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

General: Based on review of documentation, a staff member (DOH:06/03/23) did not have a current TB test or statement from a health professional on file in the facility. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation In Compliance Kitchen Requirements In Compliance Food Service In Compliance Meal Planning/Center Provides Meals In Compliance Meal Planning/Center Does Not Provide Meals In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Children's Records Not In Compliance

922 KAR 2:090 · Correction status not published

922 KAR 2:090. Section 9. Records.

General: Based on review of documentation, it was found that a child enrolled (05/23/23) in the center did not have a current immunization certificate on file in the facility. Written Documentation In Compliance Posted Documentation In Compliance Animals Not Applicable

922 KAR 2:090 · 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 Staff member hired 2/1/2010, had a negative tuberculin skin result on file that exceeded two years, and therefore is no longer valid. 2.) Staff members hired 6/3/2023, and 6/12/2023, did not have a negative tuberculin screening on file, nor a physician’s statement clearing them of active tuberculosis. Programming In Compliance Premises Not In Compliance

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 9/13/2022, 9/12/2022, and 9/7/2022, did not have proof of educational qualifications in their personnel file.

922 KAR 2:090 · Correction status not published

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

General: Based on review of documentation, staff member hired 9/7/2022, was not listed on the facility’s background check list via the KARES portal. The surveyor completed a name-based search for this individual in the KARES portal and found that they were separated from another facility on 8/26/2022. The staff member was not attached to this facility's license number in KARES; therefore, the facility did not keep an accurate employment status for each staff member. It is important to note that this staff member was not working on the date of the inspection. Supervision In Compliance Staffing Requirements In Compliance General Administration In Compliance Director Requirements Not In Compliance

922 KAR 2:280 · Correction status not published

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

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

General: Based on review of documentation, it was found that last Fire Marshal inspection was conducted on 06/09/2018. There was no documentation of a more recent inspection or evidence that an inspection had been requested. Director Requirements In Compliance Employee Records Not In Compliance

922 KAR 2:090 · Correction status not published

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

General: Based on review of documentation, three staff members hired on 09/15/2009, 04/09/2022, and 04/11/2022, did not have a current TB test or statement from a health professional on file. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Transportation 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 In Compliance Posted Documentation In Compliance Animals In Compliance

922 KAR 2:090 · Correction status not published

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

General: Based on observation, there was no emergency preparedness plan submitted to the local emergency management office for the year 2020. Posted Documentation In Compliance Animals In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2

922 KAR 2:090 · Correction status not published

922 KAR 2:120. Section 11. Toys and Furnishings.

General: Based on observation, it was found that in room 113, there were pink chairs that were ripped. This left the foam exposed and the chairs unable to be properly sanitized. Transportation In Compliance Food Service/Food Program In Compliance Food Service In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3 Inspection Report Children's Records Not In Compliance

922 KAR 2:120 · Correction status not published

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

General: Based on review of documentation, it was found that two staff members did not have evidence of the required Pediatric Abusive Head Trauma Training. The dates of hire for these staff are 05/31/2017 and 01/14/2019. A review of ECE-TRIS confirmed these findings. Programming In Compliance Premises Not In Compliance

922 KAR 2:090 · Correction status not published

922 KAR 2:090. Section 9. Records.

General: Based on review of documentation, it was found that there was not a location on the enrollment application to list the child's physician and their contact information. Upon speaking to the staff in charge during the exit interview, it was found that the applications for the summer program are a condensed version of the afterschool application so the parents did not have to fill out the lengthy normal application. There are currently eight children enrolled in the summer program; therefore, those eight children did not have a physician or physician contact listed. Written Documentation Not In Compliance

922 KAR 2:090 · Correction status not published

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

922 KAR 2:120. Section 12. Transportation.

General: Based on review of documentation, the surveyor found that there was not a current certification of inspection from the Transportation Cabinet for the 2001 Ford Club Wagon. The documentation presented for review was dated 9/28/17. Food Service/Food Program In Compliance Food Service In Compliance Children's Records In Compliance Written Documentation Not In Compliance

922 KAR 2:120 · Correction status not published

922 KAR 2:090. Section 9. Records.

General: Based on review of documentation, the surveyor found that there was not a current annual professional development on file for staff. Posted Documentation In Compliance Animals Not Applicable

922 KAR 2:090 · Correction status not published

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

General: Based on observation at approximately 10:12 a.m., the surveyor observed a student volunteer and two (2) school-age children return to from the restroom and enter classroom 113. Based on interview, the surveyor found the fourteen-year-old (14) student volunteer is a participant in the summer youth program operated by Lexington-Fayette County Urban Government. The surveyor noted that the student volunteer escorted the children down the hall to the restroom by herself and was not under the direct supervision of a qualified staff person at the time of the observation. It is important to note the student volunteer had a child abuse/ neglect check on file dated 6/2/19 and a criminal record check dated 5/31/19. General Administration In Compliance Director Requirements In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Employee Records Not In Compliance

922 KAR 2:090 · Correction status not published

922 KAR 2:090. Section 8. General.

General: Based on Observation, there was not a consumer product safety sheet posted in the facility. Animals Not Applicable

922 KAR 2:090 · Correction status not published

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

General: Based on Review of Documentation, staff with hire date of 06/01/2018 did not have proof of education on file.

922 KAR 2:090 · Correction status not published

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

General: Based on Review of Documentation, staff members with hire dates of 02/01/2010, 06/01/2018 and 09/15/2009 did not have proof of negative TB screen on file. 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 In Compliance Transportation Not In Compliance

922 KAR 2:090 · Correction status not published

922 KAR 2:120. Section 12. Transportation.

General: Based on Observation, two vans (called 1 and 3) did not have CPR mouth shield included in first aid kit. Van 2 and 3 did not have a seat belt cutter. Food Service/Food Program In Compliance Food Service In Compliance Children's Records Not In Compliance

922 KAR 2:120 · Correction status not published

922 KAR 2:090. Section 9. Records.

General: Based on Review of Documentation, child with enrollment date of 06/07/2018 did not have physician name/contact information or preferred hospital on file. Written Documentation In Compliance Posted Documentation Not In Compliance

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

General: Based on Review of Documentation, staff person hired 6/12/17 did not have the results of a CA/N check on file in the facility. On 6/28/17, the staff person was observed walking alone down the hallway and out the back door to the park with two (2) children in his care. Employee Records Not In Compliance

922 KAR 2:110 · Correction status not published

922 KAR 2:110. Section 6. Reports.

General: Based on Observation, on 7/11/17 a 2-year-old child was observed being cared for in Room 113. In an interview with staff it was found that the child's mother was teaching a drum class in an outside area of the facility. It was determined that the class lasts for one (1) hour. The facility is not licensed for preschool-age children. Director Requirements Not In Compliance

922 KAR 2:110 · Correction status not published

922 KAR 2:120. Section 12. Transportation.

General: Based on Review of Documentation, two (2) of the staff designated as van drivers for the facility did not have evidence of an annual driving record on file in the facility. 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 Food Service In Compliance Children's Records Not In Compliance

922 KAR 2:120 · Correction status not published

922 KAR 2:110. Section 3. Records.

General: Based on Review of Documentation, four (4) out of the ten (10) children's files presented for review did not have documentation of a preferred hospital listed by the parent. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 4 Inspection Report Written Documentation Not In Compliance

922 KAR 2:120. Section 4. Premises Requirements.

General: Based on Observation, it was determined that one of the classrooms (Room 113) to be used by the facility as child care space was also being used for other purposes during the facility's operating hours. A schedule posted outside the door indicated that there are several meetings conducted by other agencies that take place in Room 113 during the facility's operating hours.

922 KAR 2:120 · Correction status not published

922 KAR 2:120. Section 4. Premises Requirements.

General: Based on Observation, the facility did not have a designated indoor gross motor area with a minimum of sixty (60) square feet per child in addition to the thirty-five (35) square feet per child as required. The original email request for the change of space indicated that, because of the change, the facility would no longer have an in-door gross motor space available for the children in care. The Surveyor attempted to call the Director on 6/8/17, 6/12/17 and twice on 6/13/17 to discuss the lack of a gross motor area before conducting the change of space visit. None of the messages were returned before the inspection on 6/28/17. Equipment In Compliance Posted Documentation In Compliance 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 2:120. Section 3. General Requirements.

General: Based on Review of Documentation, and based on interview the May 2016 fire drill was not documented in the book. The staff in charge indicated that they did the May fire drill, but they forgot to document it.

922 KAR 2:120 · Correction status not published

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

General: Based on Observation, during the relicensure survey the gym contained thirty-five (35) children five to thirteen (5-13) years of age and three (3) staff members. The facility was over group size. The maximum group size with a child that is five (5) years-old is thirty (30) children. The children stayed in the gym during the entire relicensure survey as a large group.

922 KAR 2:120 · Correction status not published

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

General: Based on Review of Documentation, three (3) staff did not have proof of education on file. These staff were hired on 6/8/15 (2 staff), and 6/22/15 (hired as a volunteer, then changed positions to a teacher on 6/10/16).

922 KAR 2:110 · Correction status not published

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

General: Based on Review of Documentation, the posted snack menu dated 6/20 through 6/24 listed fruit and water Monday through Friday. Water is not considered a second component for snack.

922 KAR 2:120 · Correction status not published

922 KAR 2:120. Section 11. Toys and Furnishings.

922 KAR 2:120. Section 12. Transportation.

General: Based on Interview, this regulatory requirement was not met. An interview with the staff person in charge found that one of the vehicles used to transport children during a 7/22/15 field trip to the Lexington Legends baseball game was a fifteen (15) passenger van rented from Saint Paul Church. The staff person in charge explained that the facility occassionally rents this van in addition to using the van owned by the facility due to the number of children in attendance. The staff person in charge stated that she did not know if the van had been inspected by the Trasnportation Cabinet and indicated that she was not aware of this regulatory requirement.

922 KAR 2:120 · Correction status not published

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

A PLAN OF CORRECTION WAS DUE ON 10 Aug 15 AND AS OF 10 Sep 15, THE PLAN OF CORRECTION HAS NOT BEEN RECEIVED. Transportation

922 KAR 2:090 · Correction status not published

922 KAR 2:120. Section 12. Transportation.

General: Based on Interview, the facility failed to notify the cabinet in writing of the type of vehicle used for transportation. One vehicle (fifteen (15) passenger van) was identified as the vehicle used to transport children by the facility during the relicensure survey conducted on 5/18/15. However, an interview with the staff person in charge during this visit found that one of the vehicles used to transport children during a 7/22/15 field trip to the Lexington Legends baseball game was a fifteen (15) passenger van rented from Saint Paul Church. The staff person in charge explained that the facility occasionally rents this van in addition to using the van owned by the facility due to the number of children in attendance.

922 KAR 2:110. Section 3. Records.

General: Based on Review of Documentation, it was found that the hire dates for two (2) employees were not available in the files. The staff person in charge looked at a calendar during the visit and then identified 3/28/15 and 8/11/14 as the hire dates for the two (2) staff.

922 KAR 2:110 · Correction status not published

922 KAR 2:110. Section 3. Records.

General: Based on Review of Documentation, three (3) staff did not have evidence of a current staff professional development plan on file in the facility.

922 KAR 2:110 · Correction status not published

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

General: Based on Review of Documentation, two (2) staff eligible for an annual performance review did not have documentation of a review on file in the facility. 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

922 KAR 2:110 · Correction status not published

922 KAR 2:120. Section 11. Toys and Furnishings.

General: Based on Observation, this regulatory requirement was not met. The facility's fifteen (15) passenger van used to transport children on a daily basis was not clean. The floor of the van contained numerous food/candy wrappers and pieces of paper.

922 KAR 2:120 · Correction status not published

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

922 KAR 2:110. Section 3. Records.

General: Based on Review of Documentation, it was found that out of all ten (10) children's files reviewed, none had the preferred hospital listed.

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 two (2) files out of five (5) staff files reviewed did not have evidence of an annual evaluation.

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 one (1) staff file out of six (6) staff files reviewed did not have evidence of a personnel file. The staff's date of hire is unknow but he has worked for the facility for a couple of years.

922 KAR 2:110 · Correction status not published

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

General: Based on Review of Documentation, it was found that in a review of five (5) staff files, four (4) of the staff files did not have evidene of the required 15 hours of annual training.

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 four (4) staff files out of five (5) staff files reviewed did not have evidence of a professional development plan.

922 KAR 2:110 · Correction status not published

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

General: Based on Observation, there was not a posted planned program of activities.

922 KAR 2:120 · Correction status not published

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

General: Based on Review of Documentation, there were two (2) staff hired 5/28/13 who did not have a current T.B. skin test or statement from a health professional indicating the individual is free from the symptoms of T.B. on file.

922 KAR 2:110 · Correction status not published

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

General: Based on Review of Documentation, it was found that earthquake and tornado drills are being practiced and documented as one (1) drill instead of being practiced and documented as two (2) separate drills. Posted Documentation

922 KAR 2:120 · Correction status not published

922 KAR 2:110 - Section 4 (1)

General: Based on Interview, the facility failed to provide for the safety and comfort of each child. On 11/13/12 a person identified as a volunteer ran outside after a nine (9) year old child that exited the facility without an adult. The adult male volunteer reported the incident to an administrative staff person and stated that he "took the child by his arms to restrain him from what he was doing" and indicated that the child attempted to "strike at him in the face, but missed". The adult male volunteer also reported that he escorted the child upstairs to the office the child's mother works in. The child obtained finger print bruises and an abrasion under his arms as a result of the incident. Children's Records

922 KAR 2:110 · Correction status not published

922 KAR 2:110 - Section 3

General: Based on Review of Documentation, two (2) children (both enrolled on 3/29/12) did not have an immunization certificate on file and one (1) child (enrollment date: unknown) had an immunization certificate that was no longer current as of 8/30/11.

922 KAR 2:110 · Correction status not published

922 KAR 2:110 - Section 5 (1)

General: Based on Review of Documentation, three (3) staff with hire dates 6/4/12 did not have a current TB test on file. Staff person with hire date 2/1/10 did not have a current TB test on file. 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 128 - CPR/First Aid Coverage 922 KAR 2:110 - Section 5 (3) At least one (1) person on duty and present with the children shall be currently certified by a cabinet-approved training agency in the following skills: (a)Infant and child cardiopulmonary resuscitation; and (b) Infant and child first aid. 1) CPR In Compliance 2) First Aid In Compliance 131 - Adequate Substitute(s) 922 KAR 2:110 - Section 5 (6) Child-care centers shall have available in case of need: (a) One (1) qualified substitute staff person for a Type II child-care center; or (b) Two (2) qualified substitute staff persons for a Type I child-care center 1) Type I In Compliance 131 - Adequate Substitute(s) 922 KAR 2:110 - Section 5 (6) Child-care centers shall have available in case of need: (a) One (1) qualified substitute staff person for a Type II child-care center; or (b) Two (2) qualified substitute staff persons for a Type I child-care center 2) Type II Not Applicable 139 - Training 922 KAR 2:110 - Section 5 (14) A staff person with supervisory authority over a child shall complete the following: (a) Six (6) hours of cabinet-approved orientation within the first three (3) months of employment; (b) Nine (9) hours cabinet-approved child development training within the first year of employment; and (c) Fifteen (15) hours of cabinet-approved training during each subsequent year of employment. 1) Orientation In Compliance 2) 9 hours-first year In Compliance 139 - Training 922 KAR 2:110 - Section 5 (14) A staff person with supervisory authority over a child shall complete the following: (a) Six (6) hours of cabinet-approved orientation within the first three (3) months of employment; (b) Nine (9) hours cabinet-approved child development training within the first year of employment; and (c) Fifteen (15) hours of cabinet-approved training during each subsequent year of employment. 3) 15 hours annually Not In Compliance Findings: General: Based on Review of Documentation, staff persons with hire dates 8/12/09, 9/1/09, 9/1/09, and 2/1/10 did not have the required amount of hours of training. 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 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