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

General: Based on observation, the child care center failed to maintain state regulations. Snack was served to the group at approximately 3:08 p.m. and children in care were given until 3:36 p.m. to finish said snack, at which time the large group was separated into two (2) smaller groups. Several children in care chose to not consume a snack at this time and for those that participated, a warning that snack was coming to an end was given at 3:15 p.m. From 3:08 p.m. until 3:36 p.m., children in care who chose to not consume a snack were instructed to work on homework at their tables. From 3:15 p.m. to 3:36 p.m., children in care who participated in snack and had finished eating were instructed to work on homework at their tables. Children in care without homework were not offered any other activity during this time. The surveyor observed children in care without homework with their head down on the table; children engaged in boisterous, physical play; and there were others who roamed the cafeteria from their tables to other tables and occasionally to their personal backpacks. The children in care should not be required to sit for extended periods of time without supplemental activities or materials while waiting for an activity such as snack to conclude.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation and interview, this regulation was not met. The surveyor asked the staff how they split the children up and who was in charge of each group. The response was that they keep them all together. The age of the children ranges from five (5) to eleven (11). The max group size is thirty (30) children for two (2) staff. There were four (4) staff, and thirty-three (33) children present during the inspection. The children remained together in the cafeteria from dismissal until 3:38 p.m. until half of the children lined up to go outside. The group was over group size by three (3) children for at least thirty (30) minutes.

Open Not marked corrected in the state record

Category: ratio. Open / not marked corrected.

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

General: Based on review of documentation, a staff (DOH: 09/17/24) did not have documentation of education on file at the facility at the time of inspection.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation and review of documentation, a staff (DOH: 09/17/24) did not have documentation of a negative TB test or a statement from a health care professional stating that the staff is free from active tuberculosis on file at the facility at the time of inspection.

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, a staff (DOH: 05/18/23) did not complete the required fifteen (15) hours of annual training for the year.

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, there were no attendance records for the documented drills for August 2024.

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, there was no documentation presented of fire, earthquake, tornado or lockdown drills being conducted for January- May 2024 at the facility at the time of inspection. Posted Documentation In Compliance

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on review of documentation, a staff member (DOH 12/08/22) did not have TB documentation on file.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation and ECE-TRIS, the surveyor found that two (2) staff members (DOH 05/18/23 and 05/30/23) have not received first aid and cardiopulmonary resuscitation (CPR) training. 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

Category: recordkeeping. 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, a staff member (DOH 05/30/23) did not have evidence of completing the six (6) hour cabinet-approved orientation training. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Kitchen Requirements In Compliance Food Service In Compliance Meal Planning/Center Provides Meals In Compliance Meal Planning/Center Does Not Provide Meals In Compliance Children's Records In Compliance Written Documentation In Compliance Posted Documentation 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 8. General.

General: Based on review of documentation, the surveyor found that the statement of deficiencies issued on 02/01/23 and 04/27/23, and the corresponding plan of corrections, were not posted or made available for review. Animals Not Applicable

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation and interview, this regulatory requirement was not met. At approximately 3:50 p.m., the surveyor observed thirty-four (34) children ages six to-ten-years-old and four (4) staff on the playground. The surveyor noted they were over the maximum group size by four (4) children. The staff person in charge stated that they had been on the playground since 3:30 p.m. She stated that they usually split into two (2) groups, but they could not today because the school was having a play in the cafeteria, and the girls on the run club were using the gym. It should be note that a visit was conducted on 4/13/2022, to add additional classrooms (101, 104, and 105) to the program's licensed space to be utilized by the children in care.

Open Not marked corrected in the state record

Category: ratio. Open / not marked corrected.

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

General: Based on observation, at approximately 2:58 p.m., the staff person in charge was caring for twenty-two (22) children ages six-to-eight-years-old. The staff person in charge was over-ratio by seven (7) children. At approximately 3:01 p.m., a second staff person arrived; however, forty (40) children ages six-to-eleven-years-old were now present. The surveyor noted they were over the maximum group size and staff-to-child ratio by ten (10) children. A third staff person arrived at approximately 3:16 p.m., and the children were split into two groups to correct the situation. General Administration Not In Compliance

Open Not marked corrected in the state record

Category: ratio. Open / not marked corrected.

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

General: Based on review of documentation, a written report from the State Fire Marshal office or designee was not available for review.

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

A PLAN OF CORRECTION WAS DUE ON 04/03/2023 AND AS OF 04/04/2023, THE PLAN OF CORRECTION HAS NOT BEEN RECEIVED. 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 8. General.

General: Based on interview, the surveyor found that staff were not provided a copy of child care regulations 922 KAR:090, KAR 2:210, and 922 KAR 2:280. The staff could not locate a copy of the regulations. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 4 Inspection Report

Open Not marked corrected in the state record

Category: ratio. Open / not marked corrected.

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

General: Based on review of documentation, the surveyor found no staff meeting documentation.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on review of documentation, three staff did not have an annual evaluation on file. Employee Records Not In Compliance

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on review of documentation and ECE-TRIS, a staff person hired 6/10/2021, has not received first aid and cardiopulmonary resuscitation (CPR) training.

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 and ECE-TRIS, the surveyor found the following: 1) Staff hired on 8/18/2020, 6/10/2021, 8/19/2021, 1/10/2022, and 9/24/2021, did not complete 15 hours of cabinet-approved early care and education training. 2) Staff hired on 9/24/2021, and 3/1/2022, have not completed the six-hour cabinet-approved orientation training. 3) A staff person hired on 9/24/2021, has not completed the Pediatric Abusive Head Trauma training. Programming In Compliance Premises In Compliance 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

Category: recordkeeping. Open / not marked corrected.

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

General: Based on observation, the surveyor found the children's belongings, such as backpacks and jackets, were on the cafeteria floor. The children did not have a storage device to store their personal belongings. Transportation Not Applicable Kitchen Requirements In Compliance Food Service In Compliance Meal Planning/Center Provides Meals In Compliance Meal Planning/Center Does Not Provide Meals In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 4 Inspection Report Children's Records In Compliance Written Documentation Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, five staff did not have a current professional development plan on file. 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 the following documents not posted or made available for public inspection: 1) The child care center’s license. 2) Each statement of deficiency with the corresponding plan of correction issued by the cabinet during the current licensure year. 3) Information on the Kentucky Consumer Product Safety Program. 4) The current rates for child care. 5) The minimum staff-to-child ratios and group size. 6) The daily planned program (lesson plan).

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, a daily schedule was not posted or available for review. Animals In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, staff hired on 01/10/2022 did not have a background check on file. This staff person was under the age of 18. This staff person was not working alone at the time of the inspection. Supervision In Compliance Staffing Requirements In Compliance General Administration In Compliance Employee Records Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, staff hired on 01/10/2022 did not have education documentation on file. 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, staff hired on 08/10/2021 and 01/10/2022 did not have documentation on file from a health care professional stating they were free of active tuberculosis.

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, there were 3 staff present the day of the inspection. There was no documentation on file stating that at least one of the staff present was certified in CPR and First Aid.

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

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

General: Based on review of documentation, staff hired on 08/10/2021 and 01/10/2022 did not have the required CPR/First Aid training that is required by the Cabinet. The ECE- TRIS system was reviewed.

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, staff hired on 08/10/2021 and 01/10/2022 did not complete the required Orientation. This staff member has been employed for more than 3 months. The ECE-TRIS system was reviewed.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on observation, review of documentation and interview, this regulatory requirement was not met. The following was found: 1. One staff person (hire date: 2/16/22), who was identified as a 17 year old high school student, had a child abuse/neglect check (CAN) application on file that had been filled out. However, there was no evidence on file that the application had been submitted for processing or the results obtained. 2. One staff person (unknown hire date) did not have a personnel file on site. A review of the information listed under this facility in the Kentucky National Background Check Service (KARES) database found that this staff person's name was not listed; therefore, no evidence showing whether or not the facility has initiated the process for obtaining a background check for this staff person. The staff person stated that she started working at the facility "three days ago". These two staff were observed working with the children during the visit; however, they were paired with another staff person. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:280 · 922 KAR 2:280 - Section 4. Procedures and Payments.

General: Based on review of documentation, interview and observation, this regulatory requirement was not met. The following was found: 1. One staff person (hire date: 2/16/22), who was identified as a 17 year old high school student, had a child abuse/neglect check (CAN) application on file that had been filled out. However, there was no evidence on file that the application had been submitted for processing or the results obtained. 2. One staff person (unknown hire date) did not have a personnel file on site. A review of the information listed under this facility in the Kentucky National Background Check Service (KARES) database found that this staff person's name was not listed; therefore, no evidence showing whether or not the facility has initiated the process for obtaining a background check for this staff person. The staff person stated that she started working at the facility "three days ago". These two staff were observed working with the children during the visit; however, they were paired with another staff person. Supervision In Compliance Staffing Requirements Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, this regulatory requirement was not met. The surveyor observed three staff caring for a group of 31 school age children in the gym from 3:02PM - 3:22PM. The youngest child in the group was six years old, making the maximum group size 30. The facility exceeded the group size by one child. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3 Inspection Report Employee Records Not In Compliance

Open Not marked corrected in the state record

Category: ratio. Open / not marked corrected.

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

General: Based on review of documentation, interview and observation, the facility failed to maintain staff files. One staff person observed working with the children during the visit, did not have a personnel file on site: therefore, her hire date, birthdate, educational documentation, T.B. documentation, and background check information was not available for the surveyor to review. The staff person stated that she started working at the facility "three days ago".

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, two staff (hire dates: 2/16/22 and unknown) did not have educational documentation on file.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation and interview, this regulatory requirement was not met. One staff person (hire date: unknown) did not have T.B. documentation on file. The staff person stated during interview that she started working at the facility "three days ago". Equipment Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, this regulatory requirement was not met. The surveyor observed the children’s personal belongings (backpacks and coats) lying on the floor in the gym. Food Service Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation and interview, this regulatory requirement was not met. 31 school age children were observed walking around in the gym or sitting on the gym floor while eating their snack; no tables or chairs were available to them. The staff person in charge stated that they typically eat snack at the tables in the cafeteria; however, they were not allowed access to the cafeteria on the day of the inspection due to a school activity.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation and review of documentation, one staff did not have a KARES background check. This staff person was alone with children several times while assisting with bathroom breaks. A review of KARES was completed and confirmed this finding.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:280 · 922 KAR 2:280. Section 4. Procedures and Payments.

General: Based on review of documentation, one staff member who was present and alone at times with the children, did not have documentation of submitting fingerprints in KARES to initiate the background check process. A review of KARES confirmed this finding. Supervision In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 6 Inspection Report Staffing Requirements Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, on the day of the survey there were 33 children present, which is over max group size of 30 for children ages five and up. In this group there were six children who are five/six years old. Also, the group was left out of ratio several times while taking children to use the bathroom. At one point in the survey, one staff was left with 24 children while the other staff took the other nine children to the bathroom. General Administration Not In Compliance

Open Not marked corrected in the state record

Category: ratio. Open / not marked corrected.

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

General: Based on review of documentation, there was no documentation made available at the time of survey regarding a recent Fire Marshal report. The one on file was dated 2/11/2019.

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on review of documentation, there was no evidence of an abuse/neglect reporting procedure for staff on file at the facility. 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 8. General.

General: Based on review of documentation, there was no evidence of a current copy of the child care regulations presented at the time of survey.

Open Not marked corrected in the state record

Category: ratio. Open / not marked corrected.

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

General: Based on review of documentation, there was no documentation of staff meetings being conducted during the current year presented at the time of survey. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 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, two staff who were present the day of the survey, did not have staff files at the facility. Therefore, no identifying information that could be obtained.

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, two staff did not have education documentation on file at the facility. These two staff members did not have a staff file, therefore their date of hire was unknown.

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, two staff did not have have documentation of negative TB results on file at the facility. Both staff were present the day of the survey. These two staff members did not have a staff file, therefore their date of hire was unknown.

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, two staff did not have files at the facility; therefore, it is unknown if either have the required First Aid/CPR certification needed. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 6 Inspection Report First Aid/Medication 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 7. First Aid and Medicine.

General: Based on observation, the first aid kit did not have a proper, working flashlight at the time of survey. 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

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

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

General: Based on observation, the center did not meet this regulation. The center offered the children a choice of goldfish or chips for their snack. No other components were offered on the date of inspection.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, there was not a current menu on file at the facility. The only menu present was dated for October. Meal Planning/Center Does Not Provide Meals 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, one child enrolled on 8/16/21, did not have an immunization record on file at the facility.

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 following was found: 1.) Three children did not have a preferred hospital on file at the facility. 2.) Two children did not physician contact information on file at the facility. 3.) One child did not have medical or emergency information in their enrollment papers at the facility. This information is kept on a separate form from the other enrollment information; this child was missing that form. 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 8. General.

General: Based on review of documentation, there was no policies or procedures made available at the time of survey regarding staff policies, chain of command or job descriptions.

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, there was no documentation made available at the time of survey regarding a staff schedules. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 5 of 6 Inspection Report

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on review of documentation, thre was evidence provided at the time of survey of drills being conducted every three months or attendance records. The only drill on file was for 9/28/2021 which did not have attendance records.

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on review of documentation, there was no documentation of an Orientation policy on file at the facility.

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, thre was evidence provided at the time of survey of fire drills being conducted monthly or attendance records. The only drill on file was for 9/28/2021 which did not have attendance records. Posted Documentation Not In Compliance

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on review of documentation, the statement of deficiencies and plan of correction from the previous year was not avalible at the facility. Also, there was no documentation of any planned programming at the facility. Animals In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation at the beginning of the survey, there was only one staff person and eleven school-age children. At 3:21 p.m., a child told the staff person he needed to go to the restroom. At 3:24 p.m., the staff person left the cafeteria with the child and took him to the bathroom leaving ten school-age children unsupervised in the cafeteria. The bathroom is located down the hall from the cafeteria. The children in the cafeteria could not be supervised by sight and were not within range of voice. Staffing Requirements In Compliance General Administration Not In Compliance

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

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

General: Based on review of documentation, the liability insurance on file at the facility had a date of 1/1/2019 to 1/1/2020. Therefore, the insurance on file was not current.

Open Not marked corrected in the state record

Open / not marked corrected.

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

A PLAN OF CORRECTION WAS DUE ON 04/14/2021 AND AS OF 04/21/2021, THE PLAN OF CORRECTION HAS NOT BEEN RECEIVED. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report Director Requirements Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation and interview, at the beginning of the survey there was only one qualified staff person present in the cafeteria with eleven school-age children who are enrolled in the licensed program. There were other children in the cafeteria waiting for their rides to go home and were supervised by two teachers who were not part of the licensed program. The staff person who was present with the children enrolled in the licensed program asked the male teacher to take a group of children to the bathroom while she stayed in the cafeteria with the remaining children. The surveyor asked the staff person if this adult was employed by the program. She stated he is not employed by the program but is employed by the school. This male teacher was left alone with the children and does not meet the qualifications of a qualified staff person for a licensed child care facility. Employee Records Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, the following was found: 1) Out of five staff listed as staff members for the facility, there was one staff person who did not have a file on site at the time of the survey. 2) Out of the four staff files available for review, only one staff person had a documented date of hire. 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 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 last documented date an evacuation plan submitted for approval to local emergency management was 8/2/2019.

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, there was no documentation to verify that a monthly fire drill had been conducted and documented including the date, time and names of the children who participated for November 2020, December 2020, January 2021 and February 2021. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3 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, there was no documentation to verify that a monthly fire drill had been conducted and documented for November 2020, December 2020, January 2021 and February 2021. Posted Documentation Not In Compliance

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on interview, it was found that the required posted documents are kept in a binder and stored in a metal storage cabinet. The binder is not placed in an area that is accessible for public inspection.

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, there was not a posted diagram and written plan outlining the course of action to take in the event of manmade or natural disaster. A copy of a diagram was found in a binder that contained other documentation including staff files. This binder is kept in a metal storage cabinet. Animals Not Applicable Emergency Regulation Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:410 · 922 KAR 2:410E. Emergency Regulation.

General: Based on interview and review of documentation, the following was found: 1) At the time of the survey, staff did not take the children's temperatures upon arrival to the program. 2) A review of staff files found one staff person had the results of a criminal records check but did not have the results of a child abuse and neglect (CAN) check or documentation verifying an application for the results of a CAN check had been submitted. There was not a documented date of hire for this staff person.

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 Interview, it was found that staff did not have access to current copy of the regulations at the time of the survey. Employee Records In Compliance Programming In Compliance Premises In Compliance Hygienic Practices In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report First Aid/Medication Not In Compliance

Open Not marked corrected in the state record

Category: ratio. Open / not marked corrected.

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

General: Based on Observation, it was found that the first aid supplies did not include a working flashlight and a CPR mouthpiece. It was also found that the bag that contains the first aid supplies sits on a chair in the cafeteria and is accessible to the children.

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

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

General: Based on Observation, a bottle of Benedryl was found in the locked medication box. The bottle of Benedryl was not labeled for an individual child. Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Food Service In Compliance Children's Records Not In Compliance

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

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

General: Based on Review of Documentation, out of ten (10) children's files reviewed there was one (10) child who has been enrolled since August 2017 who had an immunization certificate that did not have a date documenting how long the child's immunizations are current. Written Documentation Not In Compliance

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

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

General: Based on Review of Documentation, it was found that the time each earthquake and tornado drill is conducted is not being documented. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3 Inspection Report

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 time each fire drills is conducted is not being documented. Posted Documentation Not In Compliance

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on Observation, a daily schedule that included the time activities would be conducted was not posted. Animals Not Applicable

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, there were two (2) staff who did not have evidence the criminal records check was submitted prior to employment. A staff person hired 2/18/16 had a criminal records check dated 3/11/16. A staff person hired 9/12/16 had a criminal records check dated 9/18/16. There was no documentation of when the request for the criminal records check was submitted for either staff.

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, there were two (2) staff who did not have evidence of being free of TB prior to employment. A staff person hired 2/18/16 had documentation dated 2/26/16. A staff person hired 9/16/16 had documentation dated 9/21/16. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report 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 In Compliance Children's Records In Compliance Written Documentation In Compliance Posted Documentation In Compliance Animals Not Applicable

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, it was found that the insurance information on file at the facility expired on 1-1-15. The staff person in charge stated that she had not been given a copy of the new policy.

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 Review of Documentation, it was found that the regulations being made available to the staff were dated 2005. The staff person in charge stated that the employees were not provided with a current copy of the regulations.

Open Not marked corrected in the state record

Category: ratio. Open / not marked corrected.

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

General: Based on Review of Documentation, it was found that the file for one (1) eligible employee did not contain evidence of an annual performance evaluation being completed. The staff person in charge stated that the main office kept evaluations there. No written evidence of an evaluation being completed was available for review.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on Review of Documentation, it was found that the file for an employee hired on 9-30-15 contained the results of a central registry check that was submitted on 10-13 -15. This date is not within five (5) days of the date of hire as required. In addition, the files for employees hired on 12-10-14, 8-24-15 and 9-30-15 contained the results of criminal records checks that were dated 11-12-15, 11-12-15 and 10-15-15. The submission dates for these background checks was not recorded. These background checks must be submitted prior to or on date of hire.

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, it was found that the files for employees hired on 12-10-14 and 9-30-15 contained the results of TB skin tests or screenings that were dated 12-15-14 and 10-13-15. These dates are not prior to date of hire as required. The staff person in charge stated that the main office handles the hiring paperwork.

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, it was found that 1) the files for employees hired on 12-10-14 and 8-24-15 did not contain evidence of the six (6) hour cabinet-approved orientation training being completed. This information was also not recorded in the ECE-TRIS system; 2) the file for an employee hired on 12-10-14 did not contain evidence of Pediatric Abusive Head Trauma Training being completed. There was no record of this training being completed in ECE-TRIS; 3) the file for an employee hired on 12-10-2014 and the ECE-TRIS system did not contain evidence of any additional training hours being completed during the first year of employement. 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 2:110 · 922 KAR 2:110. Section 3. Records.

General: Based on Review of Documentation, it was found that two (2) out of ten (10) children's files reviewed contained immunization certificates that did not have an expiration date noted. The site supervisor stated that she was aware of the lack of an expiration date but was unsure how to handle it.

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

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

General: Based on Interview, it was found that the facility has yet to establish their emergency preparedness plan according to KRS 199.8982. The staff person in charge stated that the plan is still being worked on. It should be noted that this regulatory violation was also cited during the relicensure survey conducted in 2014.

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, it was found that the file for one (1) eligible employee did not contain evidence of an annual professional development plan being completed. The staff person in charge stated that she did not know why a plan had not been completed.

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, it was found that the information regarding the Kentucky Consumer Product Safety Program and the website was not posted in the facility. The staff person in charge stated that she was unaware of the need to post this information.

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 Review of Documentation, the facility did not have a current copy of the regulations on site. The copy of the regulations that were on site were dated 4/6/05.

Open Not marked corrected in the state record

Category: ratio. Open / not marked corrected.

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

General: Based on Review of Documentation, one (1) staff, hired on 8/30/11, did not have a copy of an evaluation on file.

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, one (1) staff file did not contain a criminal records check and CAN check. This individual was not scheduled to work alone. This staff member was hired on 8/28/07.

Open Not marked corrected in the state record

Open / not marked corrected.

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

Based on review of documentation, one (1) staff, hired on 7/1/14, did not have proof of education on file.

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, one (1) staff had a TB skin test on file that was no longer current. The TB skin test was dated 8/24/11. This staff was hired 8/28/07. Another staff did not have a TB skin test on file. This staff was hired on 7/1/14.

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 posted snack menu for 12/06 listed "grab box" (no components of food were listed), 12/16 listed Sun Chips, 12/18 listed pudding, 12/19 listed apple sauce. A snack shall include two (2) components.

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, three (3) children did not have an immunization certificate on file and another child did not have an expiration date listed on their immunization certificate. All of these children had been enrolled in excess of thirty (30) days. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 23 of 26 Web site: http://chfs.ky.gov/ Inspection Report

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. Records.

General: Based on Review of Documentation, two (2) children's files did not have a preferred hospital listed. Two (2) other children's files did not include the year the children were born in the identifying information about the children.

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 facility did not have an emergency evacuation plan on site in accordance with KRS 199.895.

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, two (2) staff did not have professional develpment plans on file. These two (2) staff were hired on 8/28/07 and 8/30/11.

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, the facility did not have the Kentucky Consumer Product Safety Program information or website posted as specified in KRS 199.897. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 25 of 26 Web site: http://chfs.ky.gov/ Inspection Report

Open Not marked corrected in the state record

Open / not marked corrected.

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

Based on review of documentation, the surveryor found that the facility's liability insurance had expired on 1/1/2013.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 9. Statement of Deficiency and Corrective Action Plans.

A PLAN OF CORRECTION WAS DUE ON 27 Mar 14 AND AS OF 14 Apr 14, THE PLAN OF CORRECTION HAS NOT BEEN RECEIVED.

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 one (1) staff file (hire date: 12/10/12) did not have contain an annual evaluation.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on Review of Documentation, the surveyor found one (1) staff file (hire date: 12/10/12) did not have an out of state background check on file. This staff person lives in the State of Ohio.

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 one (1) staff file (hire date: 12/10/12) did not contain proof of education.

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 that two (2) staff (hire dates: 7/28/07 and 8/31/11) had TB skin documentation on file that was no longer valid as of 8/24/13 and 9/3/13. One (1) staff file (hire date:12/10/12) did not contain TB skin documentation.

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 Review of Documentation, the surveyor found that information regarding the Kentucky Consumer Product Safety Program was not posted.

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, staff member hired on 09/25/12 had a TB skin test results dated 10/17/12. 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 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 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, staff members hired on 08/30/10, 08/12/09, 08/31/08, 08/09/10, 08/30/11 and 07/28/07 did not have the required fifteen (15) hours of cabinet approved training on file. 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

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, child enrolled on 08/21/12 had an immunization record on file with no expiration date listed. Child enrolled on 08/21/12 had an immunization record on file that had expired on 10/14/12. 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 36 of 40 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 In Compliance 2) Departure In Compliance

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110 - Section 4

General: Based on Observation, 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.

Open Not marked corrected in the state record

Open / not marked corrected.