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Home › KY › Lexington › Meadowthorpe Elementary Post Time Program
License #L359147 · Center · Licensed
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General: Based on review of documentation, a staff member (DOH: 09/16/25) did not obtain a negative TB skin test nor a statement from a medical professional stating they were free of active tuberculosis until 10/17/25, after their date of hire.
General: Based on review of documentation, a record of a quarterly shelter-in-place drill being conducted for the third quarter of 2025 was not available for review at the time of survey.
General: Based on review of documentation, a written plan detailing the reunification of children with chronic medical conditions and/or children with disabilities with their guardians in the event of an emergency was not available for review at the time of survey. Posted Documentation In Compliance
General: Based on review of documentation, a record of monthly fire drills having been conducted for October of 2025 nor December of 2025 was not available for review at the time of survey.
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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 interview and review of documentation, a staff member (DOH: 02/09/26) was not listed as a current staff member on the KARES background check report. The surveyor ascertained that the staff member had been separated on 11/10/25 after leaving the center, and when they had returned they had not been rehired and placed on the current employee listing. The staff in charge stated this staff member had been employed by the center periodically beginning in December 2024, with more time not employed than employed. The staff in charge stated she intended to terminate the staff members employment due to unrelated factors but understood the requirement going forward. Supervision In Compliance
General: Based on review of documentation, a written procedure detailing how the center would maintain supervision, ratios, and group size at various times during care was not available for review at the time of survey. General Administration In Compliance
General: Based on interview and review of documentation, documentation indicating that staff meetings had been conducted was not available at the time of survey. The staff in charge stated that a staff meeting had been conducted in August of 2025 but was unable to provide the documentation to support this statement.
General: Based on interview and review of documentation, the following was found: 1. A staff member (DOH: 09/16/25) did not have a recorded date of hire in their personnel file. The date of hire was provided verbally by the staff in charge. 2. A staff member (DOH: 02/09/26) did not have a recorded date of hire in their personnel file. The date of hire was provided verbally by the staff in charge.
General: Based on interview and review of documentation, a staff member (DOH: 02/09/26) did not have adequate proof of education available for review. The documentation provided was a certificate acknowledging the staff member had participated in a collegiate commencement ceremony but did not list a date of graduation from either college, nor high school. The staff in charge stated she intended to terminate the staff members employment due to unrelated factors but understood the requirement going forward.
General: Based on review of documentation, the following was found: 1. A staff member (DOH: 03/27/23) completed fourteen (14) of the required fifteen (15) hours of annual training for the year dated 07/01/24 to 06/30/25. 2. A staff member (DOH: 10/02/22) completed thirteen and one half (13.5) of the required fifteen (15) hours of annual training for the year dated 07/01/24 to 06/30/25. A review of ECE-TRIS confirmed these findings.
General: Based on review of documentation, a child (DOE: 08/10/22) had an immunization certificate available for review that had lapsed as of 09/06/25 and a current immunization certificate was not available for review. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 30 of 33 Inspection Report
General: Based on interview and review of documentation, the following was found: 1. Five (5) children (DOE: 08/10/22 [x3], 08/01/23, and 08/14/24) did not have a contact telephone number for their respective preferred hospitals available in their enrollment information. 2. One (1) child (DOE: 10/07/25) did not have a preferred hospital nor a contact telephone number available in their enrollment information. The guardian who completed the paperwork had marked "N/A" in the space available for a hospital and telephone number. 3. Of the ten (10) children's enrollment files reviewed, zero (0) contained authorization to seek medical treatment in the case of an emergency. The staff in charge noted that she believed this to be available in the enrollment paperwork but was unable to locate the authorization to support this statement.
General: Based on review of documentation, the following was found: 1) A staff member (DOH: 08/14/19) completed pediatric abuse head trauma (PAHT) training on 01/20/20; however, did not renew the training due 01/20/25. 2) Five (5) staff members (DOH: 09/01/23, 08/14/19, 12/04/23, 08/21/23, 08/30/23) did not have evidence of completing fifteen (15) hours of early care and education training. 3) A staff member (DOH: 08/14/24) did not take orientation within three (3) months of employment. The course was taken 12/21/24. A review of ECE-TRIS system verified this information.
General: Based on review of documentation, a staff member (DOH: 08/14/24) did not have evidence of a high school diploma, GED or Commonwealth Child Care Credential on file in the facility.
General: Based on review of documentation, a staff member (DOH: 10/02/22) did not have a current TB test or statement from a health professional on file in the facility.
General: Based on review of documentation, a child (DOE: 08/14/24) did not have current immunization certificates on file in the facility.
General: Based on interview, the staff member in charge stated that she has not conducted any lockdown/shelter-in-place drills during the hours of operation. She stated that the children practice lockdown drills during the school day. Posted Documentation In Compliance Animals Not Applicable
General: Based on review of documentation and ECE-TRIS, the surveyor found the following: 1. Three (3) staff (DOH: 09/01/14, 09/16/15, and 08/14/19), did not complete fifteen (15) hours of cabinet approved early-care and education training during the 07/01/22-06/30/23 training year. 2. A staff member (DOH: 08/23/23), has yet to complete the six (6) hour cabinet-approved orientation training. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable 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 and ECE-TRIS, staff members (DOH: 08/30/23 and 11/15/23), have yet to receive first aid and cardiopulmonary resuscitation (CPR) training.
General: Based on interview and review of documentation, the child care center failed to maintain state regulations. An immunization certificate presented for review at the time of survey for a child enrolled 08/13/2022, was no longer current as of 01/23/2023. A subsequent interview with the director found she needs to obtain a current immunization certificate for the aforementioned child. Written Documentation In Compliance Posted Documentation Not In Compliance
General: Based on observation and review of documentation, the child care center failed to maintain regulations. The statement of deficiency and plan of correction issued by the cabinet from the 2022 annual inspection was not posted in a conspicuous place and made available for public viewing at the time of the survey. Animals Not Applicable
General: Based on review of documentation, the following was found: 1.) One child enrolled on 8/11/21, did not have an immunization certificate on file at the facility. 2.) One child enrolled on 8/5/21, did not have an updated immunization certificate on file at the facility. The certificate on file expired on 11/30/21. Written Documentation Not In Compliance
General: Based on review of documentation, two staff hired on 9/16/15 and 8/14/19, did not have the required CPR/First Aid training. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation 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, there was no documentation of staff meetings being conducted during the last relicensure year on file at the facility.
General: Based on review of documentation, there was no evidence of any family involvement activities within the last relicensure year on file at the facility. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report Employee Records Not In Compliance
This renewal application inspection recorded no violations or advisories.
General: Based on review of documentation, staff hired on 09/16/15, 08/16/17, 08/14/19 and 08/20/19 did not have documentation on file from a health care professional stating they were free of active tuberculosis. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Food Service/Food Program In Compliance Food Service In Compliance Children's Records In Compliance Written Documentation Not In Compliance
General: Based on review of documentation, the copy of the licensing regulations on site were dated 2017. The most current copy of the regulations from 2018 were not available for staff review.
General: Based on observation and review of documentation, there were no current evaluations on file for review at the time of the relicensure visit. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Employee Records Not In Compliance
General: Based on observation and review of documentation, there were no current professional development plans on file at the time of the relicensure visit. Posted Documentation In Compliance Animals Not Applicable
General: Based on review of documentation, it was determined this regulatory requirement was not met. A file presented for review for a staff member with a hire date of 08/16/2017, did not contain a copy of a written performance evaluation. The file did not contain any type of notation that an evaluation had been completed for the staff member. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Food Service/Food Program In Compliance Food Service In Compliance Children's Records In Compliance Written Documentation In Compliance Posted Documentation In Compliance Animals Not Applicable
General: Based on observation and review of documentation, it was determined this regulatory requirement was not met. A staff member with a hire date of 08/16/2017, did not have a current evaluation in the file presented for review. Any type of documentation of a formal evaluation was missing from the file. Employee Records Not In Compliance
General: Based on Observation, there was no information from the Kentucky Consumer Product Safety Program as specified in KRS 199.897 posted in the facility. Animals Not Applicable
General: Based on Review of Documentation, it was determined that four (4) out of ten (10) staff files presented for review had documentation of only thirteen (13) hours each of annual training on file for the last full year of employment. A review of ECE-TRIS records supports the information found during the survey. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Food Service/Food Program In Compliance Food Service In Compliance Children's Records In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Written Documentation In Compliance Posted Documentation Not In Compliance
General: Based on Review of Documentation, this regulatory requirement was not met. The facility had an emergency preparedness plan; however, did not have evidence that the plan had been submitted to the local emergency management official.
General: Based on Review of Documentation, this regulatory requirement was not met. One (1) staff person (hire date: 8/10/16) had a child abuse/neglect check (CAN) that was submitted on 8/22/16; therefore, it was not submitted within the required time frame. This same staff person had a processed criminal records check (CRC) completed by "Criminal Watch Dog". However, this is not in compliance with Kentucky Revised statute which states criminal records checks must be processed by the Ky Justice Cabinet or Administrative Office of the Courts. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report
General: Based on Review of Documentation, one (1) staff person eligible for an annual performance review did not have documentation of a review on file in the facility. Employee Records Not In Compliance
General: Based on Review of Documentation, this regulatory requirement was not met. Three (3) staff (all were hired 8/10/16) did not have educational documentation on file.
General: Based on Review of Documentation, staff member hired on 08/13/14 and 10/27/14 did not have a current staff evaluation on file.
General: Based on Review of Documentation, staff hired on 02/09/16 did not have documentation showing that a Child Abuse and Neglect Check had been submitted. Staff hired on 09/26/15 and 08/24/15 did not have a criminal records check on file. None of the staff members were alone with children. Staff person in charge stated that she would get the necessary paperwork completed. Staff member hired on 08/13/15 has lived in New Jersey within the past five (5) years. The out of state background check that was completed on that staff person does not list the results of the background check.
General: Based on Interview, the staff person in charge was unable to locate a written staff schedule.
General: Based on Review of Documentation, the liability insurance on file had expired. The staff person in charge could not locate a copy of the current liability insurance.
General: Based on Observation, the daily activities that include dates when the activities will be conducted with the children in each classroom were not posted. 1170 - Diapering/Handwashing Not Applicable 922 KAR 2:120. Section 10. Toilet, Diapering, and Toiletry Requirements. (9) The proper methods of diapering and hand-washing shall be posted at each diaper changing area. Animals
General: Based on Interview, with the staff person in charge it was found there was no documentation available for review to assure tornado and earthquake drills were practiced quarterly for 2014. Posted Documentation
General: Based on Review of Documentation, out of twenty (20) staff files presented for review three (3) staff with hire dates of 8/13/14, 9/16/14 and 10/22/14 did not have evidence of having completed six (6) hours of orientation 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: 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 Interview, it was found that the facility did not have a director. The staff in charge stated that the old director left before the school year began and that they had not requested a director change. Director Requirements
General: Based on Review of Documentation, it was found that there was no evidence that at least one person on duty and present with the children was currently certified by a cabinet approved training agency in CPR and First Aid.
General: Based on Review of Documentation, it was found that five (5) staff files out of fifteen (15) staff files reviewed did not have evidence of a statement from a health professional stating that the individual was free of active tuberculosis. The hire dates for the staff were 08/13/2014 for four (4) staff and a hire date of 09/04/2014 for another staff person. It was also found that four (4) staff files out of fifteen staff files reviewed had a TB Skin test that was completed past their date of hire. A staff person with a hire date of 08/14/2014 had a TB skin test read on 08/19/2014. A staff person with a hire date of 08/13/2014 had a TB skin test that was read 08/22/2014. Another staff person with a hire date of 08/13/2014 had a TB skin test read 08/22/2014. A staff person with a hire date of 09/03/2014 had a TB skin test that was read on 09/23/2014.
General: Based on Review of Documentation, it was found that the facility had an emergency preparedness plan, but no evidence was found to indicate this plan was submitted to the emergency management officials.
General: Based on Review of Documentation, and based on interview the facility had three (3) children enrolled on CCAP (Child Care Assistance) in November of 2013 and the facility did not use the CCAP attendance forms to track the children's arrival and departure times.
General: Based on Review of Documentation, it was found that five (5) staff did not have written annual professional development plans on file. These staff were hired on 1/11/13, 8/1/10, 8/1/10, 8/17/10, and 12/7/12.
A PLAN OF CORRECTION WAS DUE ON 22 Apr 14 AND AS OF 01 May 14, THE PLAN OF CORRECTION HAS NOT BEEN RECEIVED.
General: Based on Review of Documentation, it was found that three (3) staff did not complete the fifteen (15) hours of cabinet-approved early care and education training within their training year. Two (2) of these staff were hired on 8/1/10 and and the other staff was hired on 8/17/10. Another staff that was hired on 1/11/13 did not complete the nine hours of training within her first year of employment (7.5 hours were completed). Two (2) additional staff did not complete orientation training within the first three (3) months of employment. These staff were hired on 10/21/13 and 1/11/13. 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
This follow-up inspection recorded no violations or advisories.
General: Based on Observation, it was found during the follow-up insepection, there were two (2) staff caring for ninety-two (92) children. The age of the youngest child in the group was six (6) years of age. It was also found that one (1) staff took a group of fourteen (14) children to the restroom leaving the other staff with seventy-eight (78) children. This staff was found to be over ratio and over group size. 45 - Ratio/Group Size Not Applicable 922 KAR 2:120. Section 2. Child Care Services. (2)(b) The age of the youngest child in the group shall determine the: 1. Staff-to-child ratio; and 2. Maximum group size.
General: Based on Review of Documentation, it was found that nine (9) staff files out of ten (10) staff files reviewed did not have evidence of a yearly 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 An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 7 of 39 Web site: http://chfs.ky.gov/ Inspection Report 3) Previous State of Residence In Compliance 4) Current State other than KY In Compliance
General: Based on Review of Documentation, it was found that seven (7) staff files out of ten (10) staff files reviewed did not have evidence of a current TB skin test or documentation from a health care professional that they are free of TB. The staffs' dates of hire were, 12/2012, 08/01/2005, 02/10/2011, 06/08/2010, and three (3) with the hire date of 08/01/2010. 128 - CPR/First Aid Coverage 922 KAR 2:110 - Section 5 (3) At least one (1) person on duty and present with the children shall be currently certified by a cabinet-approved training agency in the following skills: (a)Infant and child cardiopulmonary resuscitation; and (b) Infant and child first aid. 1) CPR In Compliance 2) First Aid In Compliance 131 - Adequate Substitute(s) 922 KAR 2:110 - Section 5 (6) Child-care centers shall have available in case of need: (a) One (1) qualified substitute staff person for a Type II child-care center; or (b) Two (2) qualified substitute staff persons for a Type I child-care center 1) Type I In Compliance 131 - Adequate Substitute(s) 922 KAR 2:110 - Section 5 (6) Child-care centers shall have available in case of need: (a) One (1) qualified substitute staff person for a Type II child-care center; or (b) Two (2) qualified substitute staff persons for a Type I child-care center 2) Type II Not Applicable 139 - Training 922 KAR 2:110 - Section 5 (14) A staff person with supervisory authority over a child shall complete the following: (a) Six (6) hours of cabinet-approved orientation within the first three (3) months of employment; (b) Nine (9) hours cabinet-approved child development training within the first year of employment; and (c) Fifteen (15) hours of cabinet-approved training during each subsequent year of employment. 1) Orientation In Compliance 2) 9 hours-first year In Compliance 139 - Training 922 KAR 2:110 - Section 5 (14) A staff person with supervisory authority over a child shall complete the following: (a) Six (6) hours of cabinet-approved orientation within the first three (3) months of employment; (b) Nine (9) hours cabinet-approved child development training within the first year of employment; and (c) Fifteen (15) hours of cabinet-approved training during each subsequent year of employment. 3) 15 hours annually Not In Compliance Findings: General: Based on Review of Documentation, it was found that eight (8) staff files out of ten (10) staff files reviewed did not have evidence of the required 15 hours of annual training. The dates of hire for the staff were, 08/01/2005, 08/17/2010, 02/10/2011, 06/08/2010, and four (4) with the hire date of 08/01/2010. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 8 of 39 Web site: http://chfs.ky.gov/ Inspection Report 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 the file for a child enrolled on 5-24-11 contained an immunization certificate from North Carolina. This document did not have an expiration date, therefore it could not be verified that the child was current on immunizations. In addition, the files for children enrolled on 6-1-11 and 8-4-11 contained immunization certificates that expired on 12-1-11 and 7-30-11 respectively. 99 - Documentation for Off Premise Trip Not Applicable 922 KAR 2:110 - Section 3 The following records shall be maintained at the child-care center for five (5) years: (4) Permission forms for each trip off the premises signed by the parent; An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 37 of 41 Web site: http://chfs.ky.gov/ Inspection Report Written Documentation 93 - Policies and Procedures 922 KAR 2:110 - Section 2 (5) Program policies and procedures shall: (a) Be in writing; and (b) Include: 1. Staff policies; 2. Job descriptions; 3. An organization chart; 4. Chain of command; and 5. Other procedures necessary to ensure implementation of: a. KRS 199.898, Rights for children in child-care programs and their parents, custodians, or guardians - posting and distribution requirements; b. 922 KAR 2:090, Child-care center licensure; c. 922 KAR 2:120, Child-care center health and safety standards; and d. This administrative regulation. 1) Writing In Compliance 2) Staff Policies In Compliance 3) Job Description In Compliance 4) Organization Chart In Compliance 5) Chain of Command In Compliance 6) Other Procedures-a) Rights for Children b)922 KAR 2:090 c) 922 KAR 2:110 d)922 KAR 2:120 In Compliance 100 - Daily Attendance Records 922 KAR 2:110 - Section 3 (5) Daily attendance records documenting the arrival and departure time of each child; 1) Arrival In Compliance 2) Departure In Compliance
General: Based on Review of Documentation, it was found that the file for an employee hired on 12-21-11 contained the results of a negative TB skin test that was dated 1-3-12. This date is not prior to the date of hire as required by the regulation. In addition, the files for three (3) employees hired on 8-1-10 and one (1) employee hired on 6-8-10 contained the results of negative TB skin tests that were dated 8-7-09, 9-18-09, 2-3-10 and 8-11-08. 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 An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 8 of 41 Web site: http://chfs.ky.gov/ Inspection Report 139 - Training 922 KAR 2:110 - Section 5 (14) A staff person with supervisory authority over a child shall complete the following: (a) Six (6) hours of cabinet-approved orientation within the first three (3) months of employment; (b) Nine (9) hours cabinet-approved child development training within the first year of employment; and (c) Fifteen (15) hours of cabinet-approved training during each subsequent year of employment. 1) Orientation Not In Compliance Findings: General: Based on Review of Documentation, it was found that the file for an employee hired on 2-10-11 contained evidence of the cabinet-approved orientation training being completed on 8-27-11. The file for an employee hired on 8-1-10 did not contain evidence of orientation training being completed. These instances are not within the three (3) month timeframe required by the regulation. 2) 9 hours-first year Not In Compliance Findings: General: Based on Review of Documentation, it was found that ten (10) employees did not complete the required nine (9) hours of additional training during their first year of employment. 139 - Training 922 KAR 2:110 - Section 5 (14) A staff person with supervisory authority over a child shall complete the following: (a) Six (6) hours of cabinet-approved orientation within the first three (3) months of employment; (b) Nine (9) hours cabinet-approved child development training within the first year of employment; and (c) Fifteen (15) hours of cabinet-approved training during each subsequent year of employment. 3) 15 hours annually In Compliance 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, a child enrolled on 12/04/23, did not have immunization documentation on file. Written Documentation Not In Compliance
General: Based on review of documentation, this regulation was not met. None of the staff were certified in CPR/First Aid at the time of the survey.
General: Based on review of documentation, there was no evidence that the facility's emergency preparedness plan had been updated and sent to the proper authority since 2019.
General: Based on review of documentation, two staff hired on 9/1/14 and 8/14/19, did not have a professional development plan on file at the facility. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3 Inspection Report
General: Based on review of documentation, there was no evidence of an orientation procedure for staff on file at the facility. Posted Documentation In Compliance Animals In Compliance
General: Based on Review of Documentation, and the Training Records Information System (TRIS), three (3) staff files (hire dates: 8/13/14, 10/27/14 and 8/12/15) did not contain the required fifteen (15) hours of training. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Food Service In Compliance Children's Records In Compliance Written Documentation Not In Compliance
General: Based on Review of Documentation and interview, nine (9) staff did not have evidence of a current staff professional development plan on file in the facility. The staff person in charge stated that she was not aware of this regulatory requirement. Posted Documentation Not In Compliance
General: Based on Review of Documentation and interview, this regulatory requirement was not met. The facility did not have a schedule of daily activities posted. The staff person in charge stated that staff had this documentation on their clipboard that they carry around with them; however, indicated that the documentation was not posted. Animals Not Applicable
General: Based on Review of Documentation, staff member hired on 09/01/14 did not have the results of a child abuse and neglect check on file. She stated that she has the results but is not for sure why there is not a copy of it in her file.
General: Based on Review of Documentation, staff hired on 02/09/16 and 08/13/14 did not have documentation from a health care professional stating that they were free from active tuberculosis. The staff person in charege verified the test were not in their files.
General: Based on Review of Documentation, staff member hired on 08/13/14 did not have any cabinet approved trainings or the required Pediatric Abuse Head Trauma class according to the ECE-TRIS training site. Staff member hired on 08/13/14 did not have the required Pediatric Abuse Head Trauma class according to the ECE-TRIS training site.
General: Based on Review of Documentation, children enrolled on 08/17/15 and 09/08/15 did not have the physician's contact information, preferred hospital information and the emergency authorization section completed on their enrollment forms. Staff person in charge stated that she would have the parent complete that section.
General: Based on Review of Documentation, staff members hired on 09/01/14, 10/27/14, and two (2) staff hired on 08/13/14 did not have a current professional development plan on file.
General: Based on Observation, during a tour of the facility it was found that first aid supplies were stored on a shelf in an unlocked room in the gym. In the first aid kit packets of burn cream. aspirin and sting relief were observed. The kit was not locked and was accessible to the children. It was also found that the burn cream, aspirin and sting relief were not labeled for an individual child. Children were observed playing in the gym at the time of the survey. Outdoor Play Area
General: Based on Observation, it was found that a CPR mouthpiece and a flashlight were not available for use as a part of the first aid supplies.
General: Based on Interview, it was found the facility did not have available for review written program policies and procedures that include but are not limited to staff policies, job descriptions, and organization chart and chain of command.
General: Based on Interview, with the staff person in charge it was found there was no documentation available for review to assure fire drills were practiced monthly for 2014.
General: Based on Interview, it was found that there are children who attend the program that receive child care assistance through the Child Care Assistance Program. However, further interview with the staff person in charge found that they are not using the required form in accordance with 922 KAR 2:160 Section 13 to document each child's time of arrival and time of departure.
General: Based on Observation, at the time of the survey conducted on 1/29/15 a staff person hired 1/19/15 was observed supervising a child alone without the results of a criminal records check and child abuse and neglect check. This staff person was in charge of letting parents in the door, taking payment and answering calls. An interview with the staff person in charge found that previously the door the parents are required to enter had been propped open in order for parents to gain entry. However, the principal of the school informed the staff person in charge they could not prop the door open. The principal of the school then suggested that the program designate a child to sit in a chair near the staff person and open the door for the parents as they arrive to pick up their child. The area is located in the hallway by the cafeteria. A child was observed sitting in the area with the staff person at approximately 3:00 p.m. It is undetermined as to how long the child remained sitting with the staff person. The program uses numeorus areas within the school which does not allow for the staff person to be supervised by a qualified staff person.
General: Based on Interview, there was no documentation available for review to verify that at least one (1) parental/family involvement activity had been conducted for 2014. Employee Records
General: Based on Observation, it was found that there was not a planned program of activities posted in writing with each age group.
General: Based on Review of Documentation, it was found the facility did not have a written procedure to inform staff of the laws of the Commonwealth pertaining to child abuse or neglect.
General: Based on Review of Documentation, at the time of the survey conducted on 1/29/15 a staff person hired 1/19/15 was observed supervising a child alone without the results of a criminal records check and child abuse and neglect check. There was no evidence on file to verify the application for the results of the criminal records check and child abuse or neglect check had been submitted. A review of staff files also found there were four (4) staff with hire dates of 9/15/14, 9/3/14, 10/22/14 and 8/14/14 who had lived out of state within the last five (5) years and did not have the results of a criminal records check from their respective state. Those states include Ohio, Illinois, California, Maryland and Michigan.
General: Based on Review of Documentation, out of twenty (20) staff files reviewed there was one (1) staff person hired 1/19/15 who did not have a high school diploma, GED or other qualifying documentation on file.
General: Based on Review of Documentation, out of twenty (20) staff files reviewed there was one (1) staff person hired 1/19/15 who did not have the results of a current T.B. skin test or a statement from a health professional indicating the individual is free from the symptoms of T.B. on file at the facility.
General: Based on Observation, it was found that a snack menu was not posted. 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 Interview, with the staff person in charge it was found there was no documentation available for review to assure earthquake and tornado drills are practiced quarterly with the date, time and names of children who participated documented for 2014.
General: Based on Interview, with the staff person in charge it was found there was no documentation available for review to assure fire drills are practiced monthly with the date, time and names of children who participated documented for 2014.
General: Based on Review of Documentation, the facility did not have a written policy that specifies the procedures taught at the orientation training will be implemented by staff.
General: Based on Observation, it was found that facility's license was not posted. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 25 of 26 Web site: http://chfs.ky.gov/ Inspection Report
General: Based on Observation, the statement of deficiencies issued by the cabinet regarding a relicensure survey conducted on 3/5/14 and a statement of deficency regarding a complaint investigation conducted on 10/15/14 were not posted. The plans of correction submitted by the facility for both of these visits were not posted. These additional items were not posted; Information on the Kentucky Safety Program and the program's website, a description of services provided by the facility, current rates for child care and each service charged separately in addition to basic child care rates and the minimum staff-to-child ratios and group size.
General: Based on Observation, there was not a written plan and diagram outlining the course of action to take in the event of a natural or manmade disaster posted.
General: Based on Observation, in room # 144 a large turtle was observed in a glass tank. This room is used as a homework room. An interview with the staff person in charge found that written parental consent had not been obtained from the parents of the children who use the classroom for homework.
General: Based on Review of Documentation, it was found that seven (7) staff files out of fifteen (15) staff files reviewed did not have evidence of a child abuse and neglect check. The files for employees hired on 08/16/2014, (3) hired on 08/13/2014, 09/04/2014, 09/03/2014 and 09/15/2014 did not contain the results of or evidence of submission for a child abuse/neglect check. These instances are not in accordance with 922 KAR 1:470 which states that a request for a central registry check must be submitted within five (5) working days after the date of employment of an individual. Two (2) of these staff were alone with approximately ten (10) fouth and fifth graders. It was also found that nine (9) staff files out of fifteen (15) staff files reviewed did not have evidence of a criminal records check. The files for employees hired on 08/16/2014, 09/01/2014, 09/04/2014, (5) hired on 08/13/2014, and 09/15/2013 did not contain the results of or evidence of a criminal records check (CRC). These instances are not in accordance with KRS 17.165 which requires that application for the criminal record of a probationary employee be made no later than the date probationary employment begins. Two (2) of these staff were alone with approximately ten (10) fouth and fifth graders. It was found that three (3) staff hired on 09/01/2014 did not receive evidence of a child abuse and neglect check until 10/09/2014; one staff hired on 08/14/2014 did not received evidence of a child abuse and neglect check until 09/24/2014; and three (3) staff hired on 08/13/2014 did not have evidence of a child abuse and neglect check until 10/09/2014. It was also found that the staff had been working alone with the children without background checks from August of 2014 until October of 2014. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 1 of 2 Web site: http://chfs.ky.gov/ Inspection Report Employee Records
General: Based on Review of Documentation, it was found that seven (7) staff files out of fifteen (15) staff files reviewed did not have evidence of a child abuse and neglect check. The files for employees hired on 08/16/2014, (3) hired on 08/13/2014, 09/04/2014, 09/03/2014 and 09/15/2014 did not contain the results of or evidence of submission for a child abuse/neglect check. These instances are not in accordance with 922 KAR 1:470 which states that a request for a central registry check must be submitted within five (5) working days after the date of employment of an individual. Two (2) of these staff were alone with approximately ten (10) fouth and fifth graders. It was also found that nine (9) staff files out of fifteen (15) staff files reviewed did not have evidence of a criminal records check. The files for employees hired on 08/16/2014, 09/01/2014, 09/04/2014, (5) hired on 08/13/2014, and 09/15/2013 did not contain the results of or evidence of a criminal records check (CRC). These instances are not in accordance with KRS 17.165 which requires that application for the criminal record of a probationary employee be made no later than the date probationary employment begins. Two (2) of these staff were alone with approximately ten (10) fouth and fifth graders. It was found that three (3) staff hired on 09/01/2014 did not receive evidence of a child abuse and neglect check until 10/09/2014; one staff hired on 08/14/2014 did not received evidence of a child abuse and neglect check until 09/24/2014; and three (3) staff hired on 08/13/2014 did not have evidence of a child abuse and neglect check until 10/09/2014. It was also found that the staff had been working alone with the children without background checks from August of 2014 until October of 2014.
General: Based on Review of Documentation, it was found that eight (8) staff files out of fifteen (15) staff files reviewed did not have evidence proof of education.
General: Based on Review of Documentation, it was found that three (3) staff did not have proof of education on file. These staff were hired on 10/16/13, 10/21/13, and 1/11/13.
General: Based on Review of Documentation, it was found that the facility had an outdated copy of the regulations on file. The copy on file was dated 1/27/10.
General: Based on Review of Documentation, it was found that four (4) staff did not have current written annual performance evaluations on file. The evaluations on file for these four (4) staff members were not dated.
General: Based on Review of Documentation, it was found that one (1) staff that was hired on 1/11/13 did not have a criminal records check conducted until 8/3/13 and a CAN check conducted until 9/12/13. These background checks were not submitted according to 922 KAR 1:470 and KRS 199.896(19).
General: Based on Review of Documentation, it was found that two (2) staff did not have written evidence of negative TB documentation. These two (2) staff were hired on 10/21/13 and 12/7/12. Two (2) other staff that were hired on 10/16/13 and 8/1/10 had TB documentation on file that was no longer current. The TB skin tests were dated 1/2/12 and 10/3/11.
General: Based on Observation, the snack menu posted was dated from February.
General: Based on Observation, the children were served Cheez-It crackers and water for snack. The facility did not serve the children two (2) snack components. 1065 - Lunch/Dinner Requirements Not Applicable 922 KAR 2:120. Section 9. Food and Meal Requirements. (19) Lunch and dinner shall include: (a) Milk; (b) Protein; (c) Bread; and (d)1. Two (2) vegetables; 2. Two (2) fruits; or 3. One (1) fruit and one (1) vegetable. Children's Records
General: Based on Review of Documentation, it was found that one (1) child had an immunization certificate on file from Florida and it did not have an expiration date on the document. Two (2) other students did not have immunization certificates on file. All three (3) students have attended the program in excess of thirty (30) days.
General: Based on Review of Documentation, it was found that there was no documentation of conducted staff meetings.
General: Based on Review of Documentation, it was found that eight (8) staff files out of ten (10) staff files reviewed did not have evidence of a yearly evaluation.
General: Based on Review of Documentation, it was found that one (1) child's file out of ten (10) children's files reviewed did not have evidence of a current immunization certificate. This child was enrolled on 08/13/2012.
General: Based on Review of Documentation, it was found that the files for ten (10) employees did not contain evidence of an annual professional development plan. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 7 of 41 Web site: http://chfs.ky.gov/ Inspection Report 107 - Maintenance of Background check/Out of State 922 KAR 2:110 - Section 3 (12) For the director, employee, volunteer, or any person with supervisory or disciplinary control over, or having direct contact with a child, results of the: (a) Criminal records check in accordance with KRS 17.165; (b) Child abuse and neglect check in accordance with 922 KAR 1:470; and (c) Background check from: 1. Previous state of residence, if the individual has been a resident outside of Kentucky in the previous five (5) years; or 2. Current state of residence, if other than Kentucky; 1) Criminal Records Check In Compliance 2) Child Abuse/Neglect Check In Compliance 3) Previous State of Residence In Compliance 4) Current State other than KY In Compliance
General: Based on Review of Documentation, it was found that there was no evidence of staff meetings having been conducted. The staff person in charge stated that the facility does not keep documentation of staff meetings.
General: Based on Review of Documentation, it was found that there was no evidence of annual evaluations being conducted by the director for nine (9) eligible employees.
General: Based on Review of Documentation, it was found that the file for an employee hired on 12-21-11 did not contain evidence of a high school diploma, GED or Commonwealth Child Care Credential.