922 KAR 2:090. Section 9. Records.

General: Based on review of documentation, one (1) child’s file reviewed did not list a preferred hospital.

922 KAR 2:090 · Correction status not published

922 KAR 2:090. Section 10. Director Requirements and Responsibilities.

General: Based on review of documentation, staff members (DOH: 08/10/16 and 08/11/23) had evaluations in their personnel files that were not dated. The surveyor was unable to determine when the evaluations had been completed.

922 KAR 2:090 · Correction status not published

922 KAR 2:090. Section 11. Staff Requirements.

General: Based on review of documentation, staff member (DOH: 09/30/22) had a negative tuberculin skin result on file that did not include a name.

922 KAR 2:090 · Correction status not published

922 KAR 2:090. Section 11. Staff Requirements.

General: Based on review of documentation, this regulatory requirement was not met. The following was found: 1.) A staff member (DOH: 01/31/24) only completed eight (8) out of fifteen (15) hours of cabinet-approved early care and education training for the 01/31/24-01/30/25 training year. 2.) A staff member (DOH: 08/20/22) had a pediatric abusive head trauma training record on file that exceeded five years, and therefore was no longer current. A review of ECE-TRIS supports these findings.

922 KAR 2:090 · Correction status not published

922 KAR 2:090. Section 9. Records.

General: Based on review of documentation, this regulatory requirement was not met. The following was found: 1.) One (1) child’s file reviewed contained an immunization record that did not have a date of expiration. The surveyor was unable to determine whether the inoculations were current. 2.) One (1) child’s file reviewed did not contain an immunization record.

922 KAR 2:090. Section 11. Staff Requirements.

General: Based on review of documentation, the following was found: 1) A staff member (DOH: 08/01/16), completed PAHT training on 08/20/18; however, did not renew the training due 08/20/23. 2) A staff member (DOH: 08/30/22) did not complete fifteen (15) hours of early care and education training. ECE-TRIS was reviewed and confirmed these findings. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Kitchen Requirements In Compliance Food Service In Compliance Meal Planning/Center Provides Meals In Compliance Meal Planning/Center Does Not Provide Meals In Compliance Children's Records In Compliance Written Documentation In Compliance Posted Documentation In Compliance Animals In Compliance

922 KAR 2:090 · Correction status not published

922 KAR 2:280. Section 3. Implementation and Enforcement.

General: Based on review of documentation, a staff member (DOH: 08/15/23) did not complete Kentucky National Background Check Service (KARES) until 08/22/23. Supervision In Compliance Staffing Requirements In Compliance General Administration In Compliance Director Requirements In Compliance Employee Records Not In Compliance

922 KAR 2:280 · Correction status not published

922 KAR 2:090. Section 11. Staff Requirements.

General: Based on review of documentation, a staff member (DOH:08/15/23) did not obtain a TB test or statement from a health professional until 08/20/23. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3 Inspection Report

922 KAR 2:090 · Correction status not published

922 KAR 2:120. Section 2. Child Care Services.

General: Based on observation, this regulation was not met. The Kindergarten group had two teachers with 23 children. The children in this group were six-years-old. One of the teachers left the room to walk children to the bathroom and cafeteria for dismissal leaving the classroom out of ratio each time. The classroom did have a third teacher briefly as stated on the plan of correction; however, that teacher's last day was May 5th. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2

922 KAR 2:120 · Correction status not published

922 KAR 2:090. Section 11. Staff Requirements.

General: Based on review of documentation, the following was found: 1.) Staff member hired 3/1/21 did not complete fifteen (15) hours of cabinet-approved early care and education training for the 3/1/22 – 6/30/22 training year. 2.) Two (2) staff members hired 2/22/2021 did not complete fifteen (15) hours of cabinet-approved early care and education training for the 2/22/22 – 6/30/22 training year. 3.) Staff member hired 8/11/2021 did not complete fifteen (15) hours of early-care and education training for the 8/11/21-8/11/22 training year. A review of ECE-TRIS supports these findings. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation 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

922 KAR 2:090 · Correction status not published

922 KAR 2:280. Section 11. Status of Employment.

General: Based on review of documentation, at least 26 individuals that are no longer employed by the facility were listed as current employees on the KARES FBI Portal. Individuals no longer employed should have a status as “separated”. In addition, a staff member employed on 9/30/22 previously worked for another facility until 9/22/22, at which time the individual separated employment. The current employer is required to list the individual as a staff member at the current child-care center. Supervision In Compliance Staffing Requirements Not In Compliance

922 KAR 2:280 · Correction status not published

922 KAR 2:280. Section 5. Checks of Other States.

General: Based on review of documentation, the following was found: 1.) Staff member hired 8/15/2022 had evidence of living in the state of New York within the past five (5) years. There was no evidence that a Child Abuse Registry Check or State- based sex offender check had been completed for the state of New York. 2.) Staff member hired 1/18/2022 had evidence of living within the state of Ohio within the past five (5) years. There was no evidence that a Child Abuse Registry Check or State- based sex offender check had been completed for the state of Ohio. 3.) Staff member hired 08/11/2022 had evidence of living within the state of Georgia within the past five (5) years. There was no evidence that a Child Abuse Registry Check or State- based sex offender check had been completed for the state of Georgia. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report

922 KAR 2:090. Section 11. Staff Requirements.

General: Based on review of documentation, staff member hired 8/11/2021, had a negative tuberculin skin result in their personnel file dated 8/1/2019, this skin result exceeds two years and is no longer valid.

922 KAR 2:090 · Correction status not published

922 KAR 2:090. Section 11. Staff Requirements.

General: Based on review of documentation, staff members hired 12/16/19, 7/1/2020, and 1/18/2019 did not complete 15 hours of Cabinet-approved early care and education training for the July 1, 2020 to June 30, 2021 year of employment. A review of ECE-TRIS supports this finding. 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 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 In Compliance Written Documentation Not In Compliance

922 KAR 2:090 · Correction status not published

922 KAR 2:090. Section 9. Records.

General: Based on review of documentation, the tornado, earthquake, and fire drills were documented as occurring at the same time; these drills require separate actions and should be documented individually. Posted Documentation In Compliance Animals In Compliance

922 KAR 2:090 · Correction status not published

922 KAR 2:090. Section 11. Staff Requirements.

General: Based on observation and review of documentation, this regulatory requirement was not met. One staff member hired on 2/22/2021, did not have proof of education on file. Programming In Compliance Premises In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Food Service/Food Program In Compliance Food Service In Compliance Children's Records Not In Compliance

922 KAR 2:090 · Correction status not published

922 KAR 2:090. Section 9. Records.

General: Based on observation and review of documentation, this regulatory requirement was not met. Four staff files did not have documented hire dates. The staff in charge verbally gave the surveyor the hire dates.

922 KAR 2:090 · Correction status not published

922 KAR 2:090. Section 9. Records.

General: Based on observation and review of documentation, this regulatory requirement was not met. The following was found: 1. A child’s enrollment paperwork was missing an immunization certificate. The child’s file contained a duplicate immunization certificate for a sibling. The child had been enrolled in excess of thirty days. 2. A child’s file contained an expired immunization certificate. The immunization certificate was dated 9/29/2020. The child had been enrolled in excess of thirty days. Written Documentation In Compliance Posted Documentation Not In Compliance

922 KAR 2:090 · Correction status not published

922 KAR 2:090. Section 9. Records.

922 KAR 2:120. Section 3. General Requirements.

General: Based on observation, there was a staff person's purse sitting on a desk in Room 305 and a staff person's purse was on the floor in Room 309. Both purses were accessible to the children in care. Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Food Service/Food Program Not In Compliance

922 KAR 2:120 · Correction status not published

922 KAR 2:120. Section 9. Food and Meal Requirements.

General: Based on observation, interview and review of documentation, the snack set out on a table for the children consisted of fruit snacks, pretzels and cups of water. In an interview with the staff person in charge, it was stated that the children are allowed to pick their own snack. She indicated that the children know that milk is available but none of the children ever choose the milk. The milk cooler was observed to be appoximately 15 feet away from the table where the snacks and water were being offered. The cooler was not open so the milk was not readily available for the children to choose. The posted menu listed fruit snacks and milk for snack on the day of the survey. The label on the fruit snacks indicates that the first two ingredients in the snack are corn syrup and sugar. The fruit snacks do not meet the requirement as an approved snack component. Most of the children observed during snack chose fruit snacks and water. A few of the children chose pretzels and water. None of the children present during snack time had two approved snack components. Food Service In Compliance Children's Records In Compliance Written Documentation In Compliance Posted Documentation In Compliance Animals In Compliance

922 KAR 2:120 · Correction status not published

922 KAR 2:120. Section 9. Food and Meal Requirements.

General: Based on observation and review of documentation, the posted snack menu included only one (1) component each day. In addition, on Fridays the snack menu listed "extras". An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Food Service Not In Compliance

922 KAR 2:120 · Correction status not published

922 KAR 2:120. Section 8. Kitchen Requirements.

General: Based on observation, the refrigerator on the stage, that was used to store the drinks for the after-school program, did not contain a thermometer. The temperature inside the refrigerator was unable to be determined. Children's Records In Compliance Written Documentation In Compliance Posted Documentation In Compliance Animals In Compliance

922 KAR 2:120 · Correction status not published

922 KAR 2:090. Section 10. Director Requirements and Responsibilities.

General: Based on interviews and a review of documentation, the facility director failed provide for the health, safety and comfort of a five (5) year-old child in regards to an incident that occurred during the after-school program on 1/16/19. Based on interviews, Room 112 is used by the after-school program for the Kindergarten children to gather and have snacks once a week. This room is approved licensed space for the program. Based on interviews and written statements provided by witnesses the Kindergarten teacher acted in the role of a staff member for the after-school children on 1/16/19 when she got upset with them for being loud and began to discipline the children in this room. The Kindergarten teacher is not a staff member of the after-school program. According to witnesses, a five (5) year-old female child did not comply with the teacher's requests to move away from another student because she was giggling and the teacher pulled her chair out from under the child. When the teacher pulled the chair back, the child fell and landed on her knees, on the floor. The teacher then told the child to get up from the floor and when she would not comply, the teacher pulled by her arms/wrists off the floor into another seat and then forced her to sit in that chair. Based on interviews and written statements the teacher put her body weight behind the chair so the child could not get up even when she struggled. During that, time the teacher commented, “I’m not touching her” to others in the room. Witness information also confirmed the teacher began to belittle the child, calling her a baby, and polling the other children in the class to see if they had any younger siblings that “act like this”. It was reported that the teacher took the child by her arms/wrists, moved her out of the classroom, then pinned her up against the wall outside of the cafeteria. The teacher told the child she did not want her in her classroom. The after-school program director was notified of what was going on and went to the area outside of the cafeteria and saw the teacher holding the five (5) year-old child up against the wall. The after-school program director directed the teacher to release the student and step away. Based on interviews the child was not physically injured during this incident. Based on the information obtained during the investigation this five (5) year-old child was belittled in front of her peers, physically dumped out of a chair, aggressively moved into a chair, and then physically moved by her wrists/arms into the hallway and pinned up against a wall. In addition, based on interviews, the other children in the classroom were uncomfortable, frightened, and upset while this incident was happening in the classroom. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Programming Not In Compliance

922 KAR 2:090. Section 9. Statement of Deficiency and Corrective Action Plans.

A PLAN OF CORRECTION WAS DUE ON 02/08/2018 AND AS OF 02/27/2018, THE PLAN OF CORRECTION HAS NOT BEEN RECEIVED.

922 KAR 2:090 · Correction status not published

922 KAR 2:120. Section 3. General Requirements.

General: Based on Review of Documentation, it was found that the fire drill documentation did not include evidence of fire drills being conducted during the months of August, November and December of 2017. Posted Documentation Not In Compliance

922 KAR 2:120 · Correction status not published

922 KAR 2:110. Section 3. Records.

General: Based on Review of Documentation, one (1) child (enrollment date: 4/15/17) had an immunization certificate on file that was no longer current as of 7/15/07. Written Documentation Not In Compliance

922 KAR 2:110 · Correction status not published

922 KAR 2:110. Section 5. Staff Requirements.

General: Based on Review of Documentation, and the Training Records Information System (TRIS), the following was found: 1. Nine (9) staff files (hire dates: 8/10/16, 8/24/15, 9/14/15, 8/17/15, 8/16/17, 2 on 10/30/17, 9/13/17 and 10/2/17) did not contain evidence of the six (6) hours of cabinet-approved training being completed within the first three (3) months of employment. 2. Six (6) staff files (hire dates: 3 on 8/10/16, 8/24/15, 9/14/15, and 8/17/15. ) did not contain evidence of the pediatric abusive head trauma training class being completed within the first year of employment. 3. Two (2) staff files (both hired 5/28/09) contained a pediatric abusive head trauma training class certificate that was dated 10/20/12; therefore, this training is no longer valid. 4. Four (4) staff files (hire dates: 12/7/15, 5/28/19, 9/14/15 and 8/10/08) did not contain the required fifteen (15) hours of training. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 6 Inspection Report Programming Not In Compliance

922 KAR 2:090. Section 6. License Issuance.

General: Based on Review of Documentation, it was found that a request for a change of director was submitted on 5-25-17. After some discussion with personnel from the Board of Education it was found that the name submitted was not accurate. Telephone calls requesting the correct name and documentation were made on 5-30-17 and 6-5-17. Telephone messages were left on 6-16-17, 6-20-17 and 6-22-17. Emails requesting the correct name and documentation were sent to the contact person on 6-8-17, 6-13-17, 6-26-17 and 7-10- 17, however, no response has been received. Read receipts were received for the two (2) most recent emails. As of this date, the facility does not have a qualified director in place.

922 KAR 2:090 · Correction status not published

922 KAR 2:090. Section 9. Statement of Deficiency and Corrective Action Plans.

A PLAN OF CORRECTION WAS DUE ON 07/24/2017 AND AS OF 08/24/2017, THE PLAN OF CORRECTION HAS NOT BEEN RECEIVED.

922 KAR 2:090 · Correction status not published

922 KAR 2:110. Section 3. Records.

General: Based on Review of Documentation, it was found the files for four (4) eligible employees did not contain evidence of an annual professional development plan. The hire dates of these employees were 08/12/2015, 12/17/2015, 05/28/2009 and 08/10/2008.

922 KAR 2:110 · Correction status not published

922 KAR 2:110. Section 4. Director Requirements and Responsibilities.

General: Based on Review of Documentation, it was found that the files of three (3) eligible employees did not contain evidence of an annual performance evaluation. The hire dates of these employees were 09/14/2015, 08/12/2015 and 08/10/2008. Employee Records Not In Compliance

922 KAR 2:110 · Correction status not published

922 KAR 2:090. Section 6. License Issuance.

General: Based on Review of Documentation, it was found that nine (9) employees did not contain evidence of a completed criminal records check. The hire dates include 08/12/2015, 09/09/2016 and seven (7) of the hire dates of these individuals was 08/10/2016. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 4 Inspection Report

922 KAR 2:090 · Correction status not published

922 KAR 2:110. Section 3. Records.

General: Based on Review of Documentation, a child whose enrollment date was 08/01/2016 did not have a Physician listed in his file. Written Documentation Not In Compliance

922 KAR 2:110 · Correction status not published

922 KAR 2:110. Section 5. Staff Requirements.

922 KAR 2:110. Section 5. Staff Requirements.

General: Based on Review of Documentation, it was found that 1) the file and ECE-TRIS record for an employee hired on 5-28-09 contained evidence of only fourteen (14) hours of annual training being completed during the last completed training year; 2) the file and ECE-TRIS record for an employee hired on 5-30-10 contained evidence of zero (0) hours of annual training being completed during the last completed training year; 3) the file and ECE-TRIS record for an employee hired on 9-5-12 contained evidence of only ten (10) hours of annual training being completed during the last completed training year; 4) the file and ECE-TRIS record for an employee hired on 5-28-09 contained evidence of zero (0) hours of annual training being completed during the last completed training year; 5) the files and ECE-TRIS records for twelve (12) employees hired more than three (3) months prior to the survey did not contain evidence of the six (6) hour cabinet-approved orientation training being completed.

922 KAR 2:110 · Correction status not published

922 KAR 2:110. Section 3. Records.

General: Based on Review of Documentation, it was found that the facility uses a check mark to indicate a child's presence in the program. A time of arrival is not noted except in cases of a child arriving late. The staff person in charge stated that he was unaware of the need to document the entrance time of the other children.

922 KAR 2:110 · Correction status not published

922 KAR 2:110. Section 3. Records.

General: Based on Review of Documentation, there was one (1) child with an enrollment date of 4/16/15 whose enrollment information did not have a preferred hospital listed. There was an additional child whose enrollment information did not contain the child's physican's name and number.

922 KAR 2:110. Section 6. Reports.

General: Based on Interview, the named director had left employment with the program at the end of last school year but this had not been reported to DRCC, The staff person in charge stated that he was going to be the director but acknowleded the required request and documentation had not been submitted. Programming

922 KAR 2:110 · Correction status not published

922 KAR 2:120. Section 3. General Requirements.

General: Based on Observation, there were five (5) separate groups of children in the cafeteria having snack; the first through the fifth grade. The children were watching the Rugrats on a large projection screen while they ate snack. This video was not part of the planned program of activity or being used as an educational tool.

922 KAR 2:120 · Correction status not published

922 KAR 2:120. Section 9. Food and Meal Requirements.

General: Based on Observation, there were five (5) separate groups of children in the cafeteria having snack; the first through the fifth grade. The children were watching the Rugrats on a large projection screen while they ate snack. Children's Records

922 KAR 2:120 · Correction status not published

922 KAR 2:110. Section 3. Records.

General: Based on Interview, a school employee's children attended the program one (1) day during a staff meeting. The children were not enrolled in the program and did not have the required information on file.

922 KAR 2:110 · Correction status not published

922 KAR 2:090. Section 5. Evacuation Plan.

General: Based on Review of Documentation, the emergency preparedness plan was not on file.

922 KAR 2:090 · Correction status not published

922 KAR 2:110. Section 3. Records.

General: Based on Review of Documentation, two (2) of the children’s files/enrollment documentation did not contain information for the family’s preferred hospital.

922 KAR 2:110 · Correction status not published

922 KAR 2:110. Section 4. Director Requirements and Responsibilities.

General: Based on Review of Documentation, the staff person in charge was unable to locate documentation of staff meetings at the time of the visit.

922 KAR 2:110 · Correction status not published

922 KAR 2:110 - Section 5 (1)

General: Based on Review of Documentation, it was found that two (2) employee files reviewed did not have T.B. test documentation completed prior to employment. One (1) staff with a hire date of 06/01/11 had a T.B. skin test read on 07/28/2011. One (1) staff with a hire date of 06/01/2011 had a T.B. skin test read on 08/15/2011. 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 2) Type II 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. 1) Orientation In Compliance 2) 9 hours-first year In Compliance An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 8 of 39 Web site: http://chfs.ky.gov/ Inspection Report 139 - Training 922 KAR 2:110 - Section 5 (14) A staff person with supervisory authority over a child shall complete the following: (a) Six (6) hours of cabinet-approved orientation within the first three (3) months of employment; (b) Nine (9) hours cabinet-approved child development training within the first year of employment; and (c) Fifteen (15) hours of cabinet-approved training during each subsequent year of employment. 3) 15 hours annually Not In Compliance Findings: General: Based on Review of Documentation, it was found that two (2) staff records did not have evidence of their completed 15 hours of annual training. 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. 317 - Driver requirements 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 In Compliance 2) Background checks In Compliance 3) Drivers license In Compliance 4) No convictions for vehicle operation In Compliance 5) No accident causing death In Compliance 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