chips and fruity snacks to the children (neither one of those are a required component for snack) but ran out of the chips and approximately half of the students received only a small bag of fruity snack. Meal Planning/Center Does Not Provide Meals In Compliance Children's Records In Compliance Written Documentation In Compliance Posted Documentation In Compliance Animals Not Applicable

922 KAR 2:120 · Correction status not published

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

General: Based on review of documentation, the following was found: 1.) Four staff members (9/9/2016, 11/23/2020, 9/17/2020, 8/19/2021) did not have evidence of completing 15 hours of annual early care and education training on file in the facility. A review of ECE-TRIS records supports the information found during the survey. 2.) A staff member hired 9/17/2020 did not take Orientation within three months of employment. The course was taken on 11/14/2022. The ECE-TRIS system was reviewed. 3.) A staff member hired 2/17/2022 did not take Orientation within three months of employment. The course was taken on 11/11/2022. The ECE-TRIS system was reviewed. 4.) A staff member hired 8/1/2022 did not take Orientation within three months of employment. The course was taken on 11/18/2022. The ECE-TRIS system was reviewed. 5.) A staff member hired 1/10/2022 did not take Orientation within three months of employment. The course was taken on 11/8/2022. The ECE-TRIS system was reviewed. 6.) A staff member hired on 9/9/2021, did not complete the required PAHT training. This staff member has been employed for more than one year. The ECE-TRIS system was reviewed. 7.) A staff member hired on 9/17/2020 did not complete the required PAHT training within the first year of employment. The course was taken on 6/8/2022. The ECE-TRIS system was reviewed. 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 Kitchen Requirements In Compliance Food Service In Compliance Meal Planning/Center Provides Meals Not In Compliance

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

A PLAN OF CORRECTION WAS DUE ON 10/17/2022 AND AS OF 10/18/2022, THE PLAN OF CORRECTION HAS NOT BEEN RECEIVED. Director Requirements In Compliance Employee Records Not In Compliance

922 KAR 2:090 · Correction status not published

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

Based on observation, a negative tuberculin skin result nor a physician’s statement clearing the individuals of active tuberculosis was not available for review for any staff member employed at the facility. The date of hire for these individuals was not available.

922 KAR 2:090 · Correction status not published

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

Based on observation, proof of education was not available for the any staff member employed at the facility. The dates of hire for these individuals were not available.

922 KAR 2:090 · Correction status not published

922 KAR 2:090. Section 9. Records.

General: Based on interview, the staff person in charge stated that personnel files were not present at the facility for any staff member, and that they had been removed to be updated. Identifying information was not available for these staff members, including documented date of hire, name, address, date of birth, proof of education qualifications, TB documentation, and background check results. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report

922 KAR 2:090 · Correction status not published

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

General: Based on review of documentation, two staff (hire dates: 11/23/20 and 3/1/22) did not have educational documentation on file. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 4 Inspection Report

922 KAR 2:090 · Correction status not published

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

General: Based on observation and interview, this regulatory requirement was not met. The surveyor observed several (approximately 15) of the children's personal belongings (backpacks and lunch boxes) lying on the floor in the cafeteria. The staff person in charge stated that they are supposed to be getting more baskets from another location soon. 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

922 KAR 2:120 · Correction status not published

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

General: Based on observation and interview, this regulatory requirement was not met. All of the children and staff were in the gym, while the surveyor was reviewing records in the cafeteria. At approximately 3:55PM, two school age children entered the cafeteria from a back hallway. The two children (one male and one female) walked across the entire length of the cafeteria to get a drink at a water fountain, waved at a couple of parents standing outside at an exterior door, and then exited the cafeteria doors that lead out into the main hallway and the gym. The male child told the surveyor that they were putting balls away in the storage closet. As the two children were exiting the cafeteria doors to return to the gym, the surveyor heard the staff person in charge ask the two children where they had been and instructed them to return to the group in the gym. These two children were not adequately supervised while they were in the cafeteria because the water fountain is not within scope of vision or range of voice from the gym. It is important to note that the surveyor toured the storage area after the children returned the balls and observed a hand saw positioned on top of a cart with wheels in the same room. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 4 Inspection Report Staffing Requirements Not In Compliance

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

A PLAN OF CORRECTION WAS DUE ON 09/24/2021 AND AS OF 10/14/2021, THE PLAN OF CORRECTION HAS NOT BEEN RECEIVED. Director Requirements Not In Compliance

922 KAR 2:090 · Correction status not published

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

General: Based on observation, it was found that both classrooms used in the trailer were dirty with items on the floor and cluttered. It should be noted that the surveyor walked into the trailer at the same time the members of the program did and the trailer was already in this condition. The staff in charge reported that it was usually this way when they entered in the afternoons.

922 KAR 2:120 · Correction status not published

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

General: Based on observation, it was found that there were cleaners and hand sanitizer accessible to the children. These items were located in the first classroom of the trailer when you first entered the classroom.

922 KAR 2:120 · Correction status not published

922 KAR 2:090. Section 9. Records.

General: Based on review of documentation, the following was found: 1.) Two children's files did not contain an immunization certificate. 2.) One child's file contained evidence of a shot record; however, there was not an expiration date listed. Therefore, it could not be determined if the record was current.

922 KAR 2:090 · Correction status not published

922 KAR 2:090. Section 9. Records.

General: Based on review of documentation, staff originally hired on 08/29/17, did not have education documentation on file.

922 KAR 2:090 · Correction status not published

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

General: Based on review of documentation, staff hired on 08/29/17, did not have written documentation on file from a health care professional stating she was free of active tuberculosis. Programming In Compliance Premises In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report 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 In Compliance Written Documentation In Compliance Posted Documentation In Compliance Animals In Compliance

922 KAR 2:090 · Correction status not published

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

General: Based on observation and interview, the child care center failed to maintain equipment in accordance with regulatory requirements. Observation of the Third to Fifth Grade classroom revealed children’s book bags and coats thrown around the classroom on tables and on the floor. There was no evidence of appropriate storage space for the belongings of the children in the classroom. Interview with the staff-in-charge revealed the children were to place their coats and book bags on the back of their chair. However, observation revealed the children’s belongings were not stored in this manner.

922 KAR 2:120 · Correction status not published

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

General: Based on review of documentation and interview, the child care center failed to maintain written documentation in accordance with regulatory requirements. Upon request, the child care center staff-in-charge failed to provide documented evidence that monthly Fire Drills and quarterly Tornado Drills were completed during the months of November 2017 to May 2018. The documentation presented indicated that the Fire and Tornado Drills were conducted on the same date at the exact same time. Interview with the staff-in-charge revealed she could not be certain exactly which drills were conducted during that time frame. Posted Documentation In Compliance Animals Not Applicable

922 KAR 2:120 · Correction status not published

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

General: Based on review of documentation and interview, the child care center failed to maintain employee records in accordance with regulatory requirements. Upon request, the child care center staff-in-charge failed to provide documented evidence of a high school diploma, GED or qualifying documentation from a comparable educational entity for staff with hire dates 08/31/18, 08/22/18, and 08/10/18, who were also stated to have supervisory control of children in care. The information provided did not indicate if the staff were currently enrolled in high school and/or anticipated graduation.

922 KAR 2:110. Section 3. Records.

General: Based on Review of Documentation, children enrolled 08/16/2017, 10/02/2017, and 01/04/2018 did not have a current immunization certificate on file in the facility. Written Documentation In Compliance Posted Documentation In Compliance Animals Not Applicable An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2

922 KAR 2:110 · Correction status not published

922 KAR 2:110. Section 3. Records.

General: Based on Review of Documentation, the facility failed to post a diagram outlining the course of action to take in case of a Fire, Tornado, or Earthquake. Animals Not Applicable

922 KAR 2:110 · Correction status not published

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

General: Based on Observation, the surveyor observed a gallon of bleach and a roll of black trash bags underneath the hand-washing sink cabinet. The cabinet doors were not secured; therefore, the items were accessible to the children in care. Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Food Service Not In Compliance

922 KAR 2:120 · Correction status not published

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

General: Based on Review of Documentation, two (2) employee files (hire dates: 1/15/16 and 8/17/16) contained criminal records checks that were dated 1/28/16 and 9/18/16. There was no documentation on file to verify if their criminal records checks were requested prior to hire as required by KRS 199.896(19). File review found that an employee hired on 12/19/16 currently lives in the state of Ohio. This employee did not have an out of state background check on file. It is important to note that this individual was not observed working alone with children during the inspection. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report

922 KAR 2:090 · Correction status not published

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

General: Based on Review of Documentation, two (2) employee files (Hire dates: 11/30/16 and 12/19/16) did not contain proof of education.

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

General: Based on Observation, it was found that 1) employees hired on 2-9-15 and 10-19-15 were working together with ten (10) school age children while they were upstairs in the computer lab. The employee hired on 2-9-15 did not have the results of a central registry check on file. The employee hired on 10-19-15 did not have the results of a criminal records check on file. These employees were alone with the children for approximately thirty (30) minutes during the survey; 2) an employee hired on 11-2-15 did not have the results of a central registry check, criminal records check or Ohio or FBI criminal records check on file. This employee was observed to be working alone with eight (8) school age children in the homework room.

922 KAR 2:110 · Correction status not published

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

General: Based on Observation, it was found that the facility did not have a schedule of daily activities posted or available for review. In addition, the statement of deficiencies issued and the plan of correction submitted for the 2014 relicensure survey was not posted. The statement of deficiencies and plan of correction posted was dated 2012. 1170 - Diapering/Handwashing Not Applicable 922 KAR 2:120. Section 10. Toilet, Diapering, and Toiletry Requirements. (9) The proper methods of diapering and hand-washing shall be posted at each diaper changing area. Animals 1175 - Animals in the Presence of Children Not Applicable 922 KAR 2:120. Section 13. Animals. (1) An animal shall not be allowed in the presence of a child in care: (a) Unless: 1. The animal is under the supervision and control of an adult; 2. Written parental consent has been obtained; and 3. The animal is certified as vaccinated against rabies; or (b) Except in accordance with subsection (3) of this section. 1185 - Prohibited Animals Not Applicable 922 KAR 2:120. Section 13. Animals. (3) An animal that is considered undomesticated, wild, or exotic shall not be allowed at a child-care center unless the animal is: (a) A part of a planned program activity lead by an animal specialist affiliated with a zoo or nature conservatory; and (b) In accordance with 301 KAR 2:081 and 301 KAR 2:082.

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

General: Based on Review of Documentation, the after school program did not have an emergency preparedness plan on file for review.

922 KAR 2:090 · Correction status not published

922 KAR 2:110. Section 3. Records.

General: Based on Review of Documentation, one (1) child's file (enrollment date: 8/14/14) did not contain immunization documention. A second child's file (enrollment date: 8/14/14) had an immunization certificate that was no longer valid as of 9/10/14.

922 KAR 2:110 · Correction status not published

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

General: Based on Review of Documentation, the menu that was posted did not have a date. 1055 - Breakfast Requirements Not Applicable 922 KAR 2:120. Section 9. Food and Meal Requirements. (17) Breakfast shall include: (a) Milk; (b) Bread; and (c)1. Fruit; 2. Vegetable; or 3. 100 percent juice.

922 KAR 2:120 · Correction status not published

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

General: Based on Observation, there was not a temperature measuring device (thermometer) in the refrigerator used to store milk and snacks.

922 KAR 2:120 · Correction status not published

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

General: Based on Observation, the walls throughout the school age area contained areas of chipped, cracked, and peeling paint. One (1) wall in the homework classroom had areas of crumbling cement that would flake and crumble like sand when touched. The staff person stated they use a large chalk board that can be moved in front of the area to keep it hidden from the students.

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

General: Based on Observation, it was found that there were multiple cobwebs attached to a shelving unit and the long bulletin board in the large classroom. Multiple cobwebs were also observed to be on the pillows being stored on top of a shelving unit in the large classroom.

922 KAR 2:120 · Correction status not published

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

General: Based on Observation, it was found that the posted snack menu was not dated. 1055 - Breakfast Requirements Not Applicable 922 KAR 2:120. Section 9. Food and Meal Requirements. (17) Breakfast shall include: (a) Milk; (b) Bread; and (c)1. Fruit; 2. Vegetable; or 3. 100 percent juice.

922 KAR 2:120 · Correction status not published

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

General: Based on Observation, it was found that one (1) of the plastic light covers in the homework room had a foot long break in it.

922 KAR 2:120 · Correction status not published

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

General: Based on Observation, it was found that a container of disinfecting wipes was located on the low shelf of the TV stand. This area is accessible to the children. The label on the container stated, "Keep Out of Reach of Children."

922 KAR 2:120 · Correction status not published

922 KAR 2:110. Section 2. General.

General: Based on Interview, it was found that the facility did not have a copy of the current regulations available for the staff.

922 KAR 2:110 - Section 4 (1)

General: Based on Review of Documentation, the surveyor found that five (5) staff did not have evaluations on file at the time of the inspection.

922 KAR 2:110 · Correction status not published

922 KAR 2:110 - Section 4

General: Based on Review of Documentation, the facility reported a change of director on July 11, 2012. However, the documentation to assure this individual is qualified to serve as director has not been received.

922 KAR 2:110 · Correction status not published

922 KAR 2:110 - Section 5 (1)

General: Based on Review of Documentation, staff person with hire date 8/30/11 had results of a T.B. test dated 9/6/11. 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 3) 15 hours annually In Compliance 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 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 An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 8 of 40 Web site: http://chfs.ky.gov/ Inspection Report