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Home › KY › Lexington › The Dolphin Club After School Program
License #L383124 · Center · Licensed
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General: Based on review of documentation, three (3) staff (DOH: 08/05/19, 08/14/23, and 09/13/23) did not evidence of an evaluation at the time of inspection.
General: Based on review of documentation, the following was found: 1) A staff (DOH: 09/13/23) did not have up to date documentation of a negative TB results or a statement from a health care professional stating that the staff is free from active tuberculosis on file at the facility. The document on file expired on 08/24/23.
General: Based on review of documentation, ten (10) children files presented for inspection, did not have a preferred hospital contact number listed.
General: Based on review of documentation, a staff (DOH: 08/25/25) did not have documentation of education on file at the facility at the time of inspection.
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Generated from this facility's specific inspection record
Data synced from Kentucky Cabinet for Health and Family Services, Division of Child Care on Jul 11, 2026 · Source records · Report an error
General: Based on review of documentation, a staff (DOH: 09/13/24) did not have evidence of completing the required CPR/First Aid training on file at the facility.
General: Based on review of documentation, the following was found during inspection: 1) A staff (DOH: 11/13/22) did not complete the required pediatric abusive head trauma training and has been employed for more than one year. 2) A staff (DOH: 11/13/22) only completed nine (9) of their fifteen (15) hours of annual training for the year dated 07/01/24 to 06/30/25. 3) A staff (DOH: 08/14/23) only completed fourteen (14) of their fifteen (15) hours of annual training for the year dated 07/01/24 to 06/30/25. 4) A staff (DOH: 09/13/23) only completed fourteen (14) of their fifteen (15) hours of annual training for the year dated 07/01/24 to 06/30/25. 5) A staff (DOH: 10/23/23) only completed one (1) of their fifteen (15) hours of annual training for the year dated 07/01/24 to 06/30/25. A review of ECE-TRIS supports these findings. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 11 of 32 Inspection Report
General: Based on observation, the children did not wash their hands before eating snack.
General: Based on review of documentation, there was no evidence presented at the time of survey of fire, earthquake, tornado, shelter-in-place, or lockdown drills being conducted at the facility.
General: Based on review of documentation, two (2) staff members (DOH: 08/05/19 and 08/10/16) did not have a professional development plan in their personnel file.
General: Based on review of documentation, one (1) child’s file reviewed did not contain a physician contact number. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3 Inspection Report Written Documentation Not In Compliance
General: Based on review of documentation, two (2) staff members (DOH: 11/21/22 and 09/13/23) did not have evidence of being trained in CPR and First Aid. A review of ECE-TRIS supports this finding. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report
General: Based on review of documentation, this regulatory requirement was not met. The following was found: 1.) Staff member (DOH: 08/24/22) completed zero (0) out of fifteen (15) hours of cabinet-approved early care and education training for the 08/24/23 to 06/30/24 training year. 2.) Staff member (DOH: 11/21/22) completed zero (0) out of fifteen (15) hours of cabinet-approved early care and education training for the 11/21/23 to 06/30/24 training year. 3.) Staff member (DOH: 09/13/23) did not have evidence of completing pediatric abusive head trauma training record on ECE-TRIS. 4.) Staff member (DOH: 09/13/23) did not have proof of completing cabinet-approved orientation training. 5.) Staff member (DOH: 11/21/22) did not have evidence of completing pediatric abusive head trauma training. 6.) Staff member (DOH: 09/20/23) only completed nine (9) out of fifteen (15) hours of cabinet-approved early care and education training for the 09/20/23 to 09/19/24 training year. 7.) Staff member (DOH: 10/23/23) did not have evidence of completing cabinet-approved orientation training. 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 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, the following was found: 1.) A staff member (DOH: 09/28/2018), did not complete the required Pediatric Abuse Head Trauma (PAHT) training. This staff member has been employed for more than one year. 2.) Two staff members (DOH: 09/28/2018 and 08/24/2022), did not have evidence of completing 15 hours of annual early care and education training on file. 3.) A staff member (DOH: 08/24/2022), did not take orientation within three months of employment. The course was taken 2/3/2023. The ECE-TRIS system 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 Not In Compliance
General: Based on review of documentation, the following was found: 1.) A staff member (DOH: 08/16/2023), did not have a current TB test or statement from a health professional on file. 2.) A staff member (DOH: 08/14/2023), did not obtain a TB test or statement from a health professional until 9/27/2023.
General: Based on review of documentation, two children enrolled 05/12/2023, and 08/16/2023, did not have current immunization certificates on file at the facility.
General: Based on review of documentation, four staff members (DOH: 08/10/2016, 08/05/2019, 08/04/2022, and 09/28/2018), did not have evidence of a professional development plan on file at the facility. Posted Documentation In Compliance Animals Not Applicable
General: Based on file review, and the Kentucky National Background Check Service (KARES), a staff member hired on 12/18/2022, has not been fingerprinted. The staff member has a provisional employment status and listed as “in process". Based on observation, the staff member was not working alone with children during the renewal inspection. Supervision In Compliance Staffing Requirements In Compliance General Administration In Compliance Director Requirements Not In Compliance
General: Based on file review and ECE-TRIS, the surveyor found the following: 1) Staff members hired on 9/28/2018, 1/09/2020, 8/10/2021, 3/4/2022, and 8/4/2022, have not completed the cabinet-approved orientation training. 2) Staff members hired on 9/28/2018, 1/9/2020, 8/10/2021, did not complete the Pediatric Abusive Head Trauma (PAHT) training that is required to be completed within one year of hire. 3) Staff members hired on 8/10/2016, 9/28/2018, 8/5/2019, and 1/9/2020, did not complete 15 hours of cabinet-approved early care and education training during the July 1, 2021- June 30, 2022 training year. 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 2 of 3 Inspection Report Equipment Not In Compliance
General: Based on review of documentation, staff members did not have a written, annual plan for professional development. Posted Documentation In Compliance Animals Not Applicable
General: Based on review of documentation, there were not written, annual professional development plans for child care staff available for review. Posted Documentation Not In Compliance
General: Based on observation, the surveyor noted the children were served only Chex Mix during snack. The children were not served a second food component. The surveyor also noted that some children had their own water bottles, but some children did not. The children, who did not have a water bottle, did not have anything to drink while they ate snack. A review of the “licensing procedure booklet” found that a snack and bottled water is to be provided to the children each day at the beginning of the program.
General: Based on review of documentation and ECE-TRIS, four staff members hired on 8/10/16, 8/15/18, 8/5/19, 8/10/19, did not complete fifteen hours of early care and education training. In addition, one staff member hired on 8/10/19, did not complete Orientation within three months of employment or complete the PAHT training within the first year of employment. Programming In Compliance Premises In Compliance Hygienic Practices Not In Compliance
General: Based on review of documentation, there was no documentation of recurring staff meetings available for review.
General: Based on observation and review of documentation, the following was found: 1. Four out of five staff employed for more than one year did not have evidence of completing 15 hours of annual early care and education training on file in the facility. 2. Staff persons hired 9/17/16 and 8/15/18, did not have documentation of completing the pediatric abusive head trauma training within the past five years. 3. Staff person hired 8/15/18, did not have evidence of completing the required orientation training in the first three months 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 An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3 Inspection Report Transportation Not Applicable Food Service/Food Program In Compliance Food Service Not In Compliance
General: Based on review of documentation, four out of four staff eligible for an annual evaluation did not have evidence of an evaluation on file in the facility. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report
General: Based on review of documentation, staff persons hired 8/6/17, 8/3/19, 7/1/19 and 8/14/19 did not have documentation of negative T.B. results on file in the facility that had been obtained within the past two years.
General: Based on Review of Documentation, it was found that the fire drill documentation did not contain evidence of a drill being conducted from September of 2017 to August of 2018. In addition, it was found that the earthquake and tornado drill documentation did not contain evidence of drills being conducted during the fourth quarter of 2017, the first quarter of 2018, the second quarter of 2018 or the third quarter of 2018. Posted Documentation Not In Compliance
General: Based on Observation, it was found that three (3) first aid kits were being stored on a table in the cafeteria. The first aid kits were accessible to the children. Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Food Service/Food Program In Compliance Food Service In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 4 Inspection Report Children's Records Not In Compliance
General: Based on Review of Documentation, it was found that the files for two (2) employees did not contain evidence of an annual evaluation being completed. Employee Records Not In Compliance
General: Based on Review of Documentation, it was found that the files for four (4) employees did not contain evidence of a high school diploma, GED or Commonwealth Childcare Credential. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 4 Inspection Report
General: Based on Observation, it was determined that two (2) staff persons hired 08/15/2017 did not have evidence of proof of education on file in the facility. Programming In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report 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 Not In Compliance
General: Based on Review of Documentation, staff person hired 08/15/2017 had the request of a CAN check dated 09/01/2017. There was no evidence on file that the application for the check had been submitted within the first five (5) days of employment as required.
General: Based on Review of Documentation, child enrolled on 08/16/2017 did not have a current immunization certificate on file in the facility.
General: Based on Review of Documentation, Four (4) children enrolled 08/19/2017 did not have a physician’s name and/or contact information on file in the facility. Three (3) out of the ten (10) children's files presented for review did not have documentation of a preferred hospital listed by the parent. All children were enrolled on 08/16/2017. Written Documentation In Compliance Posted Documentation In Compliance Animals Not Applicable
General: Based on Review of Documentation, 1. Staff persons hired 8/12/13 and 8/12/15 did not have evidence of completing the required orientation training in the first three (3) months of employment. A review of ECE-TRIS records supports the information found during the survey. 2. Three (3) staff did not have evidence of fifteen (15) hours 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. 3. Six (6) staff did not have evidence of completing the Pediatric Abusive Head Trauma training within the first year of employment. A review of ECE-TRIS records supports the information found during the survey. Programming In Compliance Premises 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 In Compliance Posted Documentation In Compliance Animals Not Applicable
General: Based on Review of Documentation, staff persons hired 8/12/13, 8/22/16 and 8/2/14 did not have documentation of negative T.B. results on file in the facility that had been obtained within the past two (2) years.
General: Based on Review of Documentation, three (3) out of thirteen (13) staff files presented for review did not have evidence of proof of education. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report
General: Based on Review of Documentation, it was found that the files for employees hired on 7-6-13 and 7-31-13 contained the results of negative TB skin tests that were read on 7-11-13 and 8-7-13. These dates are not within the two (2) year timeframe required by the regulation. The files for employees hired on 7-22-13 and 8-12-15 did not contain evidence of a TB skin test or screening being conducted.
General: Based on Review of Documentation, it was found that two (2) out of ten (10) childrens' files reviewed did not contain information regarding the parents' preferred hospital. 1080 - Documentation for Off Premise Trip Not Applicable An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 23 of 26 Web site: http://chfs.ky.gov/ Inspection Report 922 KAR 2:110. Section 3. Records. (1) A child-care center shall maintain: (b) A written record for each child: 3. To contain: g. A permission form for each trip off the premises signed by the child’s parent in accordance with 922 KAR 2:120, Section 12; Written Documentation
General: Based on Review of Documentation, it was found that the file for one (1) employee did not contain evidence that an annual performance evaluation had been condcuted.
General: Based on Review of Documentation, it was found that the files for five (5) eligible employees did not contain evidence of Pediatric Abusive Head Training being conducted. The files for five (5) employees also contained evidence of zero (0) hours of annual training being completed. The file for an employee hired on 2-8-15 did not contain evidence of the six (6) hour cabinet-approved orientation training being completed. 345 - Driver Requirements Not Applicable 922 KAR 2:120. Section 12. Transportation. (18) A driver of a vehicle transporting a child for a center shall: (a) Be at least twenty-one (21) years old; (b) Complete: 1. The background checks as described in 922 KAR 2:110; and 2. An annual check of the: a. Kentucky driver history records in accordance with KRS 186.018; or b. Driver history records through the state transportation agency that issued the driver’s license; (c) Hold a current driver’s license which has not been suspended or revoked during the last five (5) years; and (d) Not caused an accident which resulted in the death of a person. Programming
General: Based on Review of Documentation, there were no professional development plans on file.
General: Based on Review of Documentation, there were no staff evaluations on file.
General: Based on Review of Documentation, there was no documentation of a family involvement activity on file. Employee Records
General: Based on Review of Documentation, there were two (2) staff who did not have child abuse and neglect checks on file. The hire dates for these staff were 8/19/14 and 8/12/14. They were not working alone with children.
General: Based on Review of Documentation, there were four (4) staff who did not have documentation of being free of TB on file. Hire dates were 8/13/14 (two (2) staff), 7/22/13, and 7/31/13.
This follow-up inspection recorded no violations or advisories.
General: Based on Observation, upon arrival into the computer lab one (1) staff member was observed supervising twenty-one (21) children ranging in age from five (5) to six (6) years-old alone. The regulations indicate that one (1) staff can supervise fifteen (15) children if the youngest child is five (5) years-old. The site supervisor stated that he pulled the second staff member from that classroom to watch the front desk so he would be able to tour the facility.
General: Based on Review of Documentation, it was found that the after-school program has five (5) children that receive Child Care Assistance and the facility did not have a copy of the specific attendance sheet required by the program to sign the children in and out. The staff in charge was not aware of the Child Care Assistance attendance sheet.
General: Based on Review of Documentation, it was found that two (2) staff files did not have written evidence of completing a criminal records check. These two (2) staff were hired on 8/14/13 and 9/24/13. Neither of these staff were observed working alone with the children. In addition, two (2) other staff members had lived outside the state of Kentucky in the last five (5) years and did not have an out of state criminal records check conducted. One (1) staff that was hired on 8/2/13 had lived in Ohio previously and another staff hired on 9/1/13 had lived in Wisconsin within the last five years.
General: Based on Interview, it was found that the staff in charge allows the children to get water from the water fountain located in the cafeteria for snack, but he is not providing a cup for the children to get the water with. The staff in charge indicated that he was providing water bottles, but recently has changed to just allowing the children to get a drink from the fountain for snack. Meals shall be served to a child and the child shall be supplied with individual eating utensils designed for use by a child.
This initial application inspection recorded no violations or advisories.
General: Based on review of documentation, an orientation procedure stating that staff would implement what was learned in the classroom setting was not available for review.
General: Based on review of documentation, the following was found: 1.) Earthquake, fire, tornado, and lockdown drills were documented as occurring at one time. These drills require separate actions and should be documented individually. 2.) The earthquake, tornado, fire, and lockdown drills reviewed did not include a roster of children who had participated. Posted Documentation Not In Compliance
General: Based on observation and review of documentation, the following was found: 1.) The statement of deficiency and corresponding plan of correction from the 2023 licensure year was not posted for public inspection. 2.) The staff-to-child ratios were not posted for public inspection.
General: Based on observation, the emergency plan posted did not include written instructions directing building occupants on the proper actions to take in the event of an emergency. Animals Not Applicable
General: Based on review of documentation, a staff member (DOH: 03/16/2023), did not have a completed background check, sex offender registry check, and child abuse and neglect check from the state of Illinois. Supervision In Compliance Staffing Requirements In Compliance General Administration Not In Compliance
General: Based on review of documentation, there was no documentation made available at the time of the survey regarding a current Fire Marshal inspection. Director Requirements Not In Compliance
General: Based on review of documentation, three staff members (DOH: 08/05/2019, 08/04/2022, and 09/28/2018), did not have evidence of an annual evaluation on file at the facility. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 4 Inspection Report Employee Records Not In Compliance
General: Based on review of documentation, a staff member (DOH: 11/21/2022), did not have evidence of completing CPR/First Aid training on file at the facility. The ECE-TRIS system was reviewed and confirmed this finding.
General: Based on observation and interview, children's personal belongings were scattered on the cafeteria tables and floor. The staff in charge stated that they used to have laundry baskets and they were in disrepair. 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 An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 4 Inspection Report Children's Records Not In Compliance
General: Based on review of documentation, two children enrolled on 08/01/2023, and 08/16/2023, did not have physician contact information and a preferred hospital listed in their files at the facility. Written Documentation Not In Compliance
General: Based on review of documentation, staff hired on 9/28/2018, 8/5/2019, 1/9/2020, and 8/10/2021, did not have an evaluation on file. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report Employee Records Not In Compliance
General: Based on review of documentation, a staff member hired on 1/9/2020, did not have proof of education available for review. It should be noted, the staff member’s personnel file was not reviewed during the 2021 renewal inspection.
General: Based on review of documentation, staff hired on 9/28/2018, 3/4/2022, and 11/21/2022, did not have TB documentation available for review.
General: Based on file review and ECE-TRIS, staff members hired on 8/5/2019, 8/10/2020, 8/10/2021, 8/24/2022, have not completed first aid and cardiopulmonary resuscitation (CPR) training.
General: Based on observation and interview, the surveyor found the children do not have a storage device to store their personal belongings. The surveyor noted that the children’s belongings were scattered on the floor and cafeteria tables. The staff person in charge stated that he used to provide laundry baskets for the children's belongings, but the laundry baskets are in disrepair. 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 Not In Compliance
General: Based on interview and review of documentation, three staff members did not have an annual evaluation completed and on file. Employee Records Not In Compliance
General: Based on review of documentation, four staff members hired on 8/5/19, 8/10/19, and (two) 8/11/21, did not have proof of education available for review. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report
General: Based on review of documentation, three staff members hired on 8/10/16, 8/15/18, and 8/10/19, had TB documentation on file that was no longer valid. A staff member hired on 8/11/21, did not have TB documentation available for review.
General: Based on observation, the chidren did not wash their hands prior to eating snack. First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Kitchen Requirements In Compliance Food Service In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3 Inspection Report Meal Planning/Center Provides Meals Not In Compliance
General: Based on observation and interview, there was not a snack menu posted or available for review. Meal Planning/Center Does Not Provide Meals In Compliance Children's Records In Compliance Written Documentation Not In Compliance
General: Based on observation and interview, there was not a daily planned program (lesson plan) posted. Animals Not Applicable
General: Based on observation and review of documentation, two employees hired 7/1/19 and 8/14/19, and one employee with no date of employment on file, 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, there were three staff that were no longer employed by the facility listed on the facility's KARES report as currently employed at the facility. Supervision In Compliance Staffing Requirements In Compliance General Administration In Compliance Director Requirements Not In Compliance
General: Based on review of documentation, the attendance records being used by the facility were not in accordance with 922 KAR 2:160, Section 13. The person in charge indicated that there are children enrolled in the program that receive Child Care Assistance funds.
General: Based on review of documentation, there was not a copy of the current regulations on file in the facility at the time of the survey. The copy on file was from 2014.
General: Based on review of documentation, there was no evidence of any parent involvement activities on file in the facility. Employee Records Not In Compliance
General: Based on review of documentation, two of the personnel files presented for review did not include a date of employment.
General: Based on observation, there was no snack menu posted in the facility at the time of the survey. Children's Records In Compliance Written Documentation Not In Compliance
General: Based on review of documentation, there was no written schedule of staff hours on file at the time of the survey.
General: Based on review of documentation, the recorded drills did not include the times of the drills or the names of the children that participated in the drills.
General: Based on review of documentation, there was no evidence of an orientation procedure for staff on file in the facility. Posted Documentation In Compliance Animals Not Applicable
General: Based on Review of Documentation, it was found that the files for employees hired on 8-15-18, 9-20-18 and 8-15-18 did not contain evidence of a TB skin test or screening being completed.
General: Based on Review of Documentation, it was found that 1) employees hired on 8-16-17, 8-15-17, 9-17-16, 8-10-16 and 8-10-15 did not have evidence of the Pediatric Abusive Head trauma training being completed; 2) employees hired on 8-16-17 and 8-15-17 had only seven (7) and zero (0) hours of training completed during the first year of employment; 3) employees hired on 9-17-16 , 8-10-16 and 8-10-15 had only eight (8), six (6) and eleven (11) hours of training completed during the last completed training year. These findings are based on a review of the employees' files and ECE-TRIS records. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication Not In Compliance
General: Based on Review of Documentation, it was found that three (3) children's files out of ten children's files reviewed did not contain a physician's name and/or telephone number. Written Documentation Not In Compliance
General: Based on Interview and record review, it was found that the facility did not have evidence of their emergency preparedness plan being created and updated according to KRS199.8982.
General: Based on Review of Documentation, it was found that the facility did not have written job descriptions available for review.
General: Based on Review of Documentation, it was found that the fire, earthquake and tornado drill documentation did not include a list of the children who participated. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 4 Inspection Report
General: Based on Observation, it was found that the statement of deficiencies issued and the plan of correction submitted for the 2017 relicensure survey was not posted. The posted document was from 2015. Animals Not Applicable
General: Based on Review of Documentation, 1. Staff person hired 8/12/13 did not have the results of or evidence of the application for a criminal background check on file in the facility. 2. Staff person hired 9/15/15 did not have the results of or evidence of the application for a CA/N check on file in the facility. 3. Staff person hired 8/2/14 did not have the results of or evidence of the application for a CA/N check on file in the facility.
General: Based on Review of Documentation, it was found that the facility was not documenting the time a child actually came into the care of the licensed program. One generic entry time was being recorded for each child.
General: Based on Review of Documentation, it was found that the files for six (6) eligible employees did not contain evidence of a professional development plan being completed.
General: Based on Observation, it was found that the statement of deficiencies issued and the plan of correction submitted for the 2014 relicensure survey were not posted.
General: Based on Review of Documentation, none of the staff who had been employed for a year or longer had completed the required fifteen (15) hours of annual child development training, Also, there were three (3) staff who had not completed the required orientation training. The hire dates for these staff were 7/22/13, 7/31/13, and 8/14/13. 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
General: Based on Observation, it was found that during the tour of the facility only one (1) staff was present in the cafeteria with twenty-six (26) children ranging in age from seven (7) to eight (8) years-old. The staff in charge indicated that the other staff went to get something. The maximum number of children one (1) staff can supervise with the youngest child being seven (7) years-old is twenty-five (25) children.
General: Based on Review of Documentation, it was found that the after-school program did not have written evidence of conducting monthly fire drills that detailed the date, time, and children who participated in the drills.
General: Based on Review of Documentation, it was found that the facility did not have a copy of the regulations on site.
General: Based on Review of Documentation, it was found that three (3) staff did not have a copy of the Child Abuse and Neglect Check on file. The hire dates for these staff were 7/6/13, 8/2/13, and 8/2/13.
General: Based on Review of Documentation, it was found that four (4) staff did not have written proof of education on file. These four (4) staff were hired on 7/6/13, 9/1/13, 8/14/13, and 9/24/13.
General: Based on Review of Documentation, it was found that two (2) staff did not have written evidence of a negative TB skin test or a statement from a health professional that the individual is free of active TB prior to employment. These staff were hired on 8/14/13 and 9/24/13. Another staff had a TB skin test on file that was no longer current. This TB test was dated 9/16/05 and this staff member was hired on 8/2/13. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 7 of 26 Web site: http://chfs.ky.gov/ Inspection Report
General: Based on Review of Documentation, it was found that the facility did not have a staff present with current first aid and CPR on 11/4/13 from 2:35 PM-6:00 PM, 11/5/13 from 2:35 PM-4:00 PM, 11/6/13 from 5:30-6:00 PM, 11/7/13 from 5:30-6:00 PM, and 11/8/13 from 5:30 PM-6:00 PM. On Mondays on a regular basis the facility does not have a staff present with current CPR and first aid training from 2:35 PM until 4:00 PM and on Tuesdays the facility does not have a staff present with current CPR and first aid from 2:35 PM until 4:00 PM.
General: Based on Review of Documentation, it was found that eight (8) staff did not have written evidence of completing the six (6) hours of cabinet-approved orientation training within the first three (3) months of employment. These staff were hired on 7/31/13, 8/2/13, 8/2/13, 7/6/13, 7/30/13, 8/2/13, 8/2/13, and 8/2/13. 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 the background checks as described in 922 KAR 2:110; (c) Hold a current driver’s license which has not been suspended or revoked during the last five (5) years; and (d) Not caused an accident which resulted in the death of a person. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 8 of 26 Web site: http://chfs.ky.gov/ Inspection Report Programming
General: Based on Observation, it was found that the after-school program did not have a posted daily planned program of activities.
General: Based on Review of Documentation, it was found that the weekly snack menu that was posted was outdated. The posted snack menu was dated 8/19/13 through 8/22/13. 1055 - Breakfast Requirements Not Applicable An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 23 of 26 Web site: http://chfs.ky.gov/ Inspection Report 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 Review of Documentation, it was found on the posted snack menu that on some of the days the snacks did not meet the requirements. On 8/20/13 the snack menu listed nature valley snacks and bottled water. On 8/21/13 the menu listed smart chips and bottled water, and on 8/22/13 only bottled water was listed. A snack shall include two (2) of the following: milk, protein, bread, or fruit, or vegetable, or 100 percent juice. Bottled water does not count as a component. 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