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Home › KY › Lexington › Faith Lutheran Learning Center
License #L352649 · Center · Licensed
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This investigation inspection recorded no violations or advisories.
This investigation 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
This investigation inspection recorded no violations or advisories.
This investigation inspection recorded no violations or advisories.
This investigation inspection recorded no violations or advisories.
General: Based on observation, an epinephrine auto-injector was accessible to the children in the Big K-5 Room. The epinephrine auto-injector was inside the backpack that was on the classroom floor. Outdoor Play Area Not In Compliance
General: Based on observation, in the P-5 Room a staff member's keychain was hanging low and was accessible to the children in care.
General: Based on review of documentation, a child (DOE: 07/26/24) did not have physician contact information listed in their file.
General: Based on observation, a small fan was plugged in with a cable hanging low that was accessible to the children in the P-3 Room.
General: Based on review of documentation, the following was found: 1) A staff member (DOH: 09/30/20) did not have a current TB test or statement from a health professional on file at the facility. The TB test on file expired on 07/09/25. 2) A staff member (DOH: 01/06/25) did not obtain a TB test or statement from a health professional until 03/05/25.
This change of space/change in capacity inspection recorded no violations or advisories.
This investigation inspection recorded no violations or advisories.
This investigation inspection recorded no violations or advisories.
This investigation inspection recorded no violations or advisories.
This renewal application inspection recorded no violations or advisories.
This investigation inspection recorded no violations or advisories.
General: Based on review of documentation, staff member hired 10/11/2022, did not have proof of educational documentation 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 Transportation In Compliance Kitchen Requirements In Compliance Food Service In Compliance Meal Planning/Center Provides Meals In Compliance Meal Planning/Center Does Not Provide Meals In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Children's Records In Compliance Written Documentation In Compliance Posted Documentation In Compliance Animals In Compliance
General: Based on observation, a cabinet was not locked in the Chameleons room and plastic bags were found in the drawer, accessible to the children in care. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report
General: Based on interview and review of documentation, the facility had not started practicing lockdown drills. The staff person in charge stated that they are in the process of making the lockdown drill procedure. Posted Documentation In Compliance Animals Not Applicable
General: Based on observation, the classroom door had tape residue that was accumulating dirt and two vertical peeled pieces of wood in the Explorers room. Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment Not In Compliance
General: Based on review of documentation, a staff member hired 8/16/2021, did not have a current TB test or statement from a health professional on file. Programming In Compliance Premises Not In Compliance
General: Based on observation, the proper methods for diapering and hand washing were not posted in the two changing areas used by the facility. Animals Not Applicable
General: Based on observation, interview and review of documentation, there were eight children ranging in age from one to three years being cared for in the Happy Hippos classroom with two staff. The youngest child in the group was 18-months-old. In an interview with staff, it was found that the children are grouped together the entire time they are present in the facility. In an interview with the staff person in charge, it was determined that the facility did not have a procedure for transitioning toddlers or signed approval from the toddlers' parents on a transition plan. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report Premises Not In Compliance
General: Based on observation, the following was found: 1. There were two Swiffer Wet Jet mops in the play area in the Chameleons classroom. The liquid floor cleaner bottles on the mops were accessible to the children in care. 2. A staff person's purse was hanging on a hook in the School-age classroom. The purse was accessible to the children in care. 3. The door from the School-age classroom to the cleaning closet was propped open. There were numerous cleaners being stored in that area that were accessible to the children in care. Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation 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 observation, the changing pad in the bathroom near the school age classroom had orange staining across the bottom of the pad. First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation In Compliance Food Service/Food Program In Compliance Food Service In Compliance Children's Records In Compliance Written Documentation In Compliance Posted Documentation In Compliance Animals In Compliance Emergency Regulation In Compliance
General: Based on review of documentation, staff hired on 03/26/18 and 02/21/18 did not have a current evaluation on file.
General: Based on observation, the following was found: 1) There were numerous empty plastic bags found underneath a table in the hallway. The plastic bags were accessible to the children. 2) An outlet in the Flamingo's classroom did not have a protective safety cover and was accessible to the children. Employee Records In Compliance Programming In Compliance Premises In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Hygienic Practices Not In Compliance
General: Based on review of documentation, staff person hired 5/29/18 did not have evidence of completing the required orientation training in the first three (3) months of employment, did not have evidence of completing the Pediatric Abusive Head Trauma training within the first year of employment, and had evidence of only eight (8) hours of annual training on file for the last full year of employment. Staff member hired 3/13/17 did not have documentation of completing the pediatric abusive head trauma training within the past five (5) years. The training certificate on file was dated 8/24/13. Staff member hired 3/26/18 had evidence of only eight (8) hours of annual training on file for the last full year of employment and did not have evidence of completing the Pediatric Abusive Head Trauma training within the first year of employment. A review of ECE-TRIS records supports the information found during the survey. Programming In Compliance Premises Not In Compliance
General: Based on observation, the list of classroom allergies was posted on the wall in the Hippo Room without any covering to maintain confidentiality. Posted Documentation In Compliance Animals In Compliance
General: Based on observation, in the Hippo Room there was paint chipping on the blue wall in the block center. There were blue beads from the sensory table scattered on the floor in the Busy Bees room. The school-aged classroom had several fragments of paper hanging from the ceiling. Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment Not In Compliance
This change of space/change in capacity inspection recorded no violations or advisories.
General: Based on observation and review of documentation, a staff person was observed leaning over a child at naptime which restrained him and did not allow movement. There were two additional staff members present in the room that witnessed the staff restraining the child. Neither staff reported the incident or intervened. Programming Not In Compliance
General: Based on observation, a child was restless and not able to sleep at naptime. The staff did not offer the child any alternative activity to help during naptime.
General: Based on Review of Documentation and ECE-TRIS review the following was found: 1.) One staff person (DOH: 02/21/2018) did not complete the required orientation training within the ninety day time period. 2.) One staff person (DOH: 06/10/2017) did not complete the required Pedatric Abusive Head Trauma Training in the required time frame. 3.) Two staff (DOH: 06/10/2017 and 08/10/2015) did not complete the required fifteen (15) hours of cabinet approved training. Programming In Compliance Premises Not In Compliance
General: Based on Observation, it was found that in the two and three year old classroom, there was a ceiling tile that appeared to have water damage and was stained brown.
General: Based on Review of Documentation, the following was found: 1.) There was not a fire drill completed in March of 2018. 2.) There was no evidence of a tornado drill being completed at the facility since January of 2018. 3.) There was no evidence of an earthquake drill being completed at the facility since August of 2017. The Director stated that the Assisstant Director is in charge of keeping up with the drills.
General: Based on Review of Documentation, it was found that one staff (DOH: 08/25/2014) did not have evidnce of an annual professional development on file.
General: Based on Review of Documentation, four (4) staff members did not have current professional development plans on file. These four (4) staff were hired on 8/16/10, 8/25/14, 11/04/15, and 9/16/15. Posted Documentation In Compliance Animals In Compliance
General: Based on Review of Documentation, one (1) substitute staff hired on 8/10/15 did not have any training hours during her completed training year. Another staff member hired on 8/25/14 had 1.50 hours of training during her completed training year. In addition, two (2) staff did not complete orientation training within the first three (3) months of employment. These staff were hired on 10/03/16 and 4/17/17. Programming In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report Premises Not In Compliance
General: Based on Review of Documentation, two (2) staff did not have proof of education on file. These two (2) staff were hired on 7/21/17 and 4/17/17.
General: Based on Observation, outside of the bathroom, near the school-age room, a warm vanilla deodorizer refill was observed on top of a plastic storage bin. The deodorizer's label indicated to "Keep out of reach of children" and it was within reach of the children.
General: Based on Observation, a child in the Happy Hippos room was having breakast later than the other children. When he finished he did not wash his hands. He went directly to circle time with the other children.
General: Based on Review of Documentation, there were four (4) staff who did not obtain the pediatric abusive head trauma training within the required time frame. The hire dates for these staff were 8/10/15, 7/30/07, 8/25/14, and 4/29/13. The ECE-Tris database was reviewed and these staff did not have this training listed.
General: Based on Review of Documentation, a staff person hired 8/10/16 did not have documentation of meeting the education requirement on file.
General: Based on Review of Documentation, there were three (3) staff who had more than a two (2) year laspe between obtaining documentation of being free of TB. A staff person hired 8/16/10 had documentation dated 8/7/13 followed by documentation dated 2/8/16. A staff person hired 8/25/14 had documentation dated 5/8/14 followed by documentation dated 7/13/16. A staff person hired 9/15/14 had documentation dated 6/2/14 followed by documentation dated 7/29/16.
General: Based on Review of Documentation, and observation a staff member hired on 9/18/15 did not have a completed out-of-state background check on file. The staff member previously lived in West Virginia. the FBI check was submitted on 9/18/15, but the results had not yet been obtained. This staff member was observed working alone taking children to the bathroom during the follow-up survey. Two (2) groups of two (2) preschool children were observed alone with this staff member while she was taking them to the bathroom and then returning them back into their classroom. Employee Records
General: Based on Review of Documentation, and observation a staff member hired on 9/18/15 did not have a completed out-of-state background check on file. The staff member previously lived in West Virginia. the FBI check was submitted on 9/18/15, but the results had not yet been obtained. This staff member was observed working alone taking children to the bathroom during the follow-up survey. Two (2) groups of two (2) preschool children were observed alone with this staff member while she was taking them to the bathroom and then returning them back into their classroom. Written Documentation
General: Based on Review of Documentation, the facility did not have a completed emergency preparedness plan on file and no plan was submitted to the emergency management officials. This regulatory violation was previously issued during relicensure surveys conducted on 7/16/14, 7/17/13 and on 8/4/15. The plan of correction from the relicensure survey conducted on 8/4/15 indicated that the emergency preparedness plan will be completed and submitted to the local officials on 11/20/15.
General: Based on Review of Documentation, two (2) staff did not have written evidence of a professional development plan on file. These staff were hired 7/30/07 and 4/29/13.
General: Based on Review of Documentation, the facility did not have a complete copy of the regulations on file. 922 KAR 2:090 was missing from the copy on file.
General: Based on Observation, the Friendly Frogs Room (Room #5- a 2 year-old room) contained a diaper changing table and no hand washing sink. The hand washing sink was located outside of the classroom, across the hall, and inside the bathroom. The diaper changing area should be adjacent to the hand washing sink to prevent contamination of other surfaces that the child may touch on the way to the bathroom. This regulatory violation was previously issued during a relicensure suvey conducted on 7/16/14. The plan of correction indicated that the director will purchase a wall-mount diaper changing station to be placed in the bathroom behind the K-5 classroom. The plan indicated that a teacher will take the kids back there for diaper changes. The completion date listed was 8/8/14. A wall-mount diaper changing station was not observed in the bathroom.
General: Based on Review of Documentation, one (1) staff, hired on 3/30/15, lived in Illinois within the last five (5) years and she did not have an out-of-state criminal background check on file. Another staff, hired on 6/16/14, lived in Georgia within the last five (5) years and she did not have an out-of-state criminal background check on file. Neither staff member was observed working alone with the children during the relicensure survey. This regulatory violation was previously cited during a relicensure survey conducted on 7/16/14 for the same staff member hired on 6/16/14 that previously lived in Georgia.
This investigation inspection recorded no violations or advisories.
General: Based on Review of Documentation, six (6) staff did not have an annual professional development plan on file at the time of the inspection.
General: Based on Observation, the surveyor observed a diaper changing table in the Friendly Frogs Classroom and noted that there was not a hand washing sink located in the classroom. The staff person stated that two (2) children were still in diapers. The nearest sink was across the hall in the restroom.
General: Based on Observation, the surveyor observed a small rusted charcoal grill lying next to the storage building in the outdoor play area.
General: Based on Review of Documentation, two (2) staff (hire dates: 9/4/2012 and 4/29/2013) did not complete the required fifteen (15) hour cabinet approved early care and education training. The staff person hired on 9/4/12 had twelve (12) hours of training and the staff person hired on 4/29/2013 had eight (8) hours of training.
General: Based on Observation, the diapering procedure was not posted at the diaper changing area. Animals 1175 - Animals in the Presence of Children Not Applicable 922 KAR 2:120. Section 13. Animals. (1) An animal shall not be allowed in the presence of a child in care: (a) Unless: 1. The animal is under the supervision and control of an adult; 2. Written parental consent has been obtained; and 3. The animal is certified as vaccinated against rabies; or (b) Except in accordance with subsection (3) of this section. 1185 - Prohibited Animals Not Applicable 922 KAR 2:120. Section 13. Animals. (3) An animal that is considered undomesticated, wild, or exotic shall not be allowed at a child-care center unless the animal is: (a) A part of a planned program activity lead by an animal specialist affiliated with a zoo or nature conservatory; and (b) In accordance with 301 KAR 2:081 and 301 KAR 2:082.
General: Based on Review of Documentation, and interview, the facility did not submit written notification to the cabinet for approval prior to arranging transportation services. A review of the summer calendar posted in the school age classroom found that children "Catch the Bus" to go to the library every Tuesday and are scheduled to take a "Bus Trip to Kids Place" on 7/24/13. An interview with staff revealed that children are transported via a public bus during these field trips; however, transportation services had not been approved by the Cabinet and it was not listed on the license. 790 - Transportation Notification/Type and Vehicle Not Applicable 922 KAR 2:120. Section 12. Transportation. (3) Prior to transporting a child, a center providing transportation services of a child shall notify the cabinet or its designee in writing of the: (a) Type of transportation offered; (b) Type of vehicle used for transportation; 795 - Transportation Notification/Plan for Ensuring Staff Duties Not Applicable 922 KAR 2:120. Section 12. Transportation. (3) Prior to transporting a child, a center providing transportation services of a child shall notify the cabinet or its designee in writing of the: (c) Plan for ensuring staff perform duties relating to transportation properly; 800 - Transportation Notification/Full Coverage Insurance Not Applicable 922 KAR 2:120. Section 12. Transportation. (3) Prior to transporting a child, a center providing transportation services of a child shall notify the cabinet or its designee in writing of the: (d) Full insurance coverage for each vehicle; 805 - Transportation Notification/Policy & Procedures Regarding Emergency Plan for Evacuation Not Applicable 922 KAR 2:120. Section 12. Transportation. (3) Prior to transporting a child, a center providing transportation services of a child shall notify the cabinet or its designee in writing of the: (e) Agency policy and procedures relating to an emergency plan for evacuating the vehicle; 810 - Transportation Notification/Third Party Contracts Not Applicable 922 KAR 2:120. Section 12. Transportation. (3) Prior to transporting a child, a center providing transportation services of a child shall notify the cabinet or its designee in writing of the: (f) Contracts, agreements, or documents detailing arrangements with any third party for services; 815 - Transportation Notification/Safety Procedures - Transporting, Loading/Unloading and Supervision Not Applicable 922 KAR 2:120. Section 12. Transportation. (3) Prior to transporting a child, a center providing transportation services of a child shall notify the cabinet or its designee in writing of the: (g) Safety procedures for: 1. Transporting a child; 2. Loading and unloading a child; and 3. Providing adequate supervision of a child. 820 - Vehicle Equipment Not Applicable 922 KAR 2:120. Section 12. Transportation. (4) A vehicle used to transport children shall be equipped with: (a) A fire extinguisher; (b) First aid supplies as described in Section 7 of this administrative regulation; (c) Emergency reflective triangles; and (d) A device to cut the restraint system, if necessary. 825 - Transit/School Bus Not Applicable 922 KAR 2:120. Section 12. Transportation. (5) Transportation provided by licensed public transportation or a school bus shall comply with subsections (1) and (2) of this section. 830 - Vehicle Inspection Documentation Not Applicable 922 KAR 2:120. Section 12. Transportation. (6) A vehicle used to transport children shall meet the following requirements: (a) A twelve (12) or more passenger vehicle shall display a current certification of inspection from the Transportation Cabinet on the designated window. 835 - Vehicle Requirements/Traffic Stop During Loading/Unloading Not Applicable An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 18 of 26 Web site: http://chfs.ky.gov/ Inspection Report 922 KAR 2:120. Section 12. Transportation. (6) A vehicle used to transport children shall meet the following requirements: (b) A vehicle that requires traffic to stop while loading and unloading a child shall be equipped with a system of: 1. Signal lamps; 2. Identifying colors; and 3. Cautionary words. 840 - Seatbelts for Each Occupant Not Applicable 922 KAR 2:120. Section 12. Transportation. (6) A vehicle used to transport children shall meet the following requirements: (c) A vehicle shall be equipped with seat belts for each occupant to be individually secured. 845 - No Hazardous Materials Not Applicable 922 KAR 2:120. Section 12. Transportation. (6) A vehicle used to transport children shall meet the following requirements: (d) A vehicle shall not transport children and hazardous materials at the same time. 850 - Car Seats Not Applicable 922 KAR 2:120. Section 12. Transportation. (7) The appropriate car safety seat meeting federal and state motor vehicle safety standards in 49 C.F.R. 571.213 and KRS 189.285 shall be used for each child. 855 - Pre-trip Inspection Not Applicable 922 KAR 2:120. Section 12. Transportation. (8) A daily inspection of the vehicle shall be performed and documented for the following: (a) Tires; (b) Lights, signals, mirrors, gauges, and wiper blades; (c) Safety restraints; (d) Fuel; and (e) Free of debris. 860 - Ratios Not Applicable 922 KAR 2:120. Section 12. Transportation. (9)(a) The staff-to-child ratios set forth in Section 2(2) of this administrative regulation shall apply to vehicle transport, if not inconsistent with special requirements or exceptions in this section. (b) An individual who is driving with a child in the vehicle shall supervise no more than four (4) children under the age of five (5). 865 - Seating Not Applicable 922 KAR 2:120. Section 12. Transportation. (10) Each child shall: (a) Have a seat; (b) Be individually belted or harnessed in the seat; and (c) Remain seated while the vehicle is in motion. 870 - Child Unattended Not Applicable 922 KAR 2:120. Section 12. Transportation. (11) A child shall not be left: (a) Unattended at the site of aftercare delivery; and (b) Unattended in a vehicle. 875 - Pre-arranged Plan Not Applicable 922 KAR 2:120. Section 12. Transportation. (12) If the parent or designee is unavailable, a prearranged written plan shall be completed to designate where the child can be picked up. 880 - Unaccompanied Child Crossing Street Not Applicable 922 KAR 2:120. Section 12. Transportation. (13) A child shall not be picked up or delivered to a location that requires crossing the street or highway unless accompanied by an adult. 885 - Vehicle Headlamps Not Applicable 922 KAR 2:120. Section 12. Transportation. (14) A vehicle transporting a child shall have the headlamps on. 890 - Refueling Not Applicable 922 KAR 2:120. Section 12. Transportation. (15) A vehicle shall be refueled when not being used to transport a child. If emergency refueling or repair is necessary during transporting, all children shall be removed and supervised by an adequate number of adults while refueling or repair is occurring. 895 - Driver Not In Seat Not Applicable An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 19 of 26 Web site: http://chfs.ky.gov/ Inspection Report 922 KAR 2:120. Section 12. Transportation. (16) If the driver is not in the driver's seat, the: (a) Engine shall be turned off; (b) Keys shall be removed; and (c) Emergency brake shall be set. 900 - Children's Transportation Records Not Applicable 922 KAR 2:120. Section 12. Transportation. (17) Transportation services provided shall: (a) Be recorded in writing and include: 1. The first and last name of the child transported; and 2. The time each child gets on and the time each child gets off; (b) Be completed by a staff member other than the driver; and (c) Be kept for five (5) years. 905 - Hazardous Items Not Applicable 922 KAR 2:120. Section 12. Transportation. (19) Firearms, ammunition, alcohol, or illegal substances shall not be transported in a vehicle transporting children. Food Service 910 - Bottle Feeding Not Applicable 922 KAR 2:120. Section 3. General Requirements. (11) While bottle feeding an infant, the: (a) Child shall be held; and (b) Bottle shall not be: 1. Propped; 2. Left in the mouth of a sleeping infant; or 3. Heated in a microwave 915 - Kitchen Exemption Not Applicable 922 KAR 2:120. Section 4. Premises Requirements. (18) A kitchen shall not be required if: (a) The only food served is an afternoon snack to school-age children; and (b) Adequate refrigeration is maintained.
This follow-up inspection recorded no violations or advisories.
Two Year Olds: Based on Observation, it was found that one (1) staff person took a child to the bathroom for a diaper change, leaving one (1) staff person supervising twelve (12) two (2) and three (3) year old children. The required staff to child ratio when a two (2) year old is present is one (1) staff person for every ten (10) children. School Age: Based on Observation, it was found that one (1) staff person was supervising eighteen (18) children ages five (5) years to ten (10) years old. The required staff to child ratio when a five (5) year old is present is one (1) staff person for every fifteen (15) children. Employee Records 17 - Submission of background checks timely/Left alone 922 KAR 2:090 - Section 5 (2) A director, employee, volunteer, or any person with supervisory or disciplinary control over or having direct contact with a child shall submit to a background check; and (a) May be employed or work with a child on a probationary basis for up to ninety (90) calendar days, pending completion of a: 1. Child abuse or neglect check described in 922 KAR 1:470; and 2. Criminal records check required by KRS 199.896(19); and (b) Shall not be left alone in the presence of a child if each required background check has not been completed. 2) Child Abuse and Neglect Not In Compliance Findings: General: Based on Review of Documentation, it was found that the files for employees hired on 8-14-12 and 9-17-12 contained the results of child abuse and neglect checks that were submitted on 9-1-12 and 9-28-12 respectively. These dates are not within the five (5) day timeframe required by the regulation. 3) CRC Not In Compliance Findings: General: Based on Review of Documentation, it was found that the files for employees hired on 8-14-12 and 9-17-12 contained the results of criminal records checks that were submitted on 9-1-12 and 9-28-12 respectively. These dates are not prior to or on date of hire as required by the regulation. 17 - Submission of background checks timely/Left alone 922 KAR 2:090 - Section 5 (2) A director, employee, volunteer, or any person with supervisory or disciplinary control over or having direct contact with a child shall submit to a background check; and (a) May be employed or work with a child on a probationary basis for up to ninety (90) calendar days, pending completion of a: 1. Child abuse or neglect check described in 922 KAR 1:470; and 2. Criminal records check required by KRS 199.896(19); and (b) Shall not be left alone in the presence of a child if each required background check has not been completed. 4) Left alone In Compliance 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; 3) Previous State of Residence Not In Compliance Findings: General: Based on Review of Documentation, it was found that an employee hired on 8-14-12 has lived in Ohio within the last five (5) years. Her file did not contain the results of or evidence of submission for an Ohio background check. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 2 of 3 Web site: http://chfs.ky.gov/ Inspection Report
General: Based on Review of Documentation, it was found that the files for employees hired on 10-11-11, 12-20-11, 1-2-12, 1-13-12, 5-29-12, 5-29-12 and 5-29-12 did not contain evidence of a high school diploma, GED or Commonwealth Childcare Credential. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 8 of 44 Web site: http://chfs.ky.gov/ Inspection Report
General: Based on Review of Documentation, it was found that the files for two (2) eligible employees did not contain evidence of a completed annual evaluation.
General: Based on Observation, it was found that a red metal dome-shaped climbing structure was not anchored to the ground.
General: Based on Review of Documentation, it was found that a list of allegies for a child was posted in the two (2) year old classroom. The facility did not have written permission from the parent to post this information where everyone could see it.
General: Based on Review of Documentation, it was found that the files for two (2) employees hired on 5-29-12 did not contain evidence of a TB skin test. It was also found that the file for an employee hired on 1-2-12 contained the results of a TB skin test that was dated 1-13-12. This date is not prior to date of hire as required by the regulation. In addition, the files for employees hired on 10-13-97, 9-2-08 and 5-29-12 contained the results of TB skin tests that were dated 11-3-09, 10-4-09 and 7-6-10 respectively. These dates are not within the two (2) year timeframe required by the regulation. 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 Not In Compliance Findings: General: Based on Review of Documentation, it was found that the file for an employee hired on 12-20-11 contained evidence indicating that the employee completed the six (6) hour cabinet-approved orientation training on 5-9-12. This is not within the ninety (90) day timeframe required by the regulation. In addition, the files for employees hired on 10-11-11, 1-2- 12 and 1-13-12 did not contain evidence of orientation training being completed. 2) 9 hours-first year Not In Compliance Findings: General: Based on Review of Documentation, it was found that the files for employees hired on 1-3-11 and 2-17-11 contained evidence of only three (3) and four (4) hours of additional training being completed during the first year of employment. 3) 15 hours annually Not In Compliance Findings: General: Based on Review of Documentation, it was found that the file for an employee hired on 10-13-97 contained evidence of only twelve (12) hours of annual training being completed during the last completed training year. The file for an employee hired on 7-30-07 contained no evidence of training hours being completed during the last completed training year. The file for an employee hired on 9-2-08 contained evidence of only two (2) hours of annual training being completed during the last completed 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 An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 9 of 44 Web site: http://chfs.ky.gov/ Inspection Report 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 observation, a piece of the floor tile was missing by the door in the P-3 Room.
General: Based on observation, the outside play area on the side of the building was not protected by physical or natural barrier from the parking lot.
General: Based on observation, a child size blue couch was ripped in several places in the P-3 Room.
General: Based on review of documentation, the shelter-in-place and lockdown drills were not practiced separately in March of 2025.
General: Based on review of documentation, there was no written evidence of completed tornado, earthquake, shelter-in-place, and lockdown drills for the second quarter of 2025.
General: Based on review of documentation, the daily planned program of activities (lesson plan) posted in the P-3 Room was no longer current. The posted daily planned program of activities was dated for the week of 07/13/25 to 07/19/25.
General: Based on observation, a child size blue couch had a tear in the Chameleons room. Transportation In Compliance Kitchen Requirements In Compliance Food Service Not In Compliance
General: Based on observation, there was no whole milk available for the children under 24-months-old that were in attendance on the day of the survey. 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
General: Based on observation, it was found that a child enrolled in the facility receives speech therapy and occupational therapy in the facility from a third-party professional. The facility had not received permission from the child's parent for this to occur. Written Documentation Not In Compliance
General: Based on review of documentation, it was found that three out of nine staff eligible for an annual professional development plan did not have evidence of a plan on file at the facility. 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 observation, a schedule of daily activities was not posted in the Chameleons classroom and the School-age Classroom.
General: Based on review of documentation, staff person hired 2/7/19 did not have documentation of negative T.B. results on file in the facility that had been obtained within the past two (2) years. The documentation provided was dated 2/21/17. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report
General: Based on review of documentation, there was no evidence that the facility's Emergency Preparedness Plan had been updated or submitted to the proper authority for review since 2016.
A PLAN OF CORRECTION WAS DUE ON 08/28/2019 AND AS OF 09/13/2019, THE PLAN OF CORRECTION HAS NOT BEEN RECEIVED. Director Requirements Not In Compliance
General: Based on review of documentation, three (3) staff members with hire dates 5/29/18, 3/21/18, and 6/13/15 did not have evidence of an annual evaluation on file in the facility. Employee Records Not In Compliance
General: Based on observation, the Busy Bees room had a black shelf without a lock which contained a purse belonging to a staff member. This item was accessible to the children in care. A food cart containing a bleach water bottle on the second shelf was brought into the Busy Bees room during lunch time.
General: Based on observation, the following was observed: 1. The recycling can in the Busy Bees room contained an excessive amount of grime build-up. 2. The tan file cabinet located in the School-age classroom had orange residue covering the bottom of the cabinet. 3. The school-age classroom contained a blue bin in the book nook that was covered in mud. There was blue paint on the corner of the science/ writing shelf in the school-age room. 4. Two (2) LED lights were not operational at the time of inspection in the indoor gross motor room. Transportation In Compliance 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, child enrolled 9/12/13 did not have a physician’s name and contact information or medical history on file in the facility. Written Documentation Not In Compliance
General: Based on Observation, it was found that in the two and three year old classroom, there was a bottle of sculpting gel and glaze located on a desk in the classroom. This item was labeled "keep out of reach of children", and it was in reach of the children in the classroom. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report
General: Based on Observation, it was found that a toliet in the bathroom located next to the gross motor room had not been flushed. It contained urine and feces. Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation In Compliance Food Service/Food Program In Compliance Food Service In Compliance Children's Records In Compliance Written Documentation Not In Compliance
General: Based on Review of Documentation, it was found that there was not a fire drill completed in March of 2018. Posted Documentation In Compliance Animals In Compliance
General: Based on Observation, the school-age room contained cob-webs inside the widow frames.
General: Based on Observation, a ceiling tile in the indoor gross motor room was not in place and some pipes in the ceiling were exposed. Hygienic Practices In Compliance First Aid/Medication Not In Compliance
General: Based on Observation, in the Happy Hippos room, inside the locked medication box, was a bottle of Zarbee's Children's Cough Syrup without a child's name on it. Outdoor Play Area Not In Compliance
General: Based on Observation, a red metal framed fire truck was located on the playground on grass and dirt surfacing. The metal frame of the fire truck was approximately three (3) feet tall. In addition, a blue framed fishing boat was located on the playground on grass and dirt surfacing. The metal frame of the boat was approximately 4.50 feet tall. This equipment was for climbing Equipment Not In Compliance
General: Based on Observation, in the Happy Hippos Room a grey (wooden) child-sized oven door was not attached properly by its hinges. The oven door was attached by duct- tape. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3 Inspection Report Transportation In Compliance Food Service In Compliance Children's Records In Compliance Written Documentation Not In Compliance
General: Based on Review of Documentation, there were four (4) children's files reviewed that did not include documentation of a preferred hospital. The enrollment dates for the children were 3/24/12, 7/28/14, 4/16/12, 5/17/13.
General: Based on Review of Documentation, one (1) staff did not have proof of education on file. This staff was hired on 7/6/15.
General: Based on Review of Documentation and interview, the director indicated that a staff was on vacation for the week and another staff was covering her opening shift. This staff did not have current CPR or first aid training. For the week of 8/3/15 to 8/7/15 there was no one present from 6:30 AM until 8:30 AM with current CPR and first aid training.
General: Based on Review of Documentation, three (3) staff did not complete orientation training within the first three (3) months of employment. These three (3) staff did not have evidence of orientation training on file. These staff were hired on 6/2/14, 7/9/14, and 3/30/15. One (1) staff, hired 7/30/07, had only two (2) hours of cabinet-approved early care and education training on file. 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 Review of Documentation, two (2) children's files were missing a physician's phone number and another child's file was missing a doctor's name and phone number.
General: Based on Review of Documentation, the facility did not have a complete emergency preparedness plan on file. The off site location was not listed and the plan had not been submitted to the local emergency management officials. This regulatory violation was previously issued during relicensure surveys conducted on 7/16/14 and 7/17/13. The plan of correction from the relicensure survey conducted on 7/16/14 indicated that the director is working on this plan and will submit it to the proper authority and give copies to the families once complete. The completion date was 8/8/14. The emergency preparedness plan was not completed.
General: Based on Review of Documentation, the staff in charge was unable to locate an orientation policy stating the staff will implement the procedures taught in orientation training.
General: Based on Review of Documentation, there was no written parental consent on file for the children to be in the presence of the fish in Room 2-4 (preschool room).
General: Based on Review of Documentation, the last documented earthquake drill was 7/3/2013. Posted Documentation
General: Based on Review of Documentation, three (3) staff files (hire dates: 6/2/14, 6/18/2014, 6/25/14) did not contain TB documentation.
General: Based on Observation, the surveyor observed that the indicating thermometer in the silver refrigerator located in the kitchen had a reading of fifty eight (58) degrees Fahrenheit. There was not an indicating thermometer in the white refrigerator at the time of the inspection. The surveyor observed children's lunches being stored in the white refrigerator.
General: Based on Review of Documentation, two (2) staff (hire dates: 8/22/11 and 4/29/2013) did not have an annual staff evaluation on file at the time of the inspection.
General: Based on Review of Documentation, one (1) staff (hire date: 6/16/14) has resided in the state of Georgia within the last five (5) years. There was not an out of state criminal records check completed for this staff person at the time of the inspection. It is important to note that this staff person was not working alone with children during the inspection.
General: Based on Review of Documentation, six (6) staff files (hire dates: 5/27/14, 6/2/14, 6/16/14, 6/18/14, 6/23/2014, 6/25/14) did not contain proof of education.
General: Based on Observation, the surveyor observed numerous mouse droppings in the cabinets underneath the kitchen sink and in an empty drawer next to the stove.
General: Based on Observation, a section of the cement wall in the housekeeping area located in the Busy Bees Classroom had peeling blue paint. The surveyor observed a hole in the wall in the indoor gross motor room above the baseboard trim. The surveyor was able to stick her hand through the hole.
General: Based on Interview, the staff person in charge stated that she has not completed the emergency preparedness plan as required by the regulations.
General: Based on Review of Documentation, five (5) staff (hire dates: 8/16/10, 10/13/97, 7/30/07, 8/22/11 and 10/11/11) eligible for an annual professional development plan did not have documentation of a plan on file in the facility.
General: Based on Interview, and record review, the facility did not submit written notification to the cabinet for approval prior to implementation of transportation services. A review of the summer calendar posted in the school age classroom found that children "Catch the Bus" to go to the library every Tuesday and are scheduled to take a "Bus Trip to Kids Place" on 7/24/13. An interview with staff revealed that children are transported via a public bus during these field trips; however, transportation services had not been approved by the Cabinet and it was not listed on the license.
General: Based on Observation, it was found that a bottle of Motrin was being stored in an unlocked cabinet in the Pre K classroom. Outdoor Play Area
General: Based on Review of Documentation, none of the children's files/enrollment documentation contained information for the child's preferred hospital.
General: Based on Review of Documentation, one (1) staff person (hire date: 8/22/11) eligible for an annual performance review did not have documentation of a review on file in the facility. One (1) staff person (hire date: 10/13/97) had a performance review in her file from 2011; therefore, it was no longer current.
General: Based on Review of Documentation, two (2) staff (hire dates: 6/28/13 and 3/20/13) did not have educational documentation on file.
General: Based on Review of Documentation, two (2) employee files (hire dates: 8/16/10 and 10/11/11) contained results of a negative T.B. test that was no longer current. The tests were dated 8/11/10 and 2/16/11 which exceeds the two (2) year time frame.
General: Based on Review of Documentation, the following was found: 1. Eight (8) staff files (hire dates: 10/11/11, 8/13/12, 3/20/13, 9/4/12, 4/1/13, 3/25/13, 4/29/13 and 3/21/13) did not contain evidence of the six (6) hours of cabinet-approved training being completed within the first three (3) months of employment. 2. Two (2) staff files (hire dates: 10/13/97 and 10/11/11) did not contain the required fifteen (15) hours of annual training. 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 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; and (d) Not caused an accident which resulted in the death of a person. Programming
General: Based on Interview, and record review, this regulatory requirement was not met. A review of the summer calendar posted in the school age classroom found that children "Catch the Bus" to go to the library every Tuesday and are scheduled to take a "Bus Trip to Kids Place" on 7/24/13. Furthermore, there were numerous field trips listed to local swimming pools and parks listed on the calendar. Staff stated during interview that when children go on these field trips they either walk or they are transported via a public bus. The staff person in charge stated during interview that parents are provided with a copy of the summer calendar listing all the field trips at the beginning of the summer; however, stated that permission forms signed by the child's parent had not been obtained. Written Documentation
General: Based on Review of Documentation, the surveyor found that the facility has yet to establish their emergency preparedness plan according to KRS 199.895.
General: Based on Review of Documentation, the following was found: 1. The current rates for child care were not posted. 2. A review of the daily schedule posted in the two (2) year old classroom revealed that activities were listed from 9:00AM - 4:00PM. The staff person in charge stated that the facility is open from 6:30AM - 6:00PM; therefore, the schedule does not reflect all hours of operation.
General: Based on Review of Documentation, it was found that the file for an employee hired on 8-14-12 did not contain evidence of a high school diploma, GED or Commonwealth Childcare Credential.
General: Based on Review of Documentation, it was found that the files for six (6) eligible employees did not contain evidence of a current professional development plan. 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 4) Current State other than KY In Compliance 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; 3) Previous State of Residence Not In Compliance Findings: General: Based on Review of Documentation, it was found that an employee hired on 2-17-11 lived in Ohio in 2010. An employee hired on 1-13-12 was found to have lived in Florida in 2009. The staff person in charge stated that the facility did not have out of state background checks for these employees.
General: Based on Review of Documentation, it was found that the file for a child enrolled on 9-12-11 contained an immunization certificate that expired on 5-30-12. The file for a child enrolled on 6-1-10 contained an immunization certificate that expired on 6-15-12.
Two Year Olds: Based on Observation, it was found that the hand-washing procedure was not posted for the diaper changing area. Animals 319 - Animal Requirements Not Applicable 922 KAR 2:120 - Section 13 (1) Animals shall be: (a) Supervised by an adult if in the presence of a child in care; and (b) Certified as properly vaccinated against rabies. 1) Supervised Not Applicable 2) Vaccinated Not Applicable 321 - Prohibited Animals Not Applicable 922 KAR 2:120 - Section 13 (3) Except if used as planned program activity in the control of an animal specialist, an animal that is considered undomesticated, wild, or exotic shall not be allowed at a child-care center. 1) Undomesticated Not Applicable 2) Wild Not Applicable 3) Exotic Not Applicable C.O. 13 - Corporation/ LLC/ Partnership 922 KAR 2:090 - Section 4 (3) If the applicant for licensure is a: (a) Corporation or a limited liability company, the application shall include a current certificate of existence or authorization from the Secretary of State; or (b) Partnership, the application shall include a written statement from each partner that the partnership is current and viable. 1) Corporation/LLC statement Not Inspected 2) Partnership statement Not Inspected