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Home › KY › Lexington › After 3 - Tates Creek Elementary
License #L358917 · Center · Licensed
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General: Based on interview and review of documentation, a staff member (DOH: 11/03/24) had TB documentation on file that was no longer valid as of 02/12/26.
This change of space/change in capacity inspection recorded no violations or advisories.
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Generated from this facility's specific inspection record
Data synced from Kentucky Cabinet for Health and Family Services, Division of Child Care on Jul 11, 2026 · Source records · Report an error
General: Based on observation, at approximately 4:17 P.M., a school-age child exited Classroom #107. A staff member asked if he was leaving, and the child responded, “Yeah.” The staff member then stepped back into the classroom while the child continued walking down the hallway and around the corner. The child was then no longer within line of sight or within sound of voice.
General: Based on review of documentation, the following was found: 1) A staff member (DOH: 08/11/2021) had TB documentation on file that was no longer valid as of 09/21/2025. 2) A staff member (DOH: 11/01/2022) had TB documentation on file that was no longer valid as of 01/05/2025. 3) A staff member (DOH: 11/01/2023) had TB documentation on file that was no longer valid as of 10/27/2025. 4) A staff member (DOH: 09/05/2025) did not have TB documentation available for review.
General: Based on review of documentation and ECE-TRIS, the following was found: 1) A staff member (DOH: 09/09/2024) has not completed the six (6)-hour cabinet approved orientation training. 2) A staff member (DOH: 08/18/2021) had zero (0) training hours out of fifteen (15) required hours during the 07/01/2024--06/30/2025 training year. 3) A staff member (DOH: 12/01/2022) only completed six (6) hours of early care and education training during the 07/01/2024-06/30/2025, training year.
General: Based on observation, the surveyor observed a group of school-age children and staff members leaving the cafeteria and entering Classroom #107. The staff member in charge explained that Classroom #307, previously approved as licensed space, was not being used this school year and that Classroom #107 was being used in its place. Upon reviewing the facility diagram, it was noted that Classroom #107 had never been approved by DRCC. The staff member in charge stated that she assumed the space was acceptable as long as it had been approved by the Fire Marshal.
General: Based on review of documentation, the following was found: 1) A staff member (09/30/19) completed only twelve (12) of the required fifteen (15) hours of early care and education training during the training year 07/01/23 to 06/30/24. 2) A staff member (08/01/21) completed only thirteen and a half (13.50) of the required fifteen (15) hours of early care and education training during the training year 07/01/23 to 06/30/24. 3) A staff member (12/01/22) completed only seven and a half (7.50) of the required fifteen (15) hours of early care and education training during the training year 07/01/23 to 06/30/24. 4) A staff member (08/19/19) completed only eight and seventy-five (8.75) of the required fifteen (15) hours of early care and education training during the training year 07/01/23 to 06/30/24. 5) A staff member (08/01/21) completed only fourteen (14) of the required fifteen (15) hours of early care and education training during the training year 07/01/23 to 06/30/24. 6) A staff member (08/11/21) completed only nine (9) of the required fifteen (15) hours of early care and education training during the training year 07/01/23 to 06/30/24. 7) A staff member (03/21/22) completed none of the required fifteen (15) hours of early care and education training during the training year 07/01/23 to 06/30/24. 8) A staff member (08/18/21) completed none of the required fifteen (15) hours of early care and education training during the training year 07/01/23 to 06/30/24. A review of ECE-TRIS verified this information.
General: Based on observation, the facility did not have the information on the Kentucky Consumer Product Safety Program and the program's website posted for public inspection.
General: Based on review of documentation, two (2) staff members did not have evaluations on file. These staff members were hired on 08/26/22 and 03/23/22. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 5 Inspection Report Employee Records Not In Compliance
General: Based on review of documentation, the following was found: 1. A staff member (DOH: 03/21/22), only completed seven and a half (7.5) of the fifteen (15) early care and education training hours within their completed training year. 2. A staff member (DOH: 10/22/21), only completed four (4) of the fifteen (15) early care and education training hours between 07/01/22 and 06/30/23. 3. A staff member (DOH: 08/31/21), only completed four and a half (4.5) of the fifteen (15) early care and education training hours between 07/01/2022 and 06/30/23. 4. A staff member (DOH: 08/31/22), only completed four and a half (4.5) of the fifteen (15) early care and education training hours within their completed training year. 5. A staff member (DOH: 12/01/21), only completed seven and a half (7.5) of the fifteen (15) early care and education training hours between 07/01/22 and 06/30/23. 6. A staff member (DOH: 11/01/22), only completed seven (7) hours of the fifteen (15) early care and education training hours within their completed training year. This staff member also did not complete the required orientation training. 7. A staff member (DOH: 08/26/22), only completed one and a half (1.5) of the fifteen (15) early care and education training hours within their completed training year. This staff member also did not complete the required orientation training. 8. A staff member (DOH: 03/23/22), only completed seven and a half (7.5) of the fifteen (15) early care and education training hours within their completed training year. The ECE-TRIS system was reviewed and confirmed these findings. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 5 Inspection Report First Aid/Medication Not In Compliance
General: Based on review of documentation, the liability insurance on file expired on 07/01/22; therefore, the insurance was no longer current. Director Requirements Not In Compliance
General: Based on review of documentation, there were no current professional development plans for any staff member on file.
General: Based on observation, the following information was not posted for public inspection: the statement of deficiencies/plan of correction, the current rates, and the consumer product information. Animals In Compliance
General: Based on review of documentation, there were no current staff evaluations for any staff members on file. Employee Records Not In Compliance
General: Based on review of documentation, staff hired on 08/31/22, did not complete the required CPR/First Aid training. The staff has been employed for more than three months. The ECE-TRIS system was reviewed and confirmed this finding.
This monitoring (dpoc) inspection recorded no violations or advisories.
This monitoring (dpoc) inspection recorded no violations or advisories.
General: Based on observation, this regulatory requirement was not met. The children's backpacks, coats, and other personal belongings were scattered in the floor of the cafeteria and on the tables in the cafeteria. Some of the personal belongings were touching each other. Storage space shall be provided in the form of shelves or other storage devices accessible to the children.
General: Based on review of documentation and observation, it was found that the facility did not have a sufficient number of qualified staff at the time of the visit. During the inspection, there were multiple staff without background checks working with the children and none of the staff had additional qualifying documentation on file such as educational documentation and T.B. documentation. The facility did not have enough qualified staff to divide the children as needed. The two staff that were paired together to work with the 2nd and 3rd grade group of children did not have evidence or results of background checks. General Administration Not In Compliance
General: Based on review of documentation, this regulatory requirement was not met. The following was found: 1. One of the children’s files/enrollment documentation did not contain information for the family’s preferred hospital. 2. One child’s file/enrollment paperwork did not have physician contact information. Both children had August 2021 enrollment dates. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 4 of 5 Inspection Report Written Documentation Not In Compliance
General: Based on review of documentation and interview, this regulatory requirement was not met. A review of the licensing binder found that there was not a copy of the most recent regulations made available to staff. The regulations on site were dated 2017. The staff person in charge stated that she printed a more recent copy of the regulations at the beginning of the school year to read about staff/child ratio requirements; however, did not maintain the new copy on site.
General: Based on review of documentation, staff hired on 10/02/17, did not have documentation on file from a health care professional stating she was free of active tuberculosis.
General: Based on observation and review of documentation, staff hired on 11/04/19, and staff hired sometime after the beginning of the 2019 school year, did not have written proof on file that a background check had been completed. There was also no information on either staff in the online Kentucky National Background Check Service system. Staff hired on 11/04/19, was not present the day of the survey. Staff member hired after the beginning of the 2019 school year was not working alone at the time of the survey.
General: Based on observation and review of documentation, staff hired on 11/04/19, and staff hired sometime after the beginning of the 2019 school year, did not have written proof on file that a background check had been completed. There was also no information on either staff in the online Kentucky National Background Check Service system. Staff hired on 11/04/19, was not present the day of the survey. Staff member hired after the beginning of the 2019 school year was not working alone at the time of the survey. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report Supervision In Compliance Staffing Requirements In Compliance General Administration In Compliance Director Requirements In Compliance Employee Records Not In Compliance
General: Based on review of documentation, staff hired on 09/25/17 and 08/15/18 did not have Orientation I and II on file. Staff hired 09/25/17 and 10/07/17 did not have the pediatric abusive head trauma class on file. Staff hired on 09/25/17, 03/20/09 and 10/02/17 did not have the required fifteen (15) hours of cabinet approved training on file. This information was verified through ECE-TRIS. 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
General: Based on review of documentation, two (2) staff hired 08/15/18 did not have documentation on file from a health care professional stating they were free of active tuberculosis.
General: Based on review of documentation, there were no current staff evaluations on file. Employee Records Not In Compliance
General: Based on review of documentation, staff hired on 08/15/18 did not have education documentation on file. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report
This change of space/change in capacity inspection recorded no violations or advisories.
General: Based on Review of Documentation, there was one (1) staff person who was rehired on 8/23/17 who had the results of a T.B. test read on 8/31/17. This was not completed prior to employment. There were two (2) staff with a hire date of 10/2/17. One (1) staff person had the results of a T.B. test read on 10/12/17 and the other staff person had the results of a T.B test read on 11/6/17. Both of the dates are after the staff person's date of hire. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report
General: Based on Review of Documentation and ECE-Tris records, there was no documentation to verify that a staff person rehired on 8/23/17 had completed six (6) ours of cabinet-approved Orientation I and II training within the first three (3) months of employment. 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 Not In Compliance
General: Based on Observation, the website and information regarding the Kentucky Consumer Product Safety Program was not posted. Animals Not Applicable An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3
General: Based on Review of Documentation, it was found that a staff person with a hire date of 08/27/2015; two (2) satff persons with a hire date of 08/02/2010 and a staff person with a hire date of 03/20/2009 had no record of completing the one and one-half (1 1/2) hours of pediatric abusive head trauma training. The staff in charge stated in the plan of correction that this training would be completed by 12/12/2016.
General: Based on Review of Documentation, it was found through a review of six (6) staff files that four (4) staff files did not contain evidence of pediatric abusive head trauma. The dates of hire for the staff were 03/20/2009, 08/02/2010, 08/02/2010 and 08/27/2015. A review of ECE-TRIS confirmed this. It was also found that all six (6) staff files did not contain evidence of the fifteen (15) hours of cabinet-approved early care and education training. A review of ECE-TRIS confirmed this. 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 Not In Compliance
General: Based on Review of Documentation, it was found that out of six (6) staff files reviewed, three (3) staff files did not have evidence of an annual professional development plan. Posted Documentation In Compliance Animals Not Applicable
General: Based on Review of Documentation, it was found through a review of ten (10) children's files that seven (7) children's files did not contain an immunization certificate. The dates of enrollment for the children were 09/02/2016, 05/20/2016, 08/04/2016, 08/11/2016 and three (3) with an enrollment date of 08/01/2016.
General: Based on Review of Documentation, the facility did not have an up to date emergency preparedness plan. The previous plan was dated 12/3/13.
General: Based on Review of Documentation, a staff hired on 3/20/09 did not have the required annual training. This staff member has completed twelve (12) hours of training. Based on review of documentation, a staff hired on 8/18/11 did not have the required annual training. This staff member has completed six (6) hours of training. Based on review of documentation, a staff member hired on 8/2/10, did not have the required annual training. This staff member has completed zero (0) hours of training. Based on review of documentation, a staff member hired 8/2/10 did not have the required annual training. This staff member has completed six (6) hours of training.
General: Based on Review of Documentation, a staff member hired on 10/16/13 did not have up to date TB verification from a qualified healthcare professional showing they are free from TB. This staff member's previous TB documentation was dated for 8/22/13. Based on review of documentation, a staff member hired on 8/12/15 did not have up to date TB verification from a qualified healthcare professional showing they are free from TB. This staff member's previous TB documentation was dated for 3/21/13. Based on review of documentation, a staff member hired on 8/18/13 did not have up to date TB verification from a qualified healthcare professional showing they are free from TB. This staff member's previous TB documentation was dated for 9/16/13.
General: Based on Review of Documentation, the facility had a written emergency plan posted; however, it did not include a diagram.
General: Based on Review of Documentation, four (4) staff (hire dates: 2 on 8/2010, 3/20/09 and 8/18/11) did not contain the required fifteen (15) hours of training.
General: Based on Review of Documentation, four (4) staff eligible did not have evidence of a current annual evaluation on file in the facility.
General: Based on Review of Documentation, four (4) staff files (hire dates: 2 on 3/20/09, 10/16/13 and 8/2010) contained results of a negative T.B. test that was no longer current. The tests were dated 12/12/11, 11/6/12, 1/2/12 and 10/3/11 which exceeds the two (2) year time frame.
General: Based on Review of Documentation, seven (7) staff eligible for an annual professional development plan did not have documentation of a plan on file in the facility. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 24 of 26 Web site: http://chfs.ky.gov/ Inspection Report
General: Based on Observation, it was found that the facility did not have any evidence of current earthquake or tornado drills. Posted Documentation
General: Based on Observation, it was found that the facility did not have a consumer product safety form posted.
General: Based on Observation, it was found that the facility did not have any block materials nor was block activities listed on the lesson plan.
General: Based on Review of Documentation, it was found that the facility did not have any evidence of current earthquake or tornado drills.
General: Based on Observation, it was found that the facility did not have any evidence of current fire drills.
General: Based on Observation, it was found that the facility did not have any evidence of current fire drills.
This renewal application inspection recorded no violations or advisories.
General: Based on Review of Documentation, there were two (2) staff who did not have a current T.B. skin test or statement from a health professional on file. It was also found that a substitute hired 8/18/11 did not have a T.B. skin test done until 11/21/11. This does not meet the requirement of the regulation because it was completed after the date of hire and not prior to employment. 128 - CPR/First Aid Coverage 922 KAR 2:110 - Section 5 (3) At least one (1) person on duty and present with the children shall be currently certified by a cabinet-approved training agency in the following skills: (a)Infant and child cardiopulmonary resuscitation; and (b) Infant and child first aid. 1) CPR In Compliance 2) First Aid In Compliance 131 - Adequate Substitute(s) 922 KAR 2:110 - Section 5 (6) Child-care centers shall have available in case of need: (a) One (1) qualified substitute staff person for a Type II child-care center; or (b) Two (2) qualified substitute staff persons for a Type I child-care center 1) Type I In Compliance 131 - Adequate Substitute(s) 922 KAR 2:110 - Section 5 (6) Child-care centers shall have available in case of need: (a) One (1) qualified substitute staff person for a Type II child-care center; or (b) Two (2) qualified substitute staff persons for a Type I child-care center 2) Type II Not Applicable 139 - Training 922 KAR 2:110 - Section 5 (14) A staff person with supervisory authority over a child shall complete the following: (a) Six (6) hours of cabinet-approved orientation within the first three (3) months of employment; (b) Nine (9) hours cabinet-approved child development training within the first year of employment; and (c) Fifteen (15) hours of cabinet-approved training during each subsequent year of employment. 1) Orientation In Compliance 2) 9 hours-first year In Compliance 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. 3) 15 hours annually Not In Compliance Findings: General: Based on Review of Documentation, there was one (1) staff person with a hire date of 3/20/09 who did not complete fifteen (15) hours of training for the 2010-2011 training year. 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
General: Based on interview and review of documentation, a staff member's personnel file (DOH:11/03/2024) was not available for review. The staff member in charge could not locate the documents.
General: Based on review of documentation, a staff member (DOH: 09/05/2025) did not have proof of education on file.
General: Based on observation, interview, and review of documentation, on the day of the renewal inspection, there were no staff members present with the children who were currently certified in First Aid and Cardiopulmonary Resuscitation (CPR). The staff member in charge identified one (1) staff member who is currently certified; however, that individual has been on leave.
General: Based on observation and review of documentation, a staff member (DOH: 02/12/24) did not have a completed KARES background check on file indicating that the staff member is eligible for employment. The KARES Employment Authorization Form on file indicated that the staff member must complete a new application. This staff member was not working alone during the renewal survey.
General: Based on review of documentation, the facility did not have written documentation of conducting shelter-in-place/ lockdown drills. Shelter-in-place/ lockdown drills shall be conducted quarterly. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 30 of 31 Inspection Report Posted Documentation Not In Compliance
General: Based on review of documentation, the following was found: 1) Documentation presented for staff member (DOH: 09/30/19), included the most recent TB skin test dated 02/08/22, which was no longer current. 2) Documentation presented for staff member (DOH: 08/01/21), included the most recent TB skin test dated 12/09/21, which was no longer current. 3) Documentation presented for staff member (DOH: 12/01/22), included the most recent TB skin test dated 10/17/22, which was no longer current. 4) Documentation presented for staff member (DOH: 08/19/19), included the most recent TB skin test dated 12/09/21, which was no longer current. 5) Documentation presented for staff member (DOH: 08/01/21), included the most recent TB skin test dated 12/09/21, which was no longer current. 6) Documentation presented for staff member (DOH: 08/15/22), included the most recent TB skin test dated 08/15/22, which was no longer current. 7) Documentation presented for staff member (DOH: 03/21/22), included the most recent TB skin test dated 04/21/22, which was no longer current. 8) Documentation presented for staff member (DOH: 08/18/21), included the most recent TB skin test dated 12/13/21, which was no longer current.
General: Based on review of documentation, three (3) children's files were missing a physician's phone number. Two (2) of the children were enrolled on 08/16/23, and the other child was enrolled on 08/21/23. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 4 of 5 Inspection Report Written Documentation Not In Compliance
General: Based on review of documentation and observation, a staff member (DOH: 10/09/23), did not have the results of the KARES background check on file. The KARES documentation on file stated a new application must be submitted. This staff member was not working alone with the children during the renewal survey. Supervision In Compliance Staffing Requirements In Compliance General Administration In Compliance Director Requirements Not In Compliance
General: Based on interview and review of documentation, five (5) staff did not have documented hire dates on file. The staff in charge verbally gave the surveyor the staff members hire dates.
General: Based on review of documentation, two (2) staff members did not have proof of education on file. These staff were hired on 11/01/22 and 08/26/22.
General: Based on observation, the facility did not have a CPR mouthpiece protector in the first aid supplies. 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 Not In Compliance
General: Based on review of documentation, a child enrolled on 08/16/23, had an immunization certificate on file without an expiration date. It could not be determined if the immunization certificate was current.
General: Based on interview and review of documentation, the staff in charge indicated that they no longer use the DCC-94E, Child Care Daily Attendance Record for the children on Child Care Assistance. The staff in charge indicated that the facility has twenty-five (25) children that participate in the Child Care Assistance Program. The child-care center shall maintain the DCC-94E attendance records in accordance with 922 KAR 2:160, Section 13, if a child receives services through the Child Care Assistance Program.
General: Based on review of documentation, four (4) staff did not have professional development plans on file. These staff were hired on 03/21/22, 11/01/22, 08/26/22, and 03/23/22.
General: Based on review of documentation, the facility did not have written evidence of conducting lockdown/shelter-in-place drills. Posted Documentation In Compliance Animals In Compliance
General: Based on review of documentation, staff hired 09/11/22, 08/11/22, 11/02/22, and two staff hired 10/30/22, did not have education documentation on file. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report
General: Based on review of documentation, staff hired on 10/30/22, did not have documentation on file from a health care professional stating that the staff was free of active tuberculosis.
General: Based on review of documentation, staff hired on 08/31/22, did not complete the required Orientation training. The staff has been employed for more than three months. The ECE-TRIS system was reviewed and confirmed this finding. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation In Compliance Kitchen Requirements In Compliance Food Service In Compliance Meal Planning/Center Provides Meals Not In Compliance
General: Based on observation, the snack menu was not posted within the facility. Meal Planning/Center Does Not Provide Meals In Compliance Children's Records Not In Compliance
General: Based on review of documentation, children enrolled 11/09/22, and 08/25/22, did not have a current immunization certificate on file. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3 Inspection Report Written Documentation Not In Compliance
General: Based on review of documentation, there were no fire, earthquake, or tornado drills for review at the time of the inspection. Posted Documentation Not In Compliance
General: Based on review of documentation and interview, this regulatory requirement was not met. A review of the staff meeting documentation revealed that the last documented staff meeting was from 2019. The staff person in charge stated that she had conducted staff meetings; however, did not maintain documentation of these meetings. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 5 Inspection Report
General: Based on review of documentation and interview, this regulatory requirement was not met. At the time of the survey, it was found that there was no documentation of current liability insurance at the facility. The staff person in charge stated that she had this documentation; however, was not able to locate it during the visit. Director Requirements Not In Compliance
General: Based on review of documentation, observation and interview, this regulatory requirement was not met. A review of the Kentucky National Background check service (KARES) found that three people identified as current staff during the inspection have a processed background check with the eligible for hire status. However, six additional staff do not have evidence or results of a background check in KARES or on file at the facility. The surveyor observed five of these staff working with the children during the inspection. The staff person in charge stated that everyone is an employee of the Fayette County School System; therefore, background check documentation is maintained in the central office. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 5 Inspection Report
General: Based on review of documentation, observation and interview, this regulatory requirement was not met. A review of the Kentucky National Background check service (KARES) found that three people identified as current staff during the inspection have a processed background check with the eligible for hire status. However, six additional staff do not have evidence of submitting fingerprints for the KARES background check system. The surveyor observed five of these staff working with the children during the inspection. The staff person in charge stated that everyone is an employee of the Fayette County School System; therefore, background check documentation is maintained in the central office. Supervision In Compliance Staffing Requirements Not In Compliance
General: Based on review of documentation and observation, this regulatory requirement was not met. Two staff (hire dates: 8/11/21 and 11/1/21) were left alone/unsupervised without evidence of the required background checks. These two staff were paired together to care for the 2nd and 3rd grade group of children during the visit. A review of the KARES database supported this finding. Employee Records Not In Compliance
General: Based on review of documentation and interview, this regulatory requirement was not met. The following was found: 1. None of the staff (nine staff total) had any documentation on file during the inspection; therefore, no identifying information for the staff members could be determined. The staff person in charge stated that she was not aware that she needed to maintain a file for each staff person and stated that everyone is an employee of the Fayette County School System; therefore, documentation is maintained in the central office. 2. The staff person in charge was not able to provide hire dates for any of the staff except herself during the visit; however, provided this documentation via phone interview on 12/1/21.
General: Based on review of documentation this regulatory requirement was not met. None of the staff (nine staff total) had educational documentation on file.
General: Based on review of documentation, this regulatory requirement was not met. None of the staff (nine staff total) had T.B. documentation on file.
General: Based on review of documentation and interview, this regulatory requirement was not met. At the time of the survey it was found that none of the staff (nine staff total) were certified in infant/child CPR and infant/child first aid. Therefore, no one was on duty at the facility on 11/30/21 who was certified in CPR or First Aid. The staff person in charge stated that she used to be certified; however, was certain that her certification had expired. She was not able to locate the documentation for the surveyor to review. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 5 Inspection Report
General: Based on review of documentation and the Training Records Information System (TRIS), the following was found: Two staff (hire dates: 8/11/21 and 8/16/21) did not complete the required Orientation training. These staff have been employed for more than three months. 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 Not In Compliance
General: Based on review of documentation, this regulatory requirement was not met. Nine children, out of the ten children's files reviewed, did not have an immunization certificate on file. One child had a 10/10/21 enrollment date listed and the additional eight children had August 2021 enrollment dates listed.
General: Based on review of documentation, this regulatory requirement was not met. The emergency preparedness plan on file had not been updated since 2018 - 2019 school year.
General: Based on review of documentation, this regulatory requirement was not met. A review of the policies and procedures found that the facility did not have a current chain of command. The chain of command had staff names listed that are no longer employed at the facility.
General: Based on review of documentation, this regulatory requirement was not met. A review of the 2021 fire drill log found that drills were not conducted during the months of August and October; therefore, drills were not conducted monthly. Posted Documentation In Compliance Animals Not Applicable
General: Based on review of documentation, one staff person did not have a hire date listed in her file. Staff person in charge stated that the staff person was hired after the beginning of the 2019 school year but did not know the month or day of employment.
General: Based on review of documentation, the following was found: 1) Staff hired on 10/02/17, 09/25/17, 10/02/17 and four staff hired on 08/25/18, did not have the required 15 hours of cabinet approved training on file. 2) Three staff hired on 08/15/18, had not completed the required pediatric abusive head trauma class within the first year of employment. 3) Staff hired on 08/15/18, did not have Orientation I and II on file. This information was verified through ECE-TRIS. 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 An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3 Inspection Report Children's Records Not In Compliance
General: Based on review of documentation, six children enrolled on 08/14/19, did not have current immunization records on file. Written Documentation Not In Compliance
General: Based on review of documentation, there were no times listed for when each fire, tornado and earthquake drill was conducted. Posted Documentation In Compliance Animals Not Applicable
General: Based on review of documentation, there were no current staff professional development plans on file. Posted Documentation In Compliance Animals Not Applicable
General: Based on Review of Documentation, there was one (1) staff person who was rehired on 8/23/17. However,the criminal records check on file at the time of the survey was date 8/22/12. The staff person in charged stated during the exit conference that a new criminal records check had been submitted and the results should be on file at the facility's main office but had not been sent to this location. This person was not observed working alone with children at the time and the staff person in charge indicated that there is always another staff person working with this staff person.
General: Based on Review of Documentation, out of ten (10) children's files reviewed there was one (1) child's enrollment information taht did not have a preferred hospital listed. There was an additional child's enrollment information that did not have the name and number of the child's physician listed. Written Documentation In Compliance Posted Documentation Not In Compliance
General: Based on Review of Documentation, it was found through a review of two (2) childrens files that there was no evidence of the preferred hospital listed. These children were both enrolled on 08/04/2016. It was also found that a child enrolled on 08/11/2016 did not have evidence of a physican contact. Written Documentation Not In Compliance
General: Based on Review of Documentation, it was found that there was no evidence of current regulations. The most recent copy observed was from 2009.
General: Based on Review of Documentation, it was found that there was no evidence of conducted staff meettings. Employee Records Not In Compliance
General: Based on Review of Documentation, it was found through a review of six (6) staff files that two (2) staff files did not have evidence of a TB skin test. The dates of hire for the staff were 03/20/2009 and 08/02/2010. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report
General: Based on Review of Documentation, it was found that there was no evidence of a recent emergency preparedness plan. The staff in charge provided a copy of the 2013 emergency preparedness plan. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3 Inspection Report
General: Based on Observation, the following staff hired on 3/20/09, 8/18/11, and 8/2/10 did not have an annual evaluation as required.
General: Based on Review of Documentation, a staff hired on 8/12/15 did not have a criminal records check completed on or before his hire date as required. The criminal records check for this staff was completed on 11/14/15. This staff member also did not have a CA/N check completed prior to or within five (5) days of his hired date as required. The CA/N check was completed on 10/26/15.
General: Based on Review of Documentation, the facility could not provide written evidence of staff meetings conducted within the past year.
General: Based on Review of Documentation, the facility did not have a menu posted.
General: Based on Observation, this regulatory requirement was not met. The surveyor observed children eating cereal bars and Cran-Grape juice for snack. The label on the Cran- Grape juice container stated "contains 15% juice". Since the drink was not 100 percent juice, the food requirements for snack were not met.
General: Based on Review of Documentation, six (6) children files (enrollment dates: 7/29/14, 9/18/14, 2 on 8/7/14, 8/18/14 and 8/4/14) out of ten (10) reviewed did not have an immunization certificate.
General: Based on Review of Documentation and interview, the facility failed to meet this regulatory requirement. A review of the attendance records during the inspection found that the facility was not using the required form provided by the Child Care Assistance Program. The staff person in charge identified several children enrolled at the facility that receive child care assistance and stated that he was not aware of this regulatory requirement.
General: Based on Review of Documentation, this regulatory requirement was not met. A review of the emergency drill log revealed that the last tornado drill was conducted March 2014 and the last earthquake drill was conducted January 2014; therefore, these drills are not conducted quarterly.
General: Based on Review of Documentation, this regulatory requirement was not met. A review of the emergency drill log revealed that the last fire drill was conducted March 2014; therefore, these drills are not conducted monthly.
General: Based on Review of Documentation, the following was found: 1. The statement of deficiencies and plan of correction from the 10/29/13 annual inspection was not posted. 2. Information on the Kentucky Consumer Product Safety Program and the program's website was not posted. 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
General: Based on Review of Documentation, this regulatory requirement was not met. The facility did not have a schedule of daily activities posted.
General: Based on Observation, it was found that the facility did nothave a menu prepared or posted in a conspicuous place.