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Home › KY › Lexington › Ashland's Creative Activities Program (A-CAP)
License #L358993 · Center · Licensed
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General: Based on review of documentation, a staff (DOH: 08/13/25) had a cleared background check in KARES but the eligibility date was 11/05/25 which was after his hire date.
General: Based on record review, there was no evidence at the time of inspection of a written policy to maintain supervision during breaks and movement from the classroom. General Administration In Compliance
General: Based on observation and interview, there was no statement of deficiency and corresponding plan of correction posted from the renewal survey conducted in 2025.
General: Based on review of documentation, a staff (DOH: 08/13/25) did not have documentation of education on file at the facility at the time of inspection.
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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 review of documentation, two (2) staff (DOH: 08/18/25 and 08/13/25) did not have documentation of negative TB results or a statement from a health care professional stating that the staff is free from active tuberculosis prior to employment on file at the facility.
General: Based on review of documentation, the following was found during inspection: 1) A staff (DOH: 09/01/23) completed three (3) of their fifteen (15) hours of annual training for the year dated 07/01/24 to 06/30/25. 2) A staff (DOH: 02/22/24) did not complete the required pediatric abusive head trauma training within the first year of employment. The training was completed on 04/15/26. A review of ECE-TRIS confirmed these findings.
General: Based on observation, the children did not was hands before or after snack.
General: Based on interview and review of documentation, there was no evidence at the time of survey of a written reunification plan with accommodations in the event of a natural disaster, fire, shelter-in-place, lockdown, or other emergency. Posted Documentation Not In Compliance
General: Based on interview and review of documentation, the staff in charge explained that the front office prints a list of children (a check list) daily who should attend afterschool program. The staff in charge had a check list for the day of the survey; however, the list was not complete, and it took the staff in charge approximately fifteen (15) minutes to get an accurate count of the children present in the Cafeteria. This check list included the names of the children, but the times were not recorded.
General: Based on review of documentation, three (3) staff members (DOH: 11/18/24, 02/22/24, and 01/26/24) did not have evidence of a high school diploma, GED, or Commonwealth Child Care Credential on file at the facility.
General: Based on observation, the children were served Pop-Tart pastry bites (flavors included: confetti cake, fudge brownie, and strawberry), as a part of their snack.
General: Based on observation, a teacher’s personal bag and cup were on the cafeteria table, and accessible to the children in care.
This investigation inspection recorded no violations or advisories.
General: Based on review of documentation, staff members (DOH 01/26/24 and 02/22/24) did not have proof of educational qualifications in their personnel file. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 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
General: Based on review of documentation, the Fire Marshal inspection report on file was outdated. Director Requirements In Compliance Employee Records Not In Compliance
General: Based on review of documentation, one (1) child had immunization records that were not current. Written Documentation Not In Compliance
General: Based on review of documentation, the following was found: 1) Staff policies were not available for review at the time of this survey.
General: Based on review of documentation, four (4) professional development plans reviewed did not include a date; therefore, the surveyor was unable to determine what year the plans had been completed. Posted Documentation In Compliance Animals Not Applicable
General: Based on review of documentation, staff member hired 11/8/2021 had a negative tuberculin skin result on file that exceeded two (2) years, and therefore was no longer current. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report
General: Based on review of documentation, the following was found: 1.)Staff member hired 8/10/2020 completed eleven (11) out of fifteen (15) hours of Cabinet-approved early care and education training for the July 1, 2021, to June 30th, 2022, training year. 2.) Staff member hired 8/11/2021 completed thirteen (13) hours of Cabinet-approved early care and education training for the August 11, 2021 to August 10, 2022, training year. 3.) Staff member hired 9/13/2022 did not have evidence of completing Cabinet-approved Orientation training. This training is required within the first ninety (90) days of employment. A review of ECE-TRIS supports these findings. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Kitchen Requirements In Compliance Food Service In Compliance Meal Planning/Center Provides Meals In Compliance Meal Planning/Center Does Not Provide Meals In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3 Inspection Report Children's Records Not In Compliance
General: Based on observation, interview, and review of documentation, the facility license was not posted nor available for review. The staff person in charge stated that she believed that this document had been discarded by janitorial staff. Animals In Compliance
General: Based on review of documentation, staff member hired 8/11/2021, did not have evidence of completing Orientation training; this training is required within the first 90 days of employment. A review of ECE-TRIS supports 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 In Compliance Meal Planning/Center Does Not Provide Meals In Compliance Children's Records Not In Compliance
General: Based on review of documentation, earthquake, tornado, and fire drill documentation was not available for review. Posted Documentation Not In Compliance
General: Based on observation and review of documentation the following was found: 1.) Staff member hired 11/8/2021, did not have a KARES based background check tied to the facility. The staff member was previously deemed eligible via KARES at an unrelated facility in 2018. The staff member completed a Child Abuse/Neglect check on 9/29/2021, and a State Police background check on 9/20/2021. This staff member was responsible for ten children aged six-to-seven-years-old and was not paired with an eligible staff member. 2.) Staff member hired 8/11/2021, did not have evidence of a KARES based background check. This staff member had completed a Child Abuse/Neglect Check on 10/5/2021, and a State Police Background check on 9/20/2021. This staff member was responsible for eight children aged 10-to-11 years-old and was not paired with an eligible staff member. 3.) Staff member hired 8/11/2021, did not have evidence of a KARES based background check. This individual completed a Child Abuse/Neglect check on 10/5/2021, and an Office of Administrative Courts background check on 5/21/18. 4.) Staff member hired 8/11/2021, did not have a KARES based background check tied to the facility; this individual was previously fingerprinted and deemed eligible for employment through a previous employer on 8/14/2019. This individual completed a Child Abuse/Neglect check on 10/5/2021, and an Office of Administrative Courts background check on 5/19/2009. 5.) Staff member hired 8/26/2020, did not have evidence of a KARES based background check. This individual completed a Child Abuse/Neglect check on 4/30/2021, and a State Police background check was completed on 8/22/2019. This staff member was responsible for seven children aged seven-to-eight-years-old and was not paired with an eligible staff member. 6.) Staff member hired 8/11/2021, did not have evidence of a KARES based background check. This individual completed a Child Abuse/Neglect background check on 8/28/2018, and again on 10/5/2021. An Office of Administrative Courts background check was completed on this individual on 10/5/2021. 7.) Staff member hired 8/10/2020, did not have evidence of a KARES based background check; this individual completed an Office of Administrative Courts background check on 6/20/2011, and a Child Abuse/Neglect check on 4/26/2021. This staff member was responsible for 11 children aged nine-to-ten-years-old and was not paired with an eligible staff member. It is important to note that during the COVID-19 crisis the KARES portal was not available until June 2021. After re-opening in June 2021 staff members were directed to complete fingerprint-based background checks prior to September 30, 2021. Supervision In Compliance Staffing Requirements In Compliance General Administration Not In Compliance
General: Based on review of documentation, it was found that four staff did not have an updated evaluation in their files.
General: Based on review of documentation, it was found that two staff hired on 8/10/20 and 8/26/20 did not have proof of a background check in their file. It is important to note, one staff person was not present and one was left unsupervised. Both staff did have proof of a recent CAN Check. Three other staff that were present during the survey did not have proof of a background or CA/N check on file at the facility. Supervision In Compliance Staffing Requirements In Compliance General Administration Not In Compliance
it was found that four staff were left alone with children without having proof of a completed background on check on file at the facility. Employee Records Not In Compliance
General: Based on observation, it was found that a staff had her phone, keys, drink and purse on a table next to the children. Also, three bottles of hand sanitizer were accessible to the children. 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 review of documentation, this regulatory requirement was not met. Information on the Kentucky Consumer Product Safety Program and the program’s website was not posed. Animals Not Applicable An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 4 Inspection Report Emergency Regulation Not In Compliance
General: Based on review of documentation and interview, this regulatory requirement was not met. The facility did not have an emergency preparedness plan on file for the surveyor to review. Posted Documentation Not In Compliance
Based on observation, interview and review of documentation, this regulatory requirement was not met. One staff person did not have evidence or results of background checks on file. The staff person in charge stated that this documentation was probably at their central office. The facility did not have a hire date documented for this staff person; however, the staff person in charge stated that the staff person was hired approximately 8/26/20. This staff person was observed working alone with a group of children on the playground throughout the entire survey. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 4 Inspection Report Employee Records Not In Compliance
General: Based on review of documentation, observation and interview, this regulatory requirement was not met. The following was found: 1. One child that was present at the facility on the day of the inspection did not have any paperwork on file; therefore, none of the required information had been obtained. The staff person in charge identified the child as a younger sibling of another child enrolled at the facility. 2. Four children that were present at the facility on the day of the inspection had enrollment paperwork on file; however, the forms did not include the child's date of birth. The staff person in charge acknowledged the finding and stated that the form was a newer version that had been filled out by the parents electronically. The staff person in charge further stated that she did not have any documentation on file at the facility with these birthdates listed. Written Documentation Not In Compliance
General: Based on review of documentation and ECE-TRIS the following was found: 1. Nine (9) staff completed only six (6) hours of the required fifteen (15) hours of early care and education training. 2. One (1) staff hired on 8/25/17 did not complete the pediatric abusive head trauma training within the required twelve-month period and six (6) staff have yet to renew the pediatric abusive head trauma training. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Food Service/Food Program Not Applicable Food Service In Compliance Children's Records In Compliance Written Documentation Not In Compliance
General: Based on review of documentation, the surveyor noted staff evaluations presented for review were completed in 2017. There were no current staff evaluations on file. Employee Records Not In Compliance
General: Based on review of documentation, staff hired on 8/10/10, 8/9/16 and 8/11/16, had TB skin documentation on file that was no longer valid as of 9/9/18, 3/13/19, and 3/15/19. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report
General: Based on review of documentation, the surveyor found professional development plans on file for staff were completed in 2017. There was not a current annual professional plan on file for staff development. Posted Documentation In Compliance Animals Not Applicable
General: Based on Review of Documentation, there were three (3) staff (hire dates - 8/15/12, 6/24/09, 8/22/15) who had the results of a T.B. test that exceeded the two (2) year minimum.
General: Based on Review of Documentation, it was found there was only one staff person who was certified in first aid training. There was another staff person who had certificates on file for CPR and first aid training from American Health Care Academy. However, this is not an approved source for CPR and first aid training. Therefore, at the time of the survey there was no one currently certifed in CPR from an approved source. Let it also be noted that there has only been a person certified in first aid by an approved source and no one with CPR training since school started in August 2017. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report
General: Based on Review of Documentation, there were two (2) children who have been enrolled in the program since August 2017 who did not have an immunization certificate that verifies the child is current on all immunizations. Written Documentation Not In Compliance
General: Based on Review of Documentation, there were no documented quartely practiced earthquake and tornado drills for 2017. Posted Documentation In Compliance Animals Not Applicable
General: Based on Review of Documentation, a staff person hired 8/10/09 had a TB skin test dated 12/5/14. She did not have any evidence of being free of TB on file that was dated within the past two (2) years.
General: Based on Review of Documentation, a staff person hired 8/10/09 had a TB skin test dated 12/5/14. She did not have any evidence of being free of TB on file that was dated within the past two (2) years. Also, two (2) staff did not have evidence of being free of TB prior to employment. The staff hired 8/9/16 had documentation dated 3/13/15. The staff hired 8/11/16 had documentation dated 3/15/17. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report
General: Based on Review of Documentation, a child enrolled on 5/23/16 had "closest" listed for the preferred hospital. Written Documentation In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3 Inspection Report Posted Documentation Not In Compliance
General: Based on Review of Documentation, two (2) staff hired 8/9/16 and 8/11/16 had criminal records checks dated 11/9/16. The staff person in charge stated that the criminal records checks completed for these staff upon employment had gotten lost and had to be resubmitted.
General: Based on Observation, the snack menu that was posted was from April. The director acknowledged the information. 1055 - Breakfast Requirements Not Applicable 922 KAR 2:120. Section 9. Food and Meal Requirements. (17) Breakfast shall include: (a) Milk; (b) Bread; and (c)1. Fruit; 2. Vegetable; or 3. 100 percent juice. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 22 of 25 Web site: http://chfs.ky.gov/ Inspection Report
General: Based on Review of Documentation, one (1) child's enrollment paperwork did not include a physician's phone number. Another child's enrollment paperwork had the preferred hosptial left blank. Three (3) other children's enrollment forms listed "any" or "closest" for the preferred hospital. The director acknowledged the information. 1080 - Documentation for Off Premise Trip Not Applicable 922 KAR 2:110. Section 3. Records. (1) A child-care center shall maintain: (b) A written record for each child: 3. To contain: g. A permission form for each trip off the premises signed by the child’s parent in accordance with 922 KAR 2:120, Section 12; Written Documentation
General: Based on Review of Documentation, the facility did not have an updated emergency prepardeness plan on file. The date on the emergency prepardeness plan was 10/6/11. According to KRS 199.895 the facility shall provide an updated copy of the emergency prepardeness plan to the local emergency management officals annually. The director was not aware that the plan had to updated annually.
General: Based on Review of Documentation, out of ten (10) staff files reviewed there were two (2) staff with hire dates of 8/15/12 and one (1) staff person with a hire date of 8/23/10 who did not have evidence of having completed fifteen (15) hours of training for the 2013-2014 training year. 345 - Driver Requirements Not Applicable 922 KAR 2:120. Section 12. Transportation. (18) A driver of a vehicle transporting a child for a center shall: (a) Be at least twenty-one (21) years old; (b) Complete: 1. The background checks as described in 922 KAR 2:110; and 2. An annual check of the: a. Kentucky driver history records in accordance with KRS 186.018; or b. Driver history records through the state transportation agency that issued the driver’s license; (c) Hold a current driver’s license which has not been suspended or revoked during the last five (5) years; and (d) Not caused an accident which resulted in the death of a person. Programming
General: Based on Observation, during an inspection of the first aid kit there was one (1) tube of Triple Antibiotic Ointment and a tube of Neosporin cream that was not labeled for an individual child. There were also packets of burn ointment that was not labeled for an individual child. Outdoor Play Area
General: Based on Review of Documentation, out of ten (10) files reviewed there was one (1) child's enrollment information that did not include the name and number of the child's physician. In addition there was another child whose enrollment information did not include a preferred hospital. 1080 - Documentation for Off Premise Trip Not Applicable 922 KAR 2:110. Section 3. Records. (1) A child-care center shall maintain: (b) A written record for each child: 3. To contain: g. A permission form for each trip off the premises signed by the child’s parent in accordance with 922 KAR 2:120, Section 12; Written Documentation
General: Based on Review of Documentation, the staffs' professional development plans were dated for 4/2012. Therefore, the plans had not been completed annually.
General: Based on Review of Documentation, there were four (4) staff who had documentation of being free of TB that was dated more than two (2) years in the past. Hire dates: 6/24/09, 8/10/10, 8/10/09, 8/10/10. Also, a staff person hired 9/4/13 had TB documentation dated 11/4/13, it was not prior to employment.
General: Based on Interview, the suveyor found that the staff person in charge did not have documentation of staff meetings.
General: Based on Review of Documentation, the surveyor found during file review that one (1) child (enrollment date: 8/15/12) did not have a valid immunization certificate on file. The immunization presented for review did not have a date listed.
General: Based on Review of Documentation, the surveyor found that four (3) staff (hire dates: 8/10/09, 8/10/10, and 8/23/10) had TB skin documentation on file that was no longer valid as of (7/29/12, 7/27/11, and 7/26/12) One (1) staff person re-hired on 8/17/12 had TB skin documentation on file; however, the TB skin documentation was no longer valid as of 7/27/2011.
General: Based on Observation, children's allergies are posted in the cafeteria and available for viewing by anyone that enters.
General: Based on Review of Documentation, staff with hire date 8/10/09 did not have a professional development plan on file. 107 - Maintenance of Background check/Out of State 922 KAR 2:110 - Section 3 (12) For the director, employee, volunteer, or any person with supervisory or disciplinary control over, or having direct contact with a child, results of the: (a) Criminal records check in accordance with KRS 17.165; (b) Child abuse and neglect check in accordance with 922 KAR 1:470; and (c) Background check from: 1. Previous state of residence, if the individual has been a resident outside of Kentucky in the previous five (5) years; or 2. Current state of residence, if other than Kentucky; 1) Criminal Records Check In Compliance 2) Child Abuse/Neglect Check In Compliance 3) Previous State of Residence In Compliance 4) Current State other than KY In Compliance
General: Based on Review of Documentation, staff with hire date 8/10/10 did not have a current TB test on file. 128 - CPR/First Aid Coverage 922 KAR 2:110 - Section 5 (3) At least one (1) person on duty and present with the children shall be currently certified by a cabinet-approved training agency in the following skills: (a)Infant and child cardiopulmonary resuscitation; and (b) Infant and child first aid. 1) CPR In Compliance 2) First Aid In Compliance 131 - Adequate Substitute(s) 922 KAR 2:110 - Section 5 (6) Child-care centers shall have available in case of need: (a) One (1) qualified substitute staff person for a Type II child-care center; or (b) Two (2) qualified substitute staff persons for a Type I child-care center 1) Type I In Compliance 131 - Adequate Substitute(s) 922 KAR 2:110 - Section 5 (6) Child-care centers shall have available in case of need: (a) One (1) qualified substitute staff person for a Type II child-care center; or (b) Two (2) qualified substitute staff persons for a Type I child-care center 2) Type II Not Applicable 139 - Training 922 KAR 2:110 - Section 5 (14) A staff person with supervisory authority over a child shall complete the following: (a) Six (6) hours of cabinet-approved orientation within the first three (3) months of employment; (b) Nine (9) hours cabinet-approved child development training within the first year of employment; and (c) Fifteen (15) hours of cabinet-approved training during each subsequent year of employment. 1) Orientation In Compliance 2) 9 hours-first year In Compliance 139 - Training 922 KAR 2:110 - Section 5 (14) A staff person with supervisory authority over a child shall complete the following: (a) Six (6) hours of cabinet-approved orientation within the first three (3) months of employment; (b) Nine (9) hours cabinet-approved child development training within the first year of employment; and (c) Fifteen (15) hours of cabinet-approved training during each subsequent year of employment. 3) 15 hours annually Not In Compliance Findings: General: Based on Review of Documentation, staff with hire date 8/10/09 had twelve (12) hours of training, not the required fifteen (15) available for review in her file. 317 - Driver requirements Not Applicable 922 KAR 2:120 - Section 12 (18) A driver of a vehicle transporting a child for a center shall: (a) Be at least twenty one (21) years old; (b) Complete the background checks as described in 922 KAR 2:110; (c) Hold a current driver’s license which has not been suspended or revoked during the last five (5) years; (d) Not have had any convictions concerning vehicle operation in the past twelve (12) months; and (e) Not caused an accident which resulted in the death of a person. 1) Be 21 years old or over Not Applicable An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 8 of 39 Web site: http://chfs.ky.gov/ Inspection Report 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 review of documentation, a staff member (DOH: 11/18/24) did not complete a background check within the KARES system until 03/17/25. Therefore, this staff member worked at the center for approximately five (5) months without the required background check.
General: Based on review of documentation, two (2) staff members (DOH: 11/18/24 and 01/26/24) did not have a current TB test or statement from a health professional on file at the facility.
General: Based on review of documentation, a staff member (DOH: 08/11/21) completed pediatric abusive head trauma (PAHT) training on 11/04/19; however, did not renew the training due 11/04/24. A review of ECE-TRIS system verified this information.
General: Based on review of documentation, the orientation policy was not available for review at the time of this survey. Posted Documentation In Compliance Animals In Compliance
General: Based on observation and review of documentation, only one (1) staff member employed by the facility was certified in CPR/ First aid administration. This staff member was present during the inspection process; however, the staff member left at 3:30 p.m. There was not a staff member present with CPR/ First aid certification present for the remainder of the day.
General: Based on review of documentation, staff members hired respectively on 8/10/2020, 8/11/21, 8/11/21, and 8/26/2019 did not have evidence of being trained in CPR/ First aid administration.
General: Based on review of documentation, one (1) child’s file reviewed did not contain an immunization record. A second child’s file reviewed had an immunization record that was no longer valid as of 1/23/2023. Both children had been enrolled for more than thirty (30) days.
General: Based on review of documentation, three (3) children’s files reviewed did not list a physician's contact number, nor a preferred hospital. Written Documentation Not In Compliance
General: Based on observation and review of documentation, Fire Marshal documentation was not available for review.
General: Based on review of documentation, a procedure informing staff members of the laws pertaining to child abuse and neglect was not available for review. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 4 Inspection Report Director Requirements Not In Compliance
General: Based on observation and review of documentation, four staff members (dates of hire: 11/8/21, 8/11/21, 8/10/21, and 8/26/2020) present on the date of the inspection did not have a completed background check; these four individuals were left alone and responsible for their own classrooms. These staff members were not paired with an eligible staff member. Employee Records Not In Compliance
General: Based on review of documentation, staff member hired 8/10/2020, had a negative tuberculin skin result dated 10/7/2019; this result exceeds two years and is no longer current.
General: Based on interview and review of documentation, the ten children’s files reviewed did not have an immunization record. The staff person in charge reported that this documentation may have been in the children’s school files at the school office; however, this staff member did not have access to those records. Each child has been enrolled more than 30 days. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 4 Inspection Report Written Documentation Not In Compliance
General: Based on review of documentation, a staff schedule indicating staff members working hours was not available for review.
General: Based on observation, it was found that the center did not meet the minimum two requirements for snack. Snack that was served during the visit consisted of animal crackers, fruit snacks and water. Snack should include two (2) of the following: milk, protein, bread, vegetable or fruit (which can include 100% fruit juice). Meal Planning/Center Does Not Provide Meals In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 4 Inspection Report Children's Records Not In Compliance
General: Based on review of documentation, there was not proof of updated liability insurance coverage on file at the center. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 4 Inspection Report
General: Based on observation, it was found that two electrical outlets were uncovered in the cafeteria and accessible to children. Director Requirements Not In Compliance
General: Based on review of documentation, it was found that the center did not have an updated copy of the regulations.
General: Based on observation and review of documentation, three staff were found to not have files on site. It is important to note, these staff were present and left alone with children. Due to not having a file on site, identifying information could not be determined.
General: Based on review of documentation, it was found that four staff were missing proof of education in their file.
General: Based on review of documentation, it was found that six staff either did not have negative TB documentation or the documentation was no longer current. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 4 Inspection Report
General: Based on review of documentation, it was found that five staff members did not receive the required 15 hours of training for the year from 7/1/2020-6/30/2021. A review of ECE-TRIS confirmed this finding. Programming In Compliance Premises Not In Compliance
General: Based on review of documentation, it was found that one child did not have any emergency medical information included in their enrollment paperwork which included physician's contact, preferred hospital and emergency care information. Also, one child did not have a preferred hospital name in their enrollment paperwork. Written Documentation Not In Compliance
General: Based on review of documentation, it was found that five staff were missing an updated professional development plan. Posted Documentation In Compliance Animals In Compliance
A PLAN OF CORRECTION WAS DUE ON 04/02/2021 AND AS OF 04/07/2021, THE PLAN OF CORRECTION HAS NOT BEEN RECEIVED. Director Requirements Not In Compliance
General: Based on review of documentation and interview, this regulatory requirement was not met. A review of staff files during the inspection found one staff person that did not have the date of employment listed in their file. After speaking to the staff person in question, the staff person in charge stated that she did not know the exact date; however, indicated that the staff person was hired approximately 8/26/20.
General: Based on review of documentation and interview, this regulatory requirement was not met. The staff person in charge stated during interview that they do not have any substitutes in case of need; however, indicated that they are in process of hiring someone. 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 Not In Compliance
General: Based on observation, this regulatory requirement was not met. A review of the facility menu that was posted found two days that the required food components were not listed for snack. Pretzels and water were listed on the day of the inspection (3/4/21). Cereal bar and water were listed on 3/3/21. Food Service In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 4 Inspection Report Children's Records Not In Compliance
General: Based on review of documentation and the Training Records Information System (TRIS), the following was found: 1. One staff person (hire date: 8/22/15) did not have evidence of completing the required ECE 202 training class (Requirements for Reopening Child Care in Kentucky). 2. One staff person did not have evidence or results of background checks on file. The staff person in charge stated that this documentation was probably at their central office. The facility did not have a hire date documented for this staff person; however, the staff person in charge stated that the staff person was hired approximately 8/26/20. It is important to note that this staff person was observed working alone with a group of children on the playground throughout the entire survey.
General: Based on Review of Documentation and ECE-TRIS records, there were five (5) staff who completed Pediatric Abusive Head Trauma training on 3/4/13. At the time of the survey these five (5) staff had not taken the training again as required by the regulation. In addition there were were three (3) staff with hire dates of 8/22/15, 8/10/10 and 9/4/13 who did not have evidence of having completed fifteen (15) hours of required training for the 2016-2017 training year. 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 Not In Compliance
General: Based on Review of Documentation, there were seven (7) staff who did not complete the required fifteen (15) hours of training for their current training year. The ECE-Tris database was reviewed and confirmed the lack of training. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Food Service In Compliance Children's Records Not In Compliance
General: Based on Observation, the programs rates were not posted. Animals Not Applicable
General: Based on Observation, during snack a child was served Doritoes and a Capri Sun. The remainder of the children were served a Nutrigrain bar and milk. An interview with staff indicated that the child was not served the same snack as the other children due to religious reasons. Staff also indicated that the child brings his own snack each day. A review of the child's file found there was not documentation to verify the child can not eat the snack items provided by the facility. In addition the facility did not suppliment the snack with components that meet snack requirements. 1065 - Lunch/Dinner Requirements Not Applicable 922 KAR 2:120. Section 9. Food and Meal Requirements. (19) Lunch and dinner shall include: (a) Milk; (b) Protein; (c) Bread; and (d)1. Two (2) vegetables; 2. Two (2) fruits; or 3. One (1) fruit and one (1) vegetable. Children's Records