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 one (1) staff’s (DOH: 12/05/15) file contained an evaluation dated for 12/09/22; therefore, the staff's evaluation was not completed annually. During interview, staff-in-charge stated that she could not locate a more recent performance evaluation for the staff member. Employee Records In Compliance Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Outdoor Play Area 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 and interview, the surveyor found that the mulch protective covering at the bottom of the slide was depleted, exposing the dirt and a white drainage pipe in the ground. Staff-in-charge stated she would have the protective surface replenished. 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 and interview, the surveyor found a broken seat with sharp edges on a children's table located in a corner of the playground; therefore, the equipment was not free from sharp points, safe or in good repair. During interview, staff-in-charge stated she would have the seat with the table fixed or removed. Transportation In Compliance Kitchen Requirements In Compliance Food Service In Compliance Meal Planning/Center Provides Meals In Compliance Meal Planning/Center Does Not Provide Meals In Compliance Children's Records In Compliance Written Documentation In Compliance Posted Documentation In Compliance Animals Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 15. Animals.

General: Based on observation, the surveyor observed a frog in a tank by which all children had to walk by on the way to the restrooms. The surveyor found the following children’s files (DOE: 07/09/24, DOE: 02/21/24, DOE: 01/24/23, DOE: 01/24/23, DOE: 11/20/22, DOE: 05/31/22, DOE: 04/04/22, DOE: 02/10/22, DOE: 04/14/21, and DOE: 03/06/21) did not contain written parental consent for children to be in the presence of the frog.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the surveyor found the following: 1. A mini refrigerator that was observed to not be secure placed on top of a cubby shelf in the Preschool Classroom. The shelf was observed to separate the Preschool and One Year Old Classrooms. 2. A plunger and toilet brush was observed placed beside the toilet in the last restroom located in the Three Year Old Classroom. Therefore, the health, safety, and comfort of the children was compromised. Director Requirements Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, the surveyor found the following: 1. A staff’s (DOH: 11/30/16) file contained an annual written performance evaluation dated 08/20/21; therefore, the evaluation was not completed annually. 2. A staff’s (DOH: 09/16/22) did not contain an annual written performance evaluation; therefore, the evaluation was not completed annually. Through interview with staff-in-charge, the surveyor learned that the documentation was not available for review for the staff mentioned. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 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 documentation, the surveyor found the following: 1. A staff’s (DOH: 12/05/15) file contained documentation of a TB skin test dated 09/03/21; therefore, the staff’s file did not contain documentation of a current TB skin test or a statement from a health professional stating that the staff was free from active tuberculosis. 2. A staff’s (DOH: 09/16/22) file contained documentation of a TB skin test dated 07/28/21; therefore, the staff’s file did not contain documentation of a current TB skin test or a statement from a health professional stating that the staff was free from active tuberculosis. Through interview with staff-in-charge, the surveyor learned that a current TB skin test for the staff mentioned was not available for review.

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. A staff (DOH: 04/12/23) did not obtain six (6) hours of cabinet-approved orientation training; therefore, the training was not completed within the first three (3) months of employment. 2. A staff (DOH: 09/16/22) obtained six (6) hours of cabinet-approved orientation training on 01/25/23; therefore, the training was not completed within the first three (3) months of employment. 3. A staff (DOH: 09/16/22) obtained thirteen and one-half (13 ½) hours of the required fifteen (15) hours of cabinet-approved early care and education training for the review period 09/16/22 – 09/15/23. 4. A staff (DOH: 05/17/22) obtained zero (0) hours of the required fifteen (15) hours of cabinet-approved early care and education training for the review period 05/17/23 – 06/30/23. Programming In Compliance Premises Not In Compliance

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on observation, the surveyor found a build up of residue on the countertop behind the faucet in the Infant Classroom; therefore, the countertop was not kept clean.

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on observation, the surveyor found the following: 1. One (1) ceiling tile located in the back corner of the Two Year Old Classroom that contained what appeared to be water stains; therefore, the ceiling tile was not in good repair. 2. Five (5) ceiling tiles in the Three Year Old Classroom that contained what appeared to be water stains; therefore, the ceiling tiles were not in good repair. During interview, staff-in-charge stated that there was a water leak and the owner repaired the roof using tar. Staff-in-charge stated that she would have the owner look at the roof again. Hygienic Practices In Compliance First Aid/Medication In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3 Inspection Report 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. The surveyor observed what appeared to be a large bench seat located by the exit door on the playground that contained warped/bowed boards on the top. The surveyor observed the sharp end of nails exposed underneath the boards on each end of the bench. During interview, staff-in-charge stated that the boards were placed over and around two (2) pillars to make them inaccessible to the children. Staff-in-charge stated that the children are not allowed to sit on top of the boards and that she would have the boards repaired. 2. The surveyor observed a small blue swing located under the play structure that contained excess chain hanging down on each side of the swing. 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 play structure with a slide and swings on the playground was observed to be depleted and to not have an adequate fall zone. Equipment In Compliance Transportation In Compliance Kitchen Requirements In Compliance Food Service In Compliance Meal Planning/Center Provides Meals In Compliance Meal Planning/Center Does Not Provide Meals In Compliance Children's Records In Compliance Written Documentation Not In Compliance

Open Not marked corrected in the state record

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: 12/05/15) file contained a professional development plan dated 12/06/21; therefore, the plan was not completed annually. 2. A staff’s (DOH: 11/30/16) file contained a professional development plan dated 08/30/21; therefore, the plan was not completed annually. 3. A staff’s (DOH: 09/16/22) file did not contain a professional development plan; therefore, the surveyor was unable to determine that the plan was completed annually. Through interview with staff-in-charge, the surveyor learned that the documentation was not available for review for the staff mentioned. Posted Documentation In Compliance Animals In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the surveyor discovered the following: 1. A brown substance on four (4) ceiling tiles by the door located in the Three-Year-Old Classroom. 2. A brown substance on one (1) ceiling tile in the corner located in the Two-Year-Old Classroom. Staff reported she would have the ceiling tiles replaced. Hygienic Practices In Compliance First Aid/Medication In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report 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 of the playground, the surveyor found the protective surface was depleted underneath and in the surrounding areas of a wooden climbing/slide/swing structure. Staff reported she has mulch that needs added to the playground. 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 Not Applicable 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 2:120 · 922 KAR 2:120. Section 12. Toilet, Diapering, and Toiletry Requirements.

General: Based on observation, the surveyor found the following: 1. The sink contained stains in and around the sink bowl in the girls' restroom located in the Two Year Old Classroom; therefore, the sink was not kept clean. 2. The sink contained stains in the around the sink bowl in the boys' restroom located in the Two Year Old Classroom; therefore, the sink was not kept clean.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the surveyor found that the urinal contained brown stains in the boys' restroom located in the Two Year Old Classroom; therefore, the urinal was not kept in clean condition. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 5 of 7 Inspection Report Hygienic Practices Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, the surveyor found the following: 1. A staff’s (DOH: 07/19/21) file did not contain documentation of background checks submitted through the Kentucky National Background Check Service. Based on review of the Kentucky National Background Check Service, the staff person was listed as ‘in process’ and had not submitted to fingerprints. During interview, staff-in-charge confirmed that the staff person had not submitted to fingerprints as of 08/27/21; therefore, the staff person was hired prior to clearance for employment. The surveyor observed the staff person working alone with children in the One Year Old Classroom. During interview, staff-in-charge stated that she was not aware that the staff person had to submit to fingerprints prior to employment. The staff’s file contained a completed Criminal Records Background Check (CRC) dated 07/19/21. The staff’s file did not contain a completed Child Abuse/Neglect Background Check (CAN). Staff-in-charge stated that the CAN check was not completed for the staff person due to a background check being submitted through the Kentucky National Background Check Service. 2. A staff’s (DOH: 08/26/21) file did not contain documentation of background checks submitted through the Kentucky National Background Check Service. Based on review of the Kentucky National Background Check Service, the staff person was listed as ‘in process’ and had not submitted to fingerprints. During interview, staff-in-charge confirmed that the staff person had not submitted to fingerprints as of 08/27/21; therefore, the staff person was hired prior to clearance for employment. During interview, staff-in-charge stated that she was not aware that the staff person had to submit to fingerprints prior to employment. Staff-in-charge stated that the staff person has not worked alone with children. The surveyor did not observe the staff person working alone with children. The staff’s file contained a Child Abuse/Neglect Background Check (CAN) and Criminal Records Background Check (CRC) completed by the staff person on 08/26/21. Staff-in-charge stated that she mailed the CAN and CRC on 08/26/21. 3. A staff’s (DOH: 11/30/16) file did not contain documentation of background checks submitted through the Kentucky National Background Check Service. Based on review of the Kentucky National Background Check Service, the staff person did not have a completed background check. The surveyor observed the staff person working alone with children in the Two Year Old Classroom. During interview, staff-in-charge stated that the staff person has been employed with her for approximately five (5) years and that she thought the staff person had submitted to fingerprints when the rest of the staff did. Staff-in-charge stated that it could have been an oversight and that the staff person had taken some leave from work. Staff-in-charge stated that she would have sent the staff person to be fingerprinted if she had known. Staff-in-charge stated that the staff person had a completed Child Abuse/Neglect Background Check (CAN) and completed Criminal Records Background Check (CRC) on file. The staff file contained a CAN check dated 12/10/16 and CRC dated 12/06/16. 4. A staff's (DOH: 07/01/15) file did not contain documentation of background checks submitted through the Kentucky National Background Check Service. Based on review of the Kentucky National Background Check Service, the staff person did not have a completed background check. The surveyor observed the staff person to work alone with children while visiting the child-care center. Staff-in-charge stated that the staff person had submitted to fingerprints when the rest of the staff did. Staff-in-charge provided documentation that verified the date fingerprints were collected as 05/01/18. Based on review of the Kentucky National Background Check Service, the staff person was not listed as an employee at the child-care center and did not have an eligible for hire date. The staff's file contained a completed Child Abuse/Neglect Background Check dated 05/21/15 and a completed Criminal Records Background Check dated 04/22/15. Staff-in-charge stated that the staff person would resubmit to fingerprints. Supervision In Compliance Staffing Requirements In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 7 Inspection Report General Administration Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the surveyor found the following: 1. A stainless steel Haier mini fridge placed on top of a white shelf dividing the One Year Old and Three Year Old Classrooms. Staff-in-charge stated that they keep the Infants milk stored in the fridge and that she would relocate the fridge from the top of the shelf. 2. A wall shelf located partially over the diaper changing table and a crib that contained a large white container and large gray bag on the top shelf and food and diapers on the other shelves in the Infant Classroom. 3. Several cords bunched together and placed in the floor by a swing in the Infant Classroom. The cords were observed to be accessible to the children. Staff-in-charge stated that she was aware of the cords and was planning to have them fixed to where they were not accessible to the children. 4. An electrical outlet missing one (1) outlet cover plug located by a set of cubbies in the Preschool Classroom. 5. What appeared to be a loose red telephone cord coming down from the ceiling by a window in the Preschool Classroom. The cord was observed to be within reach to the children. Staff-in-charge stated that the cord no longer works and she would have it removed. 6. A broom and dust pan in the Three Year Old Classroom placed by the entry gate that leads into the Infant Classroom. 7. A broom and dust pan placed by the diaper changing table in the Infant Classroom. 8. A broom and dust pan placed by an exit door in the Preschool Classroom. 9. A broom and dust placed by the girls’ restroom door in the Two Year Old Classroom. 10. A plunger placed beside the toilet in the boys’ restroom in the Two Year Old Classroom.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, the surveyor found a fire marshal report dated for 04/16/15. During interview, staff-in-charge confirmed that the fire marshal has not been to the child-care center in the last two (2) years. Staff-in-charge stated that she would schedule a visit as soon as possible. Director Requirements 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 10. Director Requirements and Responsibilities.

General: Based on review of documentation, the surveyor found the following: 1. A staff’s (DOH: 11/30/16) file contained a written performance evaluation dated 11/30/18; therefore, the evaluation was not completed annually. 2. A staff’s (DOH: 12/05/15) file contained a written performance evaluation dated 12/05/18; therefore, the evaluation was not completed annually. Through interview with staff-in-charge, the surveyor learned that up-to-date annual written performance evaluations were not available for review for the staff mentioned. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 7 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 10. Director Requirements and Responsibilities.

General: Based on review of documentation, the surveyor found the following: 1. A staff’s (DOH: 11/30/16) file did not contain documentation of background checks submitted through the Kentucky National Background Check Service. Based on review of the Kentucky National Background Check Service, the staff person did not have a completed background check. The surveyor observed the staff person working alone with children in the Two Year Old Classroom. During interview, staff-in-charge stated that the staff person has been employed with her for approximately five (5) years and that she thought the staff person had submitted to fingerprints when the rest of the staff did. Staff-in-charge stated that it could have been an oversight and that the staff person had taken some leave from work. Staff-in-charge stated that she would have sent the staff person to be fingerprinted if she had known. Staff-in-charge stated that the staff person had a completed Child Abuse/Neglect Background Check (CAN) and completed Criminal Records Background Check (CRC) on file. The staff file contained a CAN check dated 12/10/16 and CRC dated 12/06/16. 2. A staff’s (DOH: 07/19/21) file did not contain documentation of background checks submitted through the Kentucky National Background Check Service. Based on review of the Kentucky National Background Check Service, the staff person was listed as ‘in process’ and had not submitted to fingerprints. During interview, staff-in-charge confirmed that the staff person had not submitted to fingerprints as of 08/27/21; therefore, the staff person was hired prior to clearance for employment. The surveyor observed the staff person working alone with children in the One Year Old Classroom. During interview, staff-in-charge stated that she was not aware that the staff person had to submit to fingerprints prior to employment. The staff’s file contained a completed Criminal Records Background Check (CRC) dated 07/19/21. The staff’s file did not contain a completed Child Abuse/Neglect Background Check (CAN). Staff-in-charge stated that the CAN check was not completed for the staff person due to a background check being submitted through the Kentucky National Background Check Service. 3. A staff's (DOH: 07/01/15) file did not contain documentation of background checks submitted through the Kentucky National Background Check Service. Based on review of the Kentucky National Background Check Service, the staff person did not have a completed background check. The surveyor observed the staff person to work alone with children while visiting the child-care center. Staff-in-charge stated that the staff person had submitted to fingerprints when the rest of the staff did. Staff-in-charge provided documentation that verified the date fingerprints were collected as 05/01/18. Based on review of the Kentucky National Background Check Service, the staff person was not listed as an employee at the child-care center and did not have an eligible for hire date. The staff's file contained a completed Child Abuse/Neglect Background Check dated 05/21/15 and a completed Criminal Records Background Check dated 04/22/15. Staff-in-charge stated that the staff person would resubmit to fingerprints. Employee Records Not In Compliance

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

General: Based on review of documentation, the surveyor found the following: 1. A staff’s (DOH: 12/05/15) file did not contain documentation of a current TB skin test or a statement from a health professional stating that the adult was free from active tuberculosis. The file contained a TB skin test that expired 06/29/21. During interview, staff-in-charge stated that she was not aware that the TB skin test had expired. 2. A staff’s (DOH: 06/04/19) file did not contain documentation of a current TB skin test or a statement from a health professional stating that the adult was free from active tuberculosis. The file contained a TB skin test that expired 06/06/21. During interview, staff-in-charge stated that she was not aware that the TB skin test had expired.

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’s (DOH: 01/09/20) file did not contain documentation of six (6) hours of cabinet-approved orientation training; therefore, the training was not completed within the first three (3) months of employment. 2. A staff’s (DOH: 01/09/20) file did not contain documentation of one and one-half (1 ½) hours of cabinet-approved pediatric abusive head trauma training; therefore, the training was not completed within one (1) year of employment. 3. A staff (DOH: 07/01/15) completed one and one-half (1 ½) hours of cabinet-approved pediatric abusive head trauma training on 04/22/15; therefore, the training was not completed within the last five (5) years. During interview, staff-in-charge stated that she was not aware that the pediatric abusive head trauma training (PAHT) had to be completed once every five (5) years. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 4 of 7 Inspection Report Programming In Compliance Premises Not In Compliance

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on observation, the surveyor found the following: 1. An oval fish rug that contained stains in the Two Year Old Classroom; therefore, the rug was not kept clean. 2. A square planet rug that contained stains in the Three Year Old Classroom; therefore, the rug was not kept clean. 3. A square car rug that contained stains in the Three Year Old Classroom; therefore, the rug was not kept clean. 4. A blue square rug and round blue rug in the One Year Old Classroom that contained debris; therefore, the rugs were not kept clean. 5. The sink contained stains around the sink bowl in the One Year Old Classroom; therefore, the sink was not kept clean. 6. A ceiling light that contained brown stains inside the light located above a cubby in the Preschool Classroom. Staff-in-charge stated that the brown stains may have been due to a roof leak they had at one point and she would have the light repaired. 7. The sink was not draining properly in the Infant Classroom; therefore, the sink was not kept in good repair. Staff-in-charge stated that they have had issues with the plumbing in the last year and she would put in a request to have it repaired by the Landlord. 8. The sink contained stains in and around the sink bowl in the Preschool Classroom; therefore, the sink was not kept clean. 9. The sink was not draining properly in the boys' restroom located in the Two Year Old Classroom; therefore, the sink was not kept in good repair.

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on observation, the surveyor found a tear in the drywall on the ceiling above a wall shelf in the boys' restroom in the Two Year Old Classroom. Staff-in-charge stated that she would put in a request to the Landlord to have the ceiling repaired.

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. Debris on the diaper changing table underneath the diaper changing pad in the Two Year Old Classroom; therefore, the diaper changing surface was not kept clean. 2. Debris on the diaper changing table underneath the diaper changing pad in the Three Year Old Classroom; therefore, the diaper changing surface was not kept clean. First Aid/Medication In Compliance Outdoor Play Area Not In Compliance

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on observation of the playground, the surveyor found the following: 1. A long piece of splintered wood placed by the fence near the exit door. 2. Two (2) large round metal objects holding a bench seat up that contained rust. 3. A cable dangling down the side of the building that appeared to go to a brown canopy. 4. A water valve sticking out on the side of the building located in front of a plastic sand table. 5. Exposed bolts sticking out underneath the top of a wooden picnic table. 6. A warped wooden board sticking up in the corner along the side of the fence located across from a gate entrance. 7. What appeared to be a small rope with a metal object attached to it dangling down the fence located on the fence roll across from a climbing structure. 8. A small plastic basketball goal that had a broken rim and net.

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 of the playground, the surveyor found that the protective surface was depleted underneath and around a wooden climbing structure with a slide and swings and did not have an adequate fall zone.

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 two (2) small trees on each end of the fence row along the side of the playground that had branches/brush sticking through the fence. Equipment In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 6 of 7 Inspection Report 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 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: 10/14/18) file did not contain the preferred hospital or physician name and contact telephone numbers. 2. A child’s (DOE: 11/12/20) file did not contain a contact telephone number for the child’s preferred hospital. 3. A child’s (DOE: 04/25/19) file did not contain a 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 9. Records.

General: Based on review of documentation, the surveyor found the following: 1. A staff’s (DOH: 07/01/15) file contained a professional development plan dated for 07/01/18; therefore, the plan was not completed annually. 2. A staff’s (DOH: 11/30/16) file contained a professional development plan dated for 12/03/19; therefore, the plan was not completed annually. Through interview with staff-in-charge, the surveyor learned that up-to-date annual written professional development plans were not available for review for the staff mentioned. Posted Documentation In Compliance Animals In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, the surveyor was not presented with the following: 1. The staff person (DOH: 11/30/16) did not have a recent evaluation. The last one in the staff person's file is dated 11/30/18. Staff reported that she would have it completed. 2. The staff person (DOH: 9/12/19) did not have an evaulation in her file. Staff reported that she would have it completed. 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 documentation, the surveyor was not presented with documentation of the educational requirement for staff person (DOH 9/12/19). Staff reported that she was not aware evidence of the education requirement was not in the file. Programming In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report Premises Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation during a tour of the center, the surveyor discovered that there was urine left in the toilet located in the restroom within the Two Year Old Classroom. Therefore, it was not kept clean. Staff stated that she would ensure that restrooms are examined after each use. Hygienic Practices Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the surveyor found the following: 1. In the Nursery Classroom the changing pad had a hole in the vinyl covering. Therefore, it is not in good repair. Staff stated she was unaware that the chinging pad had a hole in the vinyl covering. 2. In the One Year Old Classroom, the changing pad had a hole in the vinyl covering. Staff stated she was unaware that the changing pad had a hole in the vinyl covering. 3. In the Two Year Old Classroom, the changing pad had a hole in the vinyl covering. Staff stated she was unaware that the chinging pad had a hole in the vinyl covering. 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

Category: physical safety. Open / not marked corrected.

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

General: Based on review of documentation, the surveyor was not presented with the following: 1. The staff person's (12/15/15) file did not contain a recent Professional Development Plan. The most recent one in this staff person's file was dated 12/2/18. Staff stated that she was unaware that there was not a more recent Professional Development Plan in the file. 2. The staff person's (DOH:9/12/19) file did not contain a Professional Development Plan. Staff stated that she was unaware there was not a Professional Development Plan. Posted Documentation In Compliance Animals Not Applicable Emergency Regulation In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3

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 observed the following when at the child care center: 1. The surveyor observed three (3) staff persons not wearing a facemask. Therefore, the proper Personal Protective Equipment was not being utilized. This deficiency was cited due to the following E-Reg: 922 KAR 2:400E Section 7. Personal Protective Equipment (PPE) Requirements. (1) Each adult, including parents and guardians at drop-off and pick-up, shall wear a facemask while inside a child care center: (a) Unless doing so would represent a serious risk to their health or safety and they are able to present a medical statement stating this; (b) Except during planned staff breaks and lunch away from children in care and other staff. 2. The temperature of the surveyor was not taken before the surveyor was permitted entry into the child care center. During interview, the staff stated that they have been screening individuals; however, they did not think of screening the surveyor upon entrance to the center. This deficiency was cited due to the following E-Reg: 922 KAR 2:400E Section 6. Screening and Illness Requirements. (1) Children and adults shall be screened for fever and contagious symptoms upon entry into the child care center.

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 and interview, the surveyor found that one (1) staff (DOH: 09/18/18) did not contain verification and/or documentation of education. During interview, staff was not aware the information was not in the file and would request the information immediately.

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 and interview, the surveyor found the following: 1. One (1) staff (DOH: 11/14/19) file did not contain a copy of a negative tuberculin result or a statement from a health professional that the individual was free of active tuberculosis. 2. One (1) staff (DOH: 07/01/15) file contained a negative tuberculin verification dated 05/19/17, which was no longer current. During interview, staff confirmed that the current documentation was missing. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 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/Food Program In Compliance 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 8. Kitchen Requirements.

General: Based on observation, the surveyor found that the stove was soiled; therefore, it had not been maintained in a clean manner.

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 and interview, the surveyor found that the thermometer located in the freezer in the kitchen was not maintained at zero (0) degrees Fahrenheit or lower as required. The thermometer was reading at ten (10) degrees Fahrenheit. Staff were not aware that the refrigerator was not maintained at the correct temperature. 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 presented and interview, the surveyor found the following: 1. A child’s (DOE: 10/14/18) enrollment information did not contain the general health status and medical history. 2. A child’s (DOE: 10/14/18) file did not contain a preferred physician or hospital’s information. 3. A child’s (DOE: 10/14/19) file did not contain a preferred hospital’s information. 4. A child’s (DOE: 04/26/19) file did not contain a preferred physician’s information. During interview, staff confirmed information was missing would be in files as soon as possible. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3 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 review of documentation presented and interview, the surveyor found the emergency preparedness plan lacked the following information: 1. A written evacuation route to the identified off site location. 2. Procedures to address the needs of individual children including children with special needs. 3. Instruction relating to the training of staff or the reassignment of staff duties, as appropriate. During interview, staff confirmed information was missing and would be completed as soon as possible. Posted Documentation In Compliance Animals In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation and interview, the surveyor found that only one (1) staff meeting had been documented within the past year. The Director stated that more staff meetings have occurred; however, they have not been documented. 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 documentation and interview, the surveyor found that a staff file (DOH: 9/8/15) contained a tuberculosis screening that was interpreted on 10/26/15; therefore, a tuberculosis screening was not completed every two (2) years as required. The Director was not aware that the staff was in need of an updated tuberculosis screening. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 4 Inspection Report

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, review of ECE-TRIS, and interview, the following were found: 1. A staff file (DOH: 7/1/15) presented for review contained documentation for the completion of seven (7) hours of annual training for 7/1/17 - 6/30/18. Review of ECE-TRIS, confirmed that only seven (7) hours of annual training had been completed. 2. A staff file (DOH: 12/15/15) presented for review contained documentation for the completion of ten (10) hours of annual training for 12/15/16 - 12/14/17. Review of ECE-TRIS, confirmed that only ten (10) hours of annual training had been completed. The Director stated that she thought everyone had acquired the required fifteen (15) hours of annual training. Programming Not In Compliance

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on observation and interview, the surveyor found that the lesson plan posted in the School Age Classroom was dated for 7/30/18 - 8/3/18. Staff stated that they had not completed the lesson plan for the current week. 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 following were found: 1. One (1) bottle of Spic and Span Cleaner and one (1) bottle of bleach water were hanging on a shelf next to the sink within reach of the children in the School Age Classroom. 2. There was a drink in a clear plastic cup and a bottle of sunscreen on top of the cubbies in the School Age Classroom. The items were accessible to the children. 3. There was a mug containing coffee on the shelf next to the sign in/out sheets in the School Age Classroom. The mug of coffee was accessible to the children. 4. There was a bottle of Spic and Span Cleaner on the sink in the One's Classroom. The cleaner was accessible to the children. Staff confirmed that the drinks belonged to them. The Director was aware that the cleaning chemicals needed to be stored out of reach of the children. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 4 Inspection Report

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation and interview, the surveyor found the following: 1. There was a stained ceiling tile between the School Age and Preschool Classrooms; therefore, the ceiling was not in good repair. 2. The paint on the ceiling in the boy's restroom was bubbling and peeling; therefore, the ceiling was not in good repair. The Director stated that the roof leaks and despite multiple attempts to get the landlord to fix the roof it has not been done. 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: physical safety. 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 the large dollhouse shelf located in the Two's Classroom had a thick coating of dust on the top and inside the shelves. Staff stated that all furniture is wiped down and cleaned once weekly.

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 following were found: 1. The top of the side triangle support for the swing set was cracked, the support would move and the swing set was wobbly and unstable. 2. The helicopter had two (2) metal back supports that were unbolted exposing two (2) loose bolts. Upon interview, the Director was not aware of these issues. Transportation Not Applicable Food Service/Food Program In Compliance 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 8. Kitchen Requirements.

General: Based on observation and interview, the following were found: 1. The front of the oven/range was soiled. 2. The outside of the refrigerator was soiled. The Director stated that she wipes the kitchen equipment down and cleans it several times a week. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 4 Inspection Report Children's Records Not In Compliance

Open Not marked corrected in the state record

Category: nutrition. Open / not marked corrected.

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

General: Based on review of documentation and interview, the surveyor found that a child's file (DOE: 12/5/16) did not contain the preferred physician or preferred hospital name and contact information. The Director stated that she thought all of the children's files contained this information. 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 and interview, the surveyor found that the evacuation/emergency preparedness plan was documented as being reviewed last in September of 2016. The Director stated that she reviews the emergency preparedness plan annually but has not been documenting the date that she reviews it.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation and interview, the surveyor found that the daily sign in/out sheet for 8/7/18 documented that twenty-nine (29) children had been signed in for the day; however, there were thirty-one (31) children present. The Director reported that three (3) children had been dropped off after the surveyor's arrival and had not been signed in. Posted Documentation In Compliance Animals 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 4. Director Requirements and Responsibilities.

General: Based on review of documentation, the surveyor observed that a staff member's (DOH: 7/22/15) file did not contain an updated staff performance evaluation. Employee Records In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 4 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, during a walk-through of the facility, the surveyor observed the following: 1. The lesson plan for the Preschool Classroom had not been updated for the current week. 2. There was no lesson plan posted in the classroom for one-year-old’s. 3. The lesson plan for the Afterschool Classroom had not been updated for the current week. 4. The lesson plan for the classroom for two-year-old’s had not been updated for the current week. 5. There was no lesson plan posted in the classroom for infants. 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, during the inspection of the classroom for infants, the surveyor observed the following: 1. The carpet where the infants crawl and play had small pieces of dirt and other unknown debris located on it. Infants crawling on the carpet could easily access the debris and put it in their mouths. 2. A clear, plastic spoon was located in the floor against the wall and was accessible to the infants crawling on the floor.

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, during the inspection of the children’s restrooms, the surveyor observed the following: 1. The toilet located in the girls’ restroom had dirt/debris on and behind the seat and lid of the toilet. 2. The toilet located in the boys’ restroom had dirt/debris on and behind the seat and lid of the toilet. Dirt and debris was also located around the base of the toilet. Hygienic Practices In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 4 Inspection Report 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, during the inspection of the first aid kit, the surveyor observed the cardiopulmonary resuscitation mouthpiece protector to be missing from the first aid supplies. In an interview with the director, the surveyor was informed that the director had recently taken a CPR/First Aid training and had been given a new mouthpiece protector but that it was currently located at her home. Outdoor Play Area Not In Compliance

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

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

General: Based on observation, during the inspection of the outside playground, the surveyor observed the following: 1. Weeds from outside the playground were growing through the chain-link fence into the playground area where the children play. 2. A hole located in the metal siding of the building had brown, hardened, insulation exposed that could be accessed by the children. Equipment 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 6. Sleeping and Napping Requirements.

General: Based on observation, during the inspection of the classroom for infants, the surveyor observed a nickel sized, brown stain located on a sheet covering a crib mattress. In an interview with the infant classroom staff person, the surveyor was informed that linens are washed every Friday and changed immediately if soiled. Transportation Not Applicable Food Service 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 2:110 · 922 KAR 2:110. Section 3. Records.

General: Based on review of documentation, the surveyor observed the following: 1. A child’s (DOE: 2/8/17) file did not contain the phone number for the preferred hospital. 2. A child’s (DOE: 2/8/17) file did not contain the phone number for the preferred hospital. 3. A child’s (DOE: 8/24/16) file did not contain the phone number for the child’s physician or preferred hospital. 4. A child’s (DOE: 8/24/16) file did not contain the phone number for the child’s physician or preferred hospital. 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, the surveyor observed the following: 1. A staff member’s (DOH: 12/15/15) file did not contain an updated professional development plan. 2. A staff member’s (DOH: 3/15/16) file did not contain an updated professional development plan. 3. A staff member’s (DOH: 9/8/15) file did not contain an updated professional development plan. 4. A staff member’s (DOH: 7/22/15) file did not contain an updated professional development plan. 5. A staff member’s (DOH: 7/1/15) file did not contain an updated professional development plan. Posted Documentation In Compliance 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 review of documentation of staff files, staff with DOH: 7-22-15 did not have a completed annual evaluation in their file. 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 2. General.

General: Based on observation of the child care center, the confidentiality of the children was not maintained as the following were found: 1) The children's cubbies were labeled with the individual child’s first and last name. 2) The individual classrooms had a class roster posted in plain view of anyone that entered the room; the roster included each child's first and last name along with their birthdate.

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 of the bathrooms used by the children, the following were found: 1) The girls' bathroom had six (6) cots and three (3) mats stacked against the wall, causing limited access to the toilet, i.e., there was approximately four (4) inches between the front of the toilet and the stack of cots. 2) The boys' bathroom had a broom and dustpan located by the door that was within reach and accessible to the children. 3) The boys' bathroom had a plunger located in the corner that was within reach and accessible to the children.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation of staff files, the criminal records check (CRC) was not submitted timely for four (4) staff members (DOH: 1-6-16, 12-15-15, 3-15-16, and 9-8-15), i.e., the CRC for staff hired 1-6-16 was submitted on 1-8-16, the CRC for staff hired 12-15-15 was submitted on 12-17-15, the CRC for staff hired 3-15-16 was submitted on 3 -18-16, and the CRC for staff hired 9-8-15 was submitted on 11-2-15. Based on interview, the director stated that none of the staff members were left alone with children prior to receiving these results.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation of ECE-TRIS and staff files, the following was found: 1) Staff with DOH: 7-1-15 completed zero (0) of the required nine (9) hours of annual training for the training year 7-1-15 to 6-31-16. 2) Staff with DOH: 7-1-15 has not completed the Pediatric Abusive Head Trauma (PAHT) training which is required within the first year of employment. 3) Staff with DOH: 7-22-15 has not completed the PAHT training which is required within the first year of employment.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on observation, there were five (5) children present in the toddler room on 8-5-16. Based on interview, staff stated that three (3) of the children were age one (1) and that two (2) of the children were age two (2); furthermore, staff stated that the two-year-old children stay in the toddler room all day long. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 9 of 26 Web site: http://chfs.ky.gov/ Inspection Report

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation of the infant room, one (1) infant had been placed in a baby swing that was sitting on top of the mattress inside of the crib.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation of the girls' bathroom, there was one (1) glue rodent trap on the floor behind the toilet; it was within reach and 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 4. Premises Requirements.

General: Based on observation of the toddler room, there were two (2) ceiling tiles that were not in good repair, i.e., they both had visible stains on them and were bulging. Based on interview, the director stated that there was a leak in the roof.

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on observation, the toddler room is not kept as a separate area from the older children, i.e., the only restrooms in the child care center are located in the toddler room. Based on interviews, staff stated that the two-year-old, pre-school, and school-age children all have to enter and walk through the toddler room to use the restroom.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation of the boys' bathroom, there was an unknown dark brown substance located on the potty seat that was being used on this toilet; therefore, this toilet was not kept in clean condition. Hygienic Practices

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 temperature of the refrigerator in the infant room was not kept at the required forty (40) degree Fahrenheit, i.e., it had a reading of forty-four (44) degrees Fahrenheit.

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 of the infant room, there were two (2) canisters of baby formula located on a small table next to the refrigerator. Based on interview with staff, the parents provide the canisters of formula and staff measure and prepare the bottles for the children. Based on interview with the director, the child care center does not participate in the food program and does not purchase baby formula for the children.

Open Not marked corrected in the state record

Category: ratio. Open / not marked corrected.

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

General: Based on review of documentation, the child care center did not have an emergency preparedness plan that included the following: a designated relocation site and evacuation route, procedures for notifying parents of the relocation and ensuring family reunification, procedures to address the needs of individual children including children with special needs, instructions relating to the training of staff or the reassignment of staff duties, coordination with local emergency management officials, or a program to ensure that appropriate staff are familiar with the plan's 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 of staff files, staff with DOH: 7-22-15 did not have a current professional development plan in their file. Based on interview, the director stated they thought all staff had completed a professional development plan.

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 of monthly fire drills, there was no documentation showing that the child care center had conducted a fire drill in July 2016.

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, eight (8) sippy cups/lids were located atop of the handwashing sink in the Two's room. During an interview, the teacher stated that the sippy cups were washed in this sink, rather than in the kitchen sink. The director was informed that sippy cups should not be washed in the handwashing sink because of an increased risk of bacterial contamination. 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

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) An employee (DOH 10/08/15) record did not contain a completed criminal record check or central abuse/neglect registry check (CA/N). During an interview, the director stated that she had both background check requests ready to mail. Therefore, both required background checks on this staff person were not submitted timely as required by regulations. 2) An employee (DOH 10/12/15) record did not contain a completed criminal record check. During an interview, the director stated that the staff person's criminal record check request was ready to mail. The director stated that neither staff person had worked alone in supervision of 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, an employee (DOH 10/08/15) record presented for review did not contain verification of educational qualification. During an interview, the director stated that the staff was in college and would be instructed to submit her education documents immediately.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, the following was found: 1) An employee (DOH 10/08/15) record presented for review did not contain negative tuberculin verification. 2) An employee (DOH 10/12/15) record presented for review did not contain negative tuberculin verification as required by regulations. During an interview, the director stated that she had mistakenly thought that the staff had a few days after hire to submit negative TB verification.

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 Ooservation of the One's room, the premises was not in a clean condition as a vomit-like odor was prevalent near the play pens. During an interview, the teacher stated that she had smelled the vomit-like odor during the day, but had not identified the source as of yet. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 10 of 26 Web site: http://chfs.ky.gov/ 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 10. Toilet, Diapering, and Toiletry Requirements.

General: Based on observation, the diaper changing pad in the Two's room was not clean as a crusty, yellowish substance was dried on the surface. During an interview, the teacher and director were informed that the changing surface needed to be thoroughly cleaned between uses.

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on observation, the following was found: 1) Three (3) of the five (5) playpen/play yards in use were not in compliance with federal requirements. 2) Three (3) toddlers were asleep in the playpens when the surveyor entered the One's room. During an interview, the director stated that the playpens were used daily for napping. The director was immediately informed that playpen/play yards were not permitted for sleeping. She was informed that children older than one (1) year of age must be provided a mat or cot for sleeping. The director stated that she intended to remove all playpens from the child care center so as to eliminate any future problems.

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 temperature of the refrigerator located in the Nursery was forty-four (44) degrees Fahrenheit; therefore, exceeding the regulatory requirement that nonfrozen, perishable foods be maintained at a temperature of forty (40) degrees or below. During an interview, the director was informed of food service temperature requirements.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, a child's (DOE 09/09/15) record presented for review contained a vaccination administration record which did not include a date through which vaccinations are current. During an interview, the director stated that she was not aware of the specific requirements relative to immunization certificates.

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, earthquake and tornado drills which were conducted did not include a list of children who participated in the drills as required by regulations. During an interview, the director was informed that a list of children who participated in the drill must also be included with this documentation.

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, fire drills which were conducted did not include a list of children who participated in the drills as required by regulations. During an interview, the director was informed that a list of children who participated in the drills must also be included in this documentation.

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 review of documentation, the following was found: 1) In the Two's room, the posted lesson plan of activities was dated 09/21-09/25; therefore, the lesson plans were not updated as required. 2) In the Preschool room, lesson plans were dated 07/15/15; therefore, the lesson plans were not updated as required. 3) In the One's room, lesson plans were neither posted, nor presented for review. During an interview, the director stated that she was in the process of revising all lesson plans to include more detailed planning/tasks.

Open Not marked corrected in the state record

Open / not marked corrected.