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

General: Based on review of documentation, no TB documentation was presented for a staff member (DOH: 07/30/24). An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report

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) A staff member (DOH: 08/17/22) completed only eleven (11) of the fifteen (15) hours of early care and education training during the training year 08/17/23 to 06/30/24. 2) A staff member (DOH: 06/23/21) completed only fourteen and a half (14.50) of the fifteen (15) hours of early care and education training during the training year 07/01/23 to 06/30/24. 3) A staff member (DOH: 08/03/22) did not complete the required PAHT training. This staff member has been employed more than one (1) year. A review of ECE-TRIS verified this information. 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 2:090. Section 11. Staff Requirements.

General: Based on review of documentation, the following was found: 1) A staff (DOH: 08/03/22), did not complete the required pediatric abusive head trauma (PAHT) training. The staff has been employed for more than one (1) year. 2) A staff member (DOH: 08/02/21), did not complete fifteen (15) hours of annual training for the year. 3) A staff (DOH:07/26/22), did not take orientation training within three (3) months of employment. The training was taken on 02/04/23. 4) A staff (DOH: 08/17/22), did not take orientation training within three (3) months of employment. The training was taken on 06/13/23. 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 In Compliance Written Documentation Not In Compliance

922 KAR 2:090 · Correction status not published

922 KAR 2:090. Section 8. General.

General: Based on observation, there were two uncovered electrical outlets in classroom 113/114. 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 9. Records.

General: Based on review of documentation, a staff hired (DOH: 08/03/22), did not have evidence of a recent professional development plan on file at the facility.

922 KAR 2:090 · Correction status not published

922 KAR 2:120. Section 12. Toilet, Diapering, and Toiletry Requirements.

General: Based on observation, the water temperature at the children's handwashing sink in the Blue Room was only 79 degrees. Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Kitchen Requirements Not In Compliance

922 KAR 2:120 · Correction status not published

922 KAR 2:090. Section 9. Records.

General: Based on review of documentation in children’s files, two (2) files did not list a preferred hospital or a preferred physician. Written Documentation Not In Compliance

922 KAR 2:090 · Correction status not published

922 KAR 2:090. Section 8. General.

General: Based on review of documentation, a copy of 922 KAR 2:280 was not presented for review. Posted Documentation In Compliance Animals Not Applicable

922 KAR 2:090 · Correction status not published

922 KAR 2:090. Section 9. Records.

General: Based on review of documentation in children's files, one (1) child had an immunization record that was not current, and one(1) child who was enrolled longer than 30 days did not have an immunization record on file. 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 2:090. Section 13. Reports.

General: Based on observation and interview with staff, an additional room in the building as the Pre-School Room and an additional playground that has not been added to the center's capacity. Director Requirements In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report Employee Records Not In Compliance

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

General: Based on review of documentation, it was found that the facility's Emergency Preparedness Plan was last updated and submitted to the proper authority for review on 09/13/2019. 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 review of documentation, the following was found: 1.) A staff member hired 6/23/21, did not take the Orientation training within three months of employment. The courses were taken 10/03/21. 2.) A staff member hired 6/22/21, did not have evidence of completing 15 hours of annual early care and education training. A review of ECE-TRIS confirmed these findings. Programming In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Premises Not In Compliance

922 KAR 2:090 · Correction status not published

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

General: Based on observation, there was an unlocked closet in the Junior Kindergarten room where surveyor found candy, a broom with dust pan, and staff's personal belongings. Those items were accessible to the children in care.

922 KAR 2:120 · Correction status not published

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

General: Based on observation, there was chipped paint on the walls found in the Preschool room, Junior Kindergarten room and bathroom. Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Kitchen Requirements In Compliance Food Service In Compliance Meal Planning/Center Provides Meals In Compliance Meal Planning/Center Does Not Provide Meals Not In Compliance

922 KAR 2:090. Section 9. Records.

General: Based on review of documentation and interview, this regulatory requirement was not met. A review of the attendance notebook in Room #126 found that 11 children were present; however, none of them had an arrival time documented. A staff person working in the classroom stated that she had not "taken attendance" yet. The staff person further stated that the facility opens at 7:30AM, but the majority of the children arrive around 8:00AM.

922 KAR 2:090 · Correction status not published

922 KAR 2:090. Section 9. Records.

General: Based on review of documentation, one of the children’s files/enrollment documentation did not contain information for the family’s preferred hospital. Written Documentation Not In Compliance

922 KAR 2:090 · Correction status not published

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

General: Based on observation, this regulatory requirement was not met. The surveyor toured the men's bathroom, which was identified as the bathroom used by the boys in Room #118, and observed a container of Clorox wipes sitting on the side of the sink. This item was accessible to the children. Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Food Service/Food Program In Compliance Food Service In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Children's Records Not In Compliance

922 KAR 2:120 · Correction status not published

922 KAR 2:090. Section 9. Records.

General: Based on review of documentation, this regulatory requirement was not met. The surveyor reviewed the emergency drill log from Room #118 during the visit and found that tornado drills and fire drills were practiced on the same day, at the same time in September and October 2020; therefore, they were done together, not separate. Posted Documentation In Compliance Animals Not Applicable Emergency Regulation Not In Compliance

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

General: Based on review of documentation and Training Records Information System (TRIS), the following was found: 1. One staff person (hire date: 6/12/19) did not complete the six hours of cabinet-approved training within the first three months of employment. 2. One staff file (hire date: 8/8/13) contained a pediatric abusive head trauma training class certificate that was dated 11/12/13; therefore, this training is no longer valid. 3. Six (staff did not complete the required 15 hours of training. 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, interview, and observation, this regulatory requirement was not met. During a tour of the facility the following was found: 1. A review of the attendance sheet posted in Room #118 found that a check mark is being used to document the children's attendance. No arrival or departure times are being documented. 2. A tour of Room #126 and a review of the attendance sheet in this classroom found that arrival times had not been documented for the ten children present in the room. The staff person working in the classroom stated that she had not had a chance to do it.

922 KAR 2:090 · Correction status not published

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

General: Based on review of documentation, one staff person (hire date 6/12/19) did not have T.B. documentation on file.

922 KAR 2:090 · Correction status not published

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

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

General: Based on observation, it was found that a red plastic storage bin in the junior kindergarten room had a large crack down the middle of it. This bin was used to store classroom toys and was located next to the blocks. Transportation Not Applicable 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, it was found that one (1) staff person did not have an updated professional development plan on file at the facility. This staff person's date of hire is 08/08/2013. 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 review of documentation, it was found that two (2) staff did not complete fifteen (15) hours of cabient approved training. The hire date for these two (2) staff is 08/08/2013. 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, it was found that one (1) staff file did not contain proof of education. This staff person's date of hire is 09/18/2018.

922 KAR 2:090 · Correction status not published

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

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

General: Based on Review of Documentation, it was found that two (2) staff files out of seven (7) reviewed did not have proof of a TB screen being completed. The date of hire for those employees are 8-1-11 and 8-1-13. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report

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 two (2) employee with the hire date of 8-15-16 did not complete orientation training within the 90 day regulated time frame. The completion date of orientation for these employees were found to be 4-1-17 and 1-9-17 which was confirmed by the ECE TRIS system. It was also found that four (4) employees did not have the 15 hours of training required for the previous twelve (12) months. These employees date of hire and training hours are as follows; DOH 8-15-16 has twelve (12) hours of training, DOH 8-15-16 has ten (10) hours of training, DOH 8-15-16 has eight (8) hours of training, DOH 8-1-13 has four (4) hours of training. There were three (3) employees with a hire date of 8-15-16 who showed no documentation that they have obtianed Pedatric Abusive Head Trauma Training which is required within the first 12 months of their hire date. 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

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 four (4) staff files out of seven (7) reveiwed did not have the criminal records check completed prior to their date of hire. The date of hire and date of the criminal records check are as follows; (1) DOH 8/15/16; Criminal Records Check showed date of 9-22-16, (2) DOH 8-15-16; Criminal Records Check showed date of 9-22-16, (3) DOH 8/15/17; Criminal Records Check showed date of 9-17-17, (4) DOH 8/15/16; Criminal Records Check showed date of 9-22-16. There was no documentation to indicate the request for the background check was completed prior to the date of hire.

922 KAR 2:110. Section 3. Records.

General: Based on Review of Documentation, it was found through a review of files for a child enrolled on 07/12/2016 that there was no evidence of pick-up authorization. Written Documentation In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 4 Inspection Report Posted Documentation 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 there was no evidence of liability insurance. Director Requirements Not In Compliance

922 KAR 2:090 · Correction status not published

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

General: Based on Review of Documentation, it was found through a review of six (6) staff files that four (4) staff files did not have evidence of a child abuse and neglect check. The dates of hire for all four (4) staff were 08/01/2016. It was also found that three (3) staff files out of six (6) staff files reviewed did not have evidence of a criminal records check. The dates of hire for all three (3) staff were 08/01/2016. One (1) staff person was observed to be working alone with twelve (12) four to five (4-5) year-olds that did not have evidence of a child abuse and neglect check or criminal records 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 and 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.

922 KAR 2:090 · Correction status not published

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

General: Based on Observation, there was no schedule of daily activities posted in the preschool room.

922 KAR 2:110 · Correction status not published

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

General: Based on Review of Documentation and interview with the staff person in charge, there were two (2) employees that did not have copies of their CAN check in their file. One of those employees was working in the classroom but was with another teacher and has never worked alone according to the staff person in charge. The second employee was a new hire and had not worked in the classroom as of the date of this survey. Additionally, one of those employees was also missing proof of a completed criminal records check. The staff person in charge was unable to locate it in their file.

922 KAR 2:090 · Correction status not published

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

General: Based on Observation, there were two (2) outlets in the preschool room that were missing the protective covers.

922 KAR 2:110 · Correction status not published

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

General: Based on Review of Documentation, there was no proof of education on record for an employee with a hire date of 8/13/15.

922 KAR 2:110 · Correction status not published

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

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

General: Based on Review of Documentation, the facility has three (3) specialist teachers (art, music, and gym) that work with the children approximately 20-30 minutes a week. These specialist teachers did not have a CAN check on file and only one (1) of the teachers had a criminal records check that was conducted by the facility. The other two (2) staff had criminal records check from Fayette County Public Schools and Jessamine County Public Schools. Based on interview the specialist teachers do not work alone with the children.

922 KAR 2:090 · Correction status not published

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

General: Based on Observation, the surveyor found a container of Clorox wipes inside of a plastic container located on a low shelf accessible to the children in care. The staff person in charge stated that the classroom is shared space with the church and the staff did not realize the container of Clorox wipes was on the shelf.

922 KAR 2:120 · Correction status not published

922 KAR 2:110. Section 3. Records.

General: Based on Review of Documentation, the surveyor found four (4) immunization records that were no longer valid as follows: enrollment date: 8/8/13- immunization date 8/15/13, enrollment date: 8/14/13- immunization date 9/30/13, enrollment date: 8/12/13- immunization date 7/15/13, enrollment date: 8/13/13- immunization date 2/28/13. One (1) child's file (enrollment date: 8/14/13) did not have a date listed on the immunization form. 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 · Correction status not published

922 KAR 2:110. Section 3. Records.

General: Based on Review of Documentation, the surveyor reviewed ten (10) children's files and found that the preferred hospital was not listed.

922 KAR 2:110 · Correction status not published

922 KAR 2:110. Section 3. Records.

General: Based on Review of Documentation and interview, the surveyor found that there were no fire drills conducted or documented for August and September. The staff person in charge indicated that the fire drills are done with the whole school; however, she stated that the preschool will start practicing their own drills.