922 KAR 2:120. Section 13. Toys and Furnishings.
General: Based on observation, two (2) wooden support beams on the climbing playground structure were cracked and splintered.
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Home › KY › Lexington › Lexington Montessori School
License #L376122 · Center · Licensed
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General: Based on observation, two (2) wooden support beams on the climbing playground structure were cracked and splintered.
General: Based on interview and review of documentation, the Fire Marshal inspection was dated 10/24/23. Interview with the staff-in-charge found 10/24/23 was the most recent Fire Marshall inspection conducted.
General: Based on observation, staples and push pins were stored in a low drawer and accessible to children in Classroom Primary B. The staples and push pins were not being used in a learning activity supervised by staff members.
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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 review of documentation, the child care center failed to maintain state regulations. One (1) staff member (DOH: 09/26/24) did not have proof of educational qualifications available for review at the time of survey.
General: Based on observation, the child care center failed to maintain state regulations. In the restroom used by the Primary A Classroom, two (2) toilets contained urine that had not been flushed. Hygienic Practices In Compliance
General: Based on observation, the child care center failed to maintain state regulations. A climbing apparatus in the Primary B Classroom did not have a protective surface beneath it.
General: Based on observation, the child care center failed to maintain state regulations. Several pieces of trash and broken plastic were observed on the playground at the time of survey.
General: Based on review of documentation, the child care center failed to maintain state regulations. One (1) staff member (DOH: 09/13/23) only completed six (6) of the fifteen (15) hours of required annual training for the year dated 09/13/23 to 09/13/24. A review of ECE-TRIS confirmed this finding.
General: Based on review of documentation, the child care center failed to maintain state regulations. One (1) staff member (DOH: 09/13/23) did not have a current annual professional development plan available for review. The most recent plan available was dated for the 2023 year of employment.
General: Based on observation, several pieces of trash were found on the ground of the outdoor play area, against the fence line. Equipment In Compliance Transportation Not Applicable Kitchen Requirements In Compliance Food Service In Compliance Meal Planning/Center Provides Meals In Compliance Meal Planning/Center Does Not Provide Meals In Compliance Children's Records In Compliance Written Documentation In Compliance Posted Documentation Not In Compliance
General: Based on observation, the following was found: Primary A Classroom 1.) A toaster oven was stored on top of a mini refrigerator, accessible to children in care. 2.) An extension cord (power strip) in the corner had several electrical outlets that were not covered. Director Requirements In Compliance Employee Records In Compliance Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Outdoor Play Area Not In Compliance
General: Based on review of documentation, the statement of deficiency and corresponding plan of correction from the 2023 licensure year was not posted for public inspection. The posted plan was dated for the 2021 licensure year. Animals Not Applicable
General: Based on review of documentation, a staff member hired on 9/6/2022, did not have proof of education on file.
General: Based on review of documentation, a staff member hired on 9/6/2022, did not have TB documentation on file.
General: Based on review of documentation and ECE-TRIS, a staff member hired on 9/6/2022, has not received first aid and cardiopulmonary resuscitation (CPR) training. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report
General: Based on review of documentation and ECE-TRIS, the surveyor found the following: 1) One (1) staff member hired on 9/6/2022, has yet to complete the six (6) hour cabinet-approved orientation training. 2) Three (3) staff members hired on 5/31/2012, and one (1) staff member hired on 8/20/2018, did not compete fifteen (15) hours of cabinet-approved early care and education training during the 7/1/2021-6/30/2022, training year. Programming In Compliance Premises Not In Compliance
General: Based on review of documentation, one staff hired on 8/20/18, did not have evidence of completing the required CPR/First-Aid training on file at the time of survey. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report
General: Based on observation, there was a stained ceiling tile found in the Primary B classroom. 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, two children enrolled on 6/4/21 and 8/31/21, did not have a preferred hospital on file at the facility. Written Documentation In Compliance Posted Documentation In Compliance Animals In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3
General: Based on review of documentation, one staff hired on 1/18/22, did not have evidence of education on file at the facility.
General: Based on observation, it was found that there was one uncovered electrical outlet in the Primary B classroom. This was located by a child-sized table in the classroom. Director Requirements In Compliance 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, it was found that four staff members at the facility had not renewed the Pediatric Abusive Head Trauma training. The last time these four staff members completed the training was in March of 2014. The dates of hire for these staff members are: three hired on 05/31/2012 and one hired on 01/02/2013. A review of ECE- TRIS confirmed these findings. Programming In Compliance Premises Not In Compliance
General: Based on review of documentation, it was found that there was one child's file that did not contain a preferred hospital or a physician contact on the enrollment paperwork. Written Documentation Not In Compliance
General: Based on observation and review of documentation, it was found that three staff members did not have evidence of results from the Child Abuse/Neglect check. The staff in charge reported that she had sent in one of the checks at some point last year and was told that the staff members needed to get their fingerprints taken. The staff in charge did have the Child Abuse/Neglect check forms filled out for these staff members, but they had not been sent off to get results. The dates of hire for these staff are: 09/08/2020 and 02/22/2021. During the time of inspection, one of these staff members was left alone with children.
This investigation inspection recorded no violations or advisories.
General: Based on interview and review of documentation, the following was found. 1. Out of 13 staff files reviewed, there were 10 staff who had been employed for one or more years. Further review of documentation provided through ECE-TRIS found that of those 10 staff, none of them completed the required 15-hours of cabinet-approved annual training as required by this regulation. 2. One staff person did not have record of having completed six-hours of cabinet-approved orientation training and 1.5 hours of cabinet-approved pediatric abusive head trauma training. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication Not In Compliance
General: Based on review of documentation, there was one staff person (date of hire not documented by facility) who did not have a copy of a high school diploma, GED or other qualifying education documentation on file. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report
General: Based on observation and interview, a written chain of command was not observed as posted. An interview with the staff person in charge found some changes had been made to the list, but a new copy had not been posted. The staff person in charge printed out a current chain of command and posted it at the time of the survey. Posted Documentation Not In Compliance
General: Based on review of documentation, this regulatory requirement was not met. Out of eleven (11) staff files reviewed, there was one (1) staff person with a hire date of 8/20/18 who did not have a copy of a highs chool diploma, GED or other qualifying documentation on file at the facility. There was an additional staff person who did not have a documented date of hire that did not have a copy of a high school diploma, GED or other qualifying documentation on file at the facility.
General: Based on observation, this regulatory requirement was not met. In the bathroom located in Primary A, a container of Equate brand Continuous Dispense Triple Antibiotic Ointment was found on an open shelf by the toilet. The container of ointment was not in a locked container or area and was not labeled for an individual child. Furthermore, it was found that tubes of the same antibiotic ointment are kept in all of the first aid kits that are part of the licensed space. These tubes of ointment are not labeled for an individual child and are not kept in a locked container or area. Outdoor Play Area In Compliance Equipment Not In Compliance
General: Based on observation, this regulatory requirement was not met. 1) In Primary A a large blue pillow was observed in the corner by a basket of books. The fabric on the pillow had several areas that were soiled and stained. In this same room there were two (2) trashcans located by the counter where the sink is located. The lid and outside surface of the trashcans had dried food and other dirt particles on the surface. 2) In Primary B there was a small child sized brown vinyl chair that had a tear in the seat and the back. The tears had been repaired with brown duct tape. This is not an acceptable form of repair as it does not allow for adequate cleaning and sanitation. Transportation Not Applicable Food Service/Food Program In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 5 Inspection Report Food Service Not In Compliance
General: Based on Review of Documentation, staff hired on 05/31/2012 did not have documentation of obtaining pediatric abusive head trauma training on file or in 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 1 of 2 Inspection Report Children's Records Not In Compliance
General: Based on Observation, two children with enrollment dates of 08/16/2017 did not have hospital preference listed in file. Written Documentation In Compliance Posted Documentation In Compliance Animals Not Applicable
General: Based on Observation, the bedding for the children was stored in personal bags for each children. The bags were found open on the floor with the personal bedding items being contaminated. Transportation Not Applicable Food Service In Compliance Children's Records In Compliance Written Documentation In Compliance Posted Documentation In Compliance Animals Not Applicable
General: Based on Review of Documentation, it was found three (3) employees did not complete the 15 hours of required training. The hire dates for these employees are 01/04/16, 09/07/2015, and 05/31/2012. It was found three (3) employees did not complete the Pediatric Abuse and Neglect Training (PAHT). These employees' hire dates are 08/24/2015, 08/24/2015 and 05/31/2012. It was found one (1) employee did not complete the Orientation Training; the hire date of this employee is 05/31/2012. These training hours were verified through ECE-TRIS. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Equipment Not In Compliance
General: Based on Review of Documentation, it was found six (6) employees did not have a staff evaluation. Employee Records Not In Compliance
General: Based on Observation, it was found that both toilets in the bathroom near the office were unflushed and contained urine and toilet paper. It was also found that the toilet in the right-hand stall of the bathroom located in Classroom A was unflushed and contained urine, toilet paper and feces. The teachers in the classrooms stated that they do not check to make sure the children flush when they are finished using the bathroom. Hygienic Practices
General: Based on Observation, it was found that 1) there was one (1) stained ceiling tile in the bathroom by the office; 2) in Classroom A, there was a three (3) feet long water stain on the ceiling above the math area; 3) the ceiling joint tape in Classroom A was also found to be peeling across the length of the classroom. The director stated that the facility had a pretty bad water leak at the end of last school year and repairs were still in process.
General: Based on Observation, it was found that 1) a toilet brush located in a stall in the bathroom by the office was accessible to the children; 2) the children's coats hanging in the coat room were found to be overlapping, thus increasing the potential to spread communicable diseases; 3) the toilet paper in the bathroom located in Classroom A was found to be on the floor of the stall. The toilet paper holder was found to be missing. The director stated that these issues would be fixed immediately.
General: Based on Review of Documentation, it was found that a staff person hired 9/1/14 did not have evidence of having completed six (6) hours of orientation training. In addition there were three (3) staff with a hire date of 5/31/12 who had not 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 Review of Documentation, it was found that the facility practiced and documented a quarterly disaster drill instead of conducting a separate drill and documenting the information for a tornado drill and an earthquake drill. Posted Documentation
General: Based on Review of Documentation, there was one (1) staff person with a hire date of 9/1/14 who had the results of a criminal records check dated 9/10/14. There was no documentation available for review to verify that the application for the criminal records check had been submitted prior to or on the date of hire.
General: Based on Review of Documentation, there was one (1) staff person hired 1/2/13 who did not have a current T.B. skin test or a statement from a health professional indicating they are free from the symptoms of T.B. There was one (1) staff person with a hire date of 8/19/13 who did not have the results of a T.B. skin test read until 2/7/14 and an additional staff person hired 8/1/13 did not have the results of a T.B. skin test read until 8/15/13.
General: Based on Review of Documentation, the facility was not documenting the time of arrival and time of departure of each child enrolled. 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 Interview, it was found that parents provide their child's lunch each day. However, they do not require children to bring milk to drink for lunch nor does the facility provide milk for lunch. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 23 of 26 Web site: http://chfs.ky.gov/ Inspection Report Children's Records
General: Based on Observation, during a tour of Primary B there was not a posted planned program of activities.
General: Based on Review of Documentation, two (2) staff (hire dates: 1/2/13 and 1/14/13) did not have evidence of a high school diploma, GED or Commonwealth Child Care Credential in their file.
General: Based on Review of Documentation, one (1) staff person (hire date: 1/14/13) did not have any TB test documentation 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 Not In Compliance Findings: General: Based on Review of Documentation, two (2) staff files did not contain evidence of the six (6) hours of cabinet-approved orientation training being completed within the first three (3) months of employment. The employees were hired on 1/2/13 and 1/14/13. 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. 2) 9 hours-first year Not Applicable 3) 15 hours annually Not Applicable An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 8 of 40 Web site: http://chfs.ky.gov/ Inspection Report 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 Review of Documentation, it was found that seven (7) of the staff member's hired did not have a copy of a high school diploma, GED, or Commonwealth Child Care Credential on file.
General: Based on Observation, it was found that two (2) air conditioning fan units were located inside the outdoor play area. These fans were located in an area of the outdoor play area that was accessible to the children.
General: Based on observation, the child care center failed to maintain state regulations. In the Primary B Classroom, a drink belonging to an adult was accessible to children in care.
General: Based on review of documentation, the child care center failed to maintain state regulations. One (1) staff member (DOH: 08/14/24) did not obtain a background check status of eligible for hire until 08/29/24; therefore, this staff person did not receive the appropriate status (eligible for hire) on or before their hire date.
General: Based on review of documentation, the child care center failed to maintain state regulations. One (1) staff member (DOH: 09/13/23) did not have an annual performance evaluation available for review at the time of survey. The most recent evaluation presented was from the year 2023.
General: Based on observation, the child care center failed to maintain state regulations. During the survey, the following was observed: 1. The right, rear corner of the playground had a portion of the fence line in disrepair. 2. The fencing around the air conditioning unit was in disrepair.
General: Based on observation, in the Primary A classroom, the surveyor found a staff member's purse on the floor, next to her desk. The purse was accessible to the children in care. 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 Not In Compliance
General: Based on interview, the staff member in charge stated that they did not have any milk to serve the children for lunch. Children's Records In Compliance Written Documentation In Compliance Posted Documentation In Compliance Animals In Compliance
General: Based on review of documentation, the following was found: 1.) One staff hired on 5/31/12, completed PAHT training on 3/26/14; however, did not renew the training due on 3/26/19. 2.) Three staff hired on 5/31/12, 5/31/12, and 1/2/13, did not complete the required 15 hours of training for the year. A review of ECE-TRIS confirmed these findings. Programming In Compliance Premises Not In Compliance
General: Based on review of documentation, it was found that one staff member did not have evidence of an annual professional development plan on file at the facility. Posted Documentation In Compliance Animals In Compliance 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, it was found that one staff member did not have the results of or proof of submission for an out of state criminal records check, child abuse and neglect check, or sexual offender registry check on file at the facility. This staff person was not observed working alone during the time of inspection, but it could not be determined if the staff person had not worked alone since being hired. The date of hire for this staff person is 02/22/2021. Supervision In Compliance Staffing Requirements In Compliance General Administration Not In Compliance
General: Based on observation in the Primary A classroom, there was a staff member's purse accessible on a countertop that was within reach of the children in the classroom.
General: Based on review of documentation, it was found that one staff member did not have an annual performance evaluation on file at the facility.
General: Based on review of documentation, it was found that one staff member did not have proof of education on file at the facility. The date of hire for this staff member is 02/22/2021.
General: Based on observation, it was found that in the primary A classroom, there was a pair of adult scissors in an unlocked classroom drawer. In addition, in the primary B classroom, there were batteries and staplers in an unlocked classroom drawer. All of these items were accessible to the children in the classrooms. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 4 Inspection Report
General: Based on observation, the following was found: 1.) In the Primary A classroom, there was an area of the wall that had red paint on it. 2.) In the Primary B classroom, there was an wall that was dirty with paint stains. In addition, the coat room in this classroom was missing paint on the walls. 3.) In the bathroom used by classroom A, there were holes in the wall behind the sink. 4.) In the bathroom used by classroom B, there was a stained ceiling tile from a water leak, as well as an area where the flooring was coming up. 5.) In the hallway that connects the two classrooms, there was an area of missing/peeling paint. 6.) In the front room, there was area of missing paint, in addition to the walls in this room being dirty. Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area Not In Compliance
General: Based on observation, it was found that underneath the swings on the playground, the mulch was very sparse and needed to be refilled. There was not an adequate amount of protective surfacing for the children. 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 observation and review of documentation, there were three new staff that did not have a documented date of employment. In addition, one of the staff person's file did not have a copy of a high school diploma, GED or other qualifying educational documentation. This same staff person did not have a copy of a current T.B. test or a statement from a health professional documenting the individual is free from the symptoms of T.B.
General: Based on observation, two tubes of Neosporin antibacterial ointment and a tube of after bite were stored in a cabinet in the office along with the first aid supplies. The two tubes of Neosporin ointment and afterbite ointment were not labeled for an individual adult or child. Outdoor Play Area Not In Compliance
General: Based on observation during a tour of the outdoor play area, it was found that the mulch located under the swings had worn away, leaving only dirt. This was also observed in the area under the metal climbing structure. Equipment In Compliance Transportation Not Applicable Food Service/Food Program In Compliance Food Service In Compliance Children's Records In Compliance 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, it was found that 3/14/2018, was the date the last time a copy of a current evacuation plan had been submitted to the local emergency management office. This regulation requires that this information be submitted by 12/31 of each year for the upcoming year.
General: Based on observation, a copy of a letter stating the facility had been recommended for renewal from the previous year was posted. The facility's license that contains the facility address, capacity, services provided and facility type was not posted. Animals In Compliance
General: Based on observation, this regulatory requirement was not met. It was found that the posted diagram outlining the course of action in the event of a natural or manmande disaster did not clarify the specific course of action for fire, tornado and earthquake. Animals Not In Compliance
General: Based on observation, this regulatory requirement was not met. 1) In Primary A there were several areas on the carpet that had a white substance embedded in the fibers. 2) In Primary B there was a wall vent located in the corner where a lighted globe of the world was located. The vent had an accumulation of dust on the surface. 3) The walls in the front room which is also used for child care have areas where the paint had chipped off the surface. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 5 Inspection Report
General: Based on review of documentation, this regulaotry requirement was not met. It was found that a staff person hired 11/1/17 did not have evidence of an annual performance evaluation in the file for the staff person's first year of employment. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 5 Inspection Report Employee Records Not In Compliance
General: Based on observation and review of documentation, this regulatory requirement was not met. A review of documented drills found that disaster drills were noted as the tornado drill. There was no documentation that indicated when a quarterly earthquake drill was conducted. It was also found that there was no documentation to verify that a monthly fire drill had been conducted for April and May of 2018 and August of 2018. During the exit conference with the director, it was found that the documentation for the fire drills had been filed away but it was not available for reivew. Posted Documentation Not In Compliance
General: Based on review of documentation, this regulatory requirement was not met. A review of documented drills found that disaster drills were noted as the tornado drill. There was no documentation that indicated when a quarterly earthquake drill was conducted that included the date, time and names of children who participated. It was also found that there was no documentation to verify that a monthly fire drill had been conducted for April and May of 2018 and August of 2018. During the exit conference with the director, it was found that the documentation for those drills had been filed but it was not available for reivew. Therefore the date, time and names of children who particpated were not available for review.
General: Based on observation, this regualtory requirement was not met. While the surveyor was doing paperwork in the front room located beside the office, a child from Primary B came through the office and into the bahtroom located in the front room. There was not an adult with the child and there were no adults in the office. While the child was in the bathroom, the director came into the area. The director observed the child come out of the bathroom and escorted the child back to the classroom. Staffing Requirements In Compliance General Administration In Compliance Director Requirements Not In Compliance
General: Based on review of documentation, this regulatory requirement was not met. It was found that there was not a current copy of the administrative regulations available for staff.
General: Based on observation and review of documentation, this regulatory requirement was not met. Out of eleven (11) staff files reviewed, there were two (2) staff who did not have a documented date of hire.
General: Based on observation, review of documentation, and ECE-TRIS records, this regulatory requirement was not met. 1) There were three (3) staff with hire dates of 5/31/12, 11/1/17 and 3/15/18 who did not have evidence of having completed one and one-half (1 1/2) hours of cabinet approved pediatric abusive head trauma training. 2) The staff person with a hire date of 5/31/12 also did not have evidence of having completed fifteen (15) hours of cabinet approved annual training. 3) The staff person with the hire date of 11/1/17 did not have evidence of having completed fifteen (15) hours of cabinet approved annual training. 4) A staff person with a hire date of 1/2/13 only had evidence of having completed nine (9) hours of cabinet approved annual training. Programming In Compliance Premises Not In Compliance
General: Based on observation, this regulatory requirement was not met. In Primary B a bottle of Kroger brand hand sanitizer was found at the sink in the classroom used for hand washing. There was no liquid soap visible and available at the sink. Hand sanitizer does not take the place of the use of liquid soap for handwashing. Hygienic Practices In Compliance First Aid/Medication Not In Compliance
General: Based on observation, this regulatory requirement was not met. An inspection of the interior of the refrigerator located between Primary A and Primary B found dried food and other dirt particles on the shelves used to store food used for the children. Dried food and other debris were also found on the shelves on the inside of the door.
General: Based on observation, this regulatory requirement was not met. During an inspection of the refrigerator used to store food for the children, a can of Kroger non-dairy whipped topping was on its side on one of the shelves. The lid to the can was missing, leaving the spray nozzle exposed.
General: Based on observation, this regulatory requirement was not met. An inspection of the interior of the refrigerator located between Primary A and Primary B found dried food and other dirt particles on the shelves used to store food used for the children. Dried food and other debris were also found on the shelves on the inside of the door. Children's Records In Compliance Written Documentation Not In Compliance
General: Based on review of documentation, this regulatory requirement was not met. It was found that the facility submitted the written evacuation plan for approval on 3/20/19 for the current year. This is not in accordance with KRS 199.895 and 42 U.S.C. 9858c(C)(2)(U) which requires that a written evacuation plan be submitted no later than 12/31 of each year for the upcoming year.
General: Based on review of documentation, this regulatory requirement was not met. Out of eight (8) staff eligible for a professional development plan, there was one (1) staff person with a hire date of 11/1/17 who did not have any evidence of having completed a professional development plan. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 4 of 5 Inspection Report
General: Based on observation, this regulatory requirement was not met. In Primary B there was an aquarium on a shelf. It was found through interview that the aquarium contained tadpoles. Further interview found that written permission had not been obtained from each child's parent.
General: Based on Observation, it was found that 1) in Classroom B, the carpet had a run in it approximately eight (8) feet long; 2) in the bathroom located in Classroom A, it was found that the metal wall of the left-hand stall was rusty and had bubbling paint on the bottom portion of the wall; 3) in Classroom A it was found that the veneer on the side of the counter by the microwave was peeling off. The director acknowledged the areas needing attention.
General: Based on Observation, it was found that there was not a thermometer in the refrigerator. The director stated that one would be put in there as soon as possible.
General: Based on Review of Documentation, it was found that the files for nine (9) eligibile employees did not contain evidence of annual performance evaluations being completed. The director stated that the paperwork was not on site. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 5 of 26 Web site: http://chfs.ky.gov/ Inspection Report
General: Based on Review of Documentation, it was found that the employees' dates of hire were not listed in the files. The director stated that she was unaware of the need to include this information in the files.
General: Based on Review of Documentation, it was found that the files for two (2) employees hired on 8-24-15 did not contain evidence of a high school diploma, GED or Commonwealth Childcare Credential. The director stated that she would get the information for the file.
General: Based on Review of Documentation, it was found that the files and ECE-TRIS records for five (5) employees hired on 5-31-2012 contained evidence of zero (0), twelve (12), thirteen (13), zero (0) and twelve (12) hours of annual training being completed during the last completed training year. The file and ECE-TRIS record for an employee hired on 9-1- 14 contained evidence of zero (0) hours of additional training being completed during the first year of employment. This employee had a university schedule on file. The director stated that she did not realize that she needed to have grades on file in order to count classes toward training hours. 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, it was found that a bottle of Wite Out was located on the microwave in Classroom A. The microwave is located on a low counter, thus making the bottle accessible to the children. The bottle bore the labels "Flammable" and "Keep Out of Reach of Children." The teacher in the classroom stated that she had put the bottle on the microwave without thinking. The bottle was immediately put in a locked drawer.
General: Based on Observation, it was found that 1) a light cover in the bathroom located by the office had a large water stain on it, indicating a leakage problem; 2) in Classroom A, three (3) of the flourescent light strips were found to not be functioning. The director stated that the facility had a water leak at the end of last school year and repairs were still in progress. She also stated that she was aware of the lights not functioning properly in the classroom.
General: Based on Review of Documentation, it was found that one (1) child's file out of ten (10) files reviewed contained an immunization certificate that expired on 1-30-16. The director stated that they would contact the parents and get an updated record as soon as possible.
General: Based on Review of Documentation, it was found that the documentation of the fire drill conducted in January of 2016 did not include a list of the children who participated. The director stated that she must have forgotten to get it together.
General: Based on Observation, during a tour of the facility two (2) uncovered outlets were observed in Primary A over the sink. In Primary B an uncovered outlet was observed near a small table by the door. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 5 of 26 Web site: http://chfs.ky.gov/ Inspection Report
General: Based on Review of Documentation, there was one (1) staff person with a hire date of 9/1/14 who did not have the results of a T.B. skin test read until 9/18/14.
General: Based on Observation, during a tour of both classrooms used for care empty plastic grocery bags were observed in an unlocked cabinet under the sink.
General: Based on Interview, it was found that a child enrolled is required to receive a prescription medication called Levocarnitine everyday. A reivew of records found that written permission to administer the medication was documented upon initial enrollment. However, daily written permission is not being obtained.
General: Based on Review of Documentation, it was found that perscription Levocarnitine is being administered to a child daily. However, the name of the medication and the staff person administering the medication is not being documented daily. The only information documented is the name of the child, the date and time the medication was administered.
General: Based on Observation, it was found that the p.m. snack menu with the date was not posted in either classroom.
General: Based on Review of Documentation, it was found that the facility practiced and documented the date, time and children who participated in a quarterly disaster drill instead of conducting a separate drill and doumenting the information for a tornado drill and an earthquake drill.
General: Based on Observation, during a tour of the facility a large water stain was observed on the ceiling in Primary A. A large accumulation of dust was also observed around the vents located in the ceiling in the same room.
General: Based on Review of Documentation, there was one (1) staff person with a hire date of 1/2/13 and three (3) staff with a hire date of 5/31/12 who had not completed nine (9) hours of training for the 2012-2013 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 Review of Documentation, there were six (6) staff eligible for an annual performance evaluation who did not have documentation of having an annual evaluation on file.
General: Based on Review of Documentation, there was one (1) staff person hired 8/1/13 who did not sign the application for the results of the criminal records check until 8/22/13. In addition this staff person has lived in the state of Alabama within the last five (5) years. There were no results of a criminal records check from the state of Alabama nor was there documentation to verify that an application for the results of the criminal records check had been submitted. There was an additional staff person hired 8/19/13 who did not sign the application for the results of a criminal recrods check until 8/29/13.
General: Based on Interview, it was found that the parents take turns providng an AM snack and their own child's lunch and the facility provides the PM snack. There was not a menu posted for the PM snack. 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.
General: Based on Observation, the children in Primary A were served a half of a banana for snack. There was not another component added with the snack.
General: Based on Review of Documentation of ten (10) children's files there were two (2) children who did not have a current immunization certificate on file.
General: Based on Review of Documentatio, of the ten (10) files reviewed a prefered hospital was not documented.
General: Based on Review of Documentation, there was not a written professional development plan available for review.
General: Based on Review of Documentation, there was not a documented fire drill for January 2014 listing the the names of the children who participated and the date and time the drill was conducted.
General: Based on Review of Documentation, there was no documentation to verify that a fire drill had been conducted for January 2014.