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Home › KY › Lexington › Wellington Elementary Compass Zone Afterschool Program
License #L383520 · Center · Licensed
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This investigation inspection recorded no violations or advisories.
General: Based on review of documentation, two (2) staff (DOH: 08/01/25 and 01/31/25) did not have documentation of education on file at the facility at the time of inspection. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 10 of 33 Inspection Report
General: Based on review of documentation, there was no evidence presented at the time of survey of earthquake, tornado or lockdown drills being conducted for the second quarter (April-June) of 2025 and fourth quarter (October-December) of 2024 on file at the facility.
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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, the following was found during inspection: 1) A staff (DOH: 08/01/25) had TB results on file at the facility; however, the results were dated 08/07/25, which is after the staff was hired. 2) A staff (DOH: 10/02/21) did not have up to date documentation of 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 09/27/25. 3) A staff (DOH: 06/27/25) had TB results on file at the facility; however, the results were dated 07/30/25, which is after the staff was hired. 4) A staff (DOH: 09/07/23) was due to have their TB skin test renewed by 09/02/25, but did not have a renewed test until 10/08/25. 5) A staff (DOH: 09/01/23) 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 09/28/25. 6) A staff (DOH: 08/01/25) had TB results on file at the facility; however, the results were dated 08/12/25, which is after the staff was hired.
General: Based on review of documentation, the following was found during inspection: 1) A staff (DOH: 10/01/21) completed pediatric abusive head trauma training on 01/10/20; however, did not renew training due on 01/10/25. 2) A staff (DOH: 08/31/24) completed six and a half (6.50) of the fifteen (15) hours of cabinet-annual training for the year dated 07/01/24 to 06/30/25. A review of ECE-TRIS confirmed this finding.
General: Based on review of documentation, ten (10) children's files presented for inspection, did not have a preferred hospital contact number listed.
This investigation inspection recorded no violations or advisories.
General: Based on observation and review of documentation, a staff member (DOH: 09/09/24) did not have written evidence of completing an out-of-state background check from Illinois. The KARES Employment Authorization Form indicated that the staff member previously lived in IL from 2016 to 2020, within the last five (5) years. The facility shall conduct a criminal records check, CAN check, and a sex offender registry check from Illinois. This staff member was not working alone during the renewal survey. Supervision In Compliance Staffing Requirements In Compliance General Administration In Compliance Director Requirements In Compliance Employee Records In Compliance 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 An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3 Inspection Report 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 review of documentation, a staff member (DOH: 10/15/18) did not have a current annual professional development plan on file. Posted Documentation In Compliance Animals In Compliance
This investigation inspection recorded no violations or advisories.
General: Based on review of documentation, this regulatory requirement was not met. The following was found: 1. A staff member hired on 8/05/2021, had a TB skin test on file that was no longer current. The TB skin test was dated 08/02/21, and is valid for two years. 2. A staff member hired on 8/16/2023, had a TB skin test on file that was no longer current. The TB skin test was dated 03/29/21, and is valid for two years. Programming In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3 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 Kitchen Requirements Not In Compliance
General: Based on review of documentation, this regulatory requirement was not met. A substitute staff member with a hire date of 08/05/16, did not have evidence or results of an out-of-state background check from Ohio. This staff member previously lived in Ohio within the last five years; therefore, would need a child abuse and neglect check and a sex offender registry check from Ohio. This staff member was not working alone with the children during the renewal survey. Supervision In Compliance Staffing Requirements In Compliance General Administration In Compliance Director Requirements In Compliance Employee Records Not In Compliance
General: Based on observation, this regulatory requirement was not met. The refrigerator located on the stage area, that is used to store the snacks, did not contain a thermometer; therefore, the temperature of the refrigerator could not be determined. 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 Not In Compliance
General: Based on review of documentation, the following was found: 1.) One staff member hired on 09/07/2021, did not complete the required 15 hours of annual training for the year. 2.) One staff member hired on 09/12/2022, did not complete orientation training within the first three months of employment. The training was taken on 01/05/2023. A review of ECE-TRIS was completed and confirmed these findings. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Kitchen Requirements In Compliance Food Service In Compliance Meal Planning/Center Provides Meals In Compliance Meal Planning/Center Does Not Provide Meals In Compliance Children's Records In Compliance Written Documentation In Compliance Posted Documentation In Compliance Animals In Compliance
General: Based on review of documentation, one staff member hired on 10/18/2022, has yet to complete the required CPR/First Aid training. A review of ECE-TRIS was completed and confirmed this finding.
General: Based on review of documentation, staff members hired 9/23/2019, 8/12/2018, and 8/14/19, did not have evidence CPR/ First aid training in their personnel file.
General: Based on review of documentation, staff member hired 9/23/2019 had evidence of living in Ohio within the past five years. This individual did not have a Child Abuse and Neglect check nor a Sex offender registry check for the state of Ohio in their personnel file. This staff member was paired with a qualified staff member during the inspection. Supervision In Compliance Staffing Requirements In Compliance General Administration Not In Compliance
General: Based on review of documentation, the Fire Marshal documentation was dated 3/18/2019, there was no evidence that an inspection had been requested for this location to ensure on-going compliance. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report Director Requirements Not In Compliance
General: Based on review of documentation, staff members hired 1/10/2018, 9/23/19, 8/25/2019, 8/14/19 did not have evidence of an evaluation in their personnel files. Employee Records Not In Compliance
General: Based on observation, the First Aid kit did not contain tape or a pair of scissors as required. Outdoor Play Area In Compliance Equipment In Compliance Transportation In Compliance Food Service/Food Program In Compliance Food Service In Compliance Children's Records In Compliance Written Documentation In Compliance Posted Documentation In Compliance Animals In Compliance Emergency Regulation In Compliance
General: Based on review of documentation, one staff member with a hire date of 3/8/21, did not have proof of a background check in their file. Director did not have access to results of the background check and had to request the records from the school itself before showing proof that the staff member was eligible for employment. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report First Aid/Medication Not In Compliance
This investigation inspection recorded no violations or advisories.
General: Based on review of documentation and ECE-TRIS, a staff person hired on 09/09/18, failed to complete the six-hour orientation training within 90-days as required by the regulations. The staff person completed the six-hour orientation training on 1/30/19. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Food Service/Food Program In Compliance Food Service In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Children's Records Not In Compliance
General: Based on review of documentation, this regulatory requirement was not met. A review of children's enrollment information found one child enrolled 5/2/19, who had information that referenced a local clinic as the choice of preferred hospital. A clinic does not meet the requirement of a preferred hospital. Written Documentation Not In Compliance
General: Based on review of documentation, this regulatory requirement was not met. A review of the facility's submitted evacuation plan found the date of submission to the proper agency for approval for 2019 was 3/13/19. The regulation requires that the submission for approval of the emergency evacuation plan be submitted by 12/31 of the year prior for the upcoming year. Posted Documentation In Compliance Animals Not Applicable
This investigation inspection recorded no violations or advisories.
This investigation inspection recorded no violations or advisories.
General: Based on review of documentation, it was found that the files for six (6) employees did not contain evidence of a high school diploma, GED or Commonwealth Childcare Credential.
General: Based on review of documentation, it was found that one (1) child's file out of ten (10) children's files reviewed did not contain a physician's telephone number. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 4 Inspection Report Written Documentation Not In Compliance
General: Based on interview, it was found that the facility did not have a current copy of the regulations available and the staff were not provided with a current copy.
General: Based on review of documentation, it was found that: 1) An employee hired on 4-28-16 had zero (0) hours of training completed during the last completed training year; 2) An employee hired on 6-27-16 had zero (0) hours of training completed during the last completed training year; 3) An employee hired on 8-10-16 had evidence of only twelve and a half (12.5) hours of training being completed during the last completed training year; 4) An employee hired on 8-10-16 had evidence of only nine (9) hours of training being completed during the last completed training year; 5) An employee hired on 8-10-16 had evidence of fourteen (14) hours of training being completed during the last completed training year; 6) An employee hired on 8-10-16 had evidence of only ten and a half (10.5) hours of training being completed during the last completed training year; 7) An employee hired on 8-10-16 had evidence of zero (0) hours of training being completed during the last completed training year; 8) An employee hired on 9-7-17 had evidence of only one and a half (1.5) hours of additional training being completed during the first year of employment; 9) An employee hired on 9-6-17 had evidence of only six and a half (6.5) hours of additional training being completed during the first year of employment; 10) An employee hired on 1-10-18 did not have evidence on file regarding the completion of the six-hour cabinet-approved orientation training being completed; 11) An employee hired on 10-10-17 did not have evidence on file regarding the completion of the six-hour cabinet-approved orientation training being completed; 12) An employee hired on 8-10-16 did not have evidence of Pediatric Abusive Head Trauma training being completed. These findings are based on a review of the employees' files and their ECE-TRIS files. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Food Service/Food Program In Compliance Food Service In Compliance Children's Records Not In Compliance
General: Based on Interview, it was found that the mother of a child that exited the school building unnoticed on 8-21-18 had been allowed in the past to pick him up in the vestibule in between the sets of double doors. The procedure for student pick-up in the Parent Handbook states, "Please enter through the front door and come into the front office to check your student out of Compass Zone. The receptionist will radio the appropriate group for your child to be dismissed. All parents and guardians will need to wait in the office area for their child. This pick-up procedure was not followed by the facility consistently. In addition, the Safety and Communication slide from the facility training conducted at the beginning of the school year includes the statements/topics, "Making sure the students are always in eyesight..." and “Make sure every child is checked out with front desk before sending them home.” On 8-21-18 a five-year-old child that was being picked up walked unnoticed out of the school building. The runner (staff person) in the hallway and the staff person stationed in the office failed to notice the child exit the building.
General: Based on Interview, and a review of video surveillance it was found that on 8-21-18, a five-year-old child that was being picked up by his father walked unnoticed out of the building through the front doors. Prior to exiting the building, the child was brought by a teacher from the STEM lab to the runner who was on duty outside the school library. After briefly talking to the runner the child was motioned toward the office. After motioning the child toward the office, the runner ducked her head into the library to address another child for thirteen (13) seconds. While the runner was not looking, the child stood and looked out the first set of glass doors and then proceeded to open both sets of glass doors and exit the building. The glass doors are approximately fifty-one (51) feet from the library entrance. The staff person stationed in the office was found to be engaged in conversation with two (2) individuals and had her back to the glass windows, therefore, she was unable to see the child exit the building. After the child exited the building, he crossed the school parking lot, crossed two (2) lanes of traffic and went to the home of a child he knew from school. The child's whereabouts were unknown for approximately twenty-five (25) minutes. While staff at the school were searching for the child, his father received a telephone call from the child's grandfather stating that the ten-year-old brother of the other child had stopped by their house to let them know that the five-year-old child was at his house. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2
This investigation inspection recorded no violations or advisories.
This investigation inspection recorded no violations or advisories.
General: Based on Review of Documentation and interview, this regulatory requirement was not met. On 1/3/18 the facility contact person/principle reported an incident that occurred on 12/19/17 involving two (2) staff and a five (5) year old male child. The contact person/principle explained that 12/19/17 was the last day the facility was open before winter break and 1/3/18 was the first day back to school. The contact person/principle described the 12/19/17 incident by stating that the five (5) year old male child was acting out (kicking, screaming and hitting) when a staff person with a 8/10/16 hire date came up behind the child, who was seated and put her arms around his upper shoulder. The child had a red mark on his shoulder; however, the contact person/principle could not determine what the red mark was from. The red mark was brought to the attention of the contact person/principle by the child's mother a few minutes after she exited the facility with him on 12/19/17. On 1/9/18 a visit was made to the facility to interview staff and view video surveillance footage of the 12/19/17 incident. Staff stated during interview that the child became angry when his group was getting ready to go outside and he could not take a toy with him that he was playing with. Staff stated that the child's anger esculated and he started destroying the classroom by picking up baskets and throwing them around the room. The staff person with a 8/10/16 hire date stated that she moved the child into the hallway in an attempt to keep the child from hurting other children in the area and indicated that the child has intentionally attempted to hurt other children before. The video surveillance footage showed the incident with the child occurring from approximatley 3:24PM - 3:28PM. The child is shown on video hitting and kicking at the two (2) staff (hire dates 8/10/16 and 9/8/16) standing near him in the hallway. At approximatley 3:25PM the two (2) staff physically restrained the five (5) year old child in the hallway outside of the cafeteria entrance while sitting on the floor. The staff person with a 9/8/16 hire date held the child's legs and feet down while the staff person with a 8/10/16 restrained the child's upper body. The child continued to kick and flail around while the two (2) staff were restraining him. The child started off lying on his left side with the staff person observed holding his arms and hands in front of his body. The staff person then repositions her hold by pulling his upper body up in her arms as she sits on the floor. The staff person then repositions her hold again by leaning backward to pull him in her lap and sticking her arms under his arm pit areas. The staff person's hands at this point are positioned on the back of the child's neck. Approximately four (4) seconds later the staff person repositions again by holding the child in a hugging style with her arms wrapped around his upper body to hold his arms down. The staff person identified as being in charge on the day of the incident is observed standing above the child and the two (2) staff from approximately 3:24PM - 3:26PM. The staff person in charge can be seen communicating with someone via walkie-talkie; however, does not intervene in the situation. The staff person in charge stated that she was using the walkie-talkie to call for the contact person/principle to come assist in the situation. Staff stated during interview that the child has had other instances of aggressive behavior at the facility. The two (2) staff that restrained the child are not trained to perform restraints. The contact person/principle stated during interview that she has two (2) staff that are trained in Safe Crisis Management that work at the facility; however, indicated that neither person was working at the time of the incident. She further stated that she was working on developing a schedule to ensure someone with SCM training is always present during the hours of operation. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2
General: Based on Review of Documentation, this regulatory requirement was not met. One (1) child (enrollment date: 3/8/17) had an immunization certificate on file that was no longer current as of 8/30/17. Written Documentation Not In Compliance
General: Based on Review of Documentation and the Training Records Information System (TRIS), the following was found: 1. Ten (10) staff files (hire dates: 6 on 8/10/16, 9/8/16, 7/10/17, 10/25/16 and 7/13/17) did not contain evidence of the six (6) hours of cabinet-approved training being completed within the first three (3) months of employment. 2. Thirteen (13) staff files (hire dates: 6/24/16, 6/27/16, 2 on 6/28/16, 6 on 8/10/16, 9/26/16, 9/8/16 and 10/25/16) did not contain the required fifteen (15) hours of training. 3. Ten (10) staff files (hire dates: 6/24/16, 6/27/16, 6/28/16, 4 on 8/10/16, 9/26/16, 9/8/16 and 10/25/16 ) did not contain evidence of the pediatric abusive head trauma training class being completed within the first year of employment. 4. One (1) staff file (hire date: 8/10/16) contained a pediatric abusive head trauma training class certificate that was dated 2/25/12; therefore, this training is no longer valid. 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 Not In Compliance
General: Based on Review of Documentation, observation, and interview, this regulatory requirement was not met. The following was found: 1. One (1) staff file (hire date: 9/7/17) did not contain evidence or results of a criminal records check (CRC). This staff person was observed sitting at a desk in the main hallway during most of the visit. The staff person in charge identified this staff person as "the runner" and stated that she has eyes on the children while they are in the hallway transitioning from one location to another. It is important to note that another staff person is not always in the hallway with this staff person; therefore, she is alone with children. The staff person in charge stated that this staff person is also a school staff person; therefore, she must have a CRC on file at the central office. 2. One (1) staff file (hire date: 10/10/17) did not have evidence or results of a CRC or a child abuse/neglect check (CAN). This staff person was not observed working alone with children. 3. One (1) staff person (hire date: 9/6/17) had a Pennsylvania drivers license in her file; however, there was no evidence on file that the facility submitted an out of state background check for processing. The staff person in charge stated that the central office submitted this documentation, but the results have not yet been obtained.
This investigation inspection recorded no violations or advisories.
This investigation inspection recorded no violations or advisories.
This investigation inspection recorded no violations or advisories.
This investigation inspection recorded no violations or advisories.
This investigation inspection recorded no violations or advisories.
General: Based on Observation, there was not a flashlight accessible as part of the first aid supplies. During an interview with the staff person in charge it was indicated that a flashlight is available in a different room. However, the room where the flashlight was located was locked and the key the staff person in charge had would not unlock the door.
General: Based on Review of Documentation, there was one (1) staff person with a hire date of 9/26/16 who did not have a copy of a high school diploma, GED or other qualifying documentation on file.
General: Based on Review of Documentation, it was found that earthquake, tornado and fire drills are being documented as one (1) drill with the same time. In addtion the names of the children who participated were not documented for September 2016.
General: Based on Review of Documentation, it was found there was a staff person who lives in Ohio but is going to college in Kentucky. Further review found that there was not a criminal records check from the state of Ohio. The staff person was hired 8/10/16. During an interview with the staff person in charge it was found that this staff person is a "runner". The staff person was observed standing in the hallway with a walkie talkie making sure that children made it down the hall and to the front desk where there parents are waiting to pick them up. There were times when this staff person was observed alone in the hallway with the children.
This change of space/change in capacity inspection recorded no violations or advisories.
This initial application inspection recorded no violations or advisories.
General: Based on observation, this regulatory requirement was not met. The statement of deficiency and plan of correction from the renewal survey conducted on 1/19/2023, was not posted for public inspection. Animals In Compliance
General: Based on review of documentation, staff members hired 4/28/21, 9/21/21, and 8/14/19 did not have proof of educational qualifications in their personnel files.
General: Based on review of documentation, it was found: staff member hired 8/25/2019 had zero hours of training, staff member hired 10/15/2018 had nine hours of training, and staff member hired 8/12/2018 had twelve hours of training. A review of ECE-TRIS support this finding. 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 2 of 3 Inspection Report Children's Records Not In Compliance
General: Based on review of documentation, one child had “any” hospital listed as the preferred hospital; a specific hospital was not listed in their enrollment paperwork. Written Documentation In Compliance Posted Documentation In Compliance Animals In Compliance
General: Based on review of documentation, it was found that the files for employees hired on 1-24-18, 9-8-18, 9-25-18, 8-16-18, 2-5-18, 8-15-18 and two (2) with unknown hire dates did not contain a TB skin test or screening. The files for seven (7) employees hired on 8-10-16 contained the results of TB skin tests or screenings dated 6-17-16, 8-8-16, 8-9-16, 8-6 -16, 8-9-16, 8-10-16 and 8-9-16. The files for employees hired on 8-14-18, 4-28-16, 6-27-16 and 9-8-16 contained the results of a TB skin test of screening that was dated 9-15-16, 4- 15-16, 6-21-16 and 9-8-16. These dates are not within the two-year timeframe required by the regulation. In addition, it was found that the file for an employee hired on 1-15-18 contained the results of a TB skin test dated 1-24-18. This date is not prior to date of hire as required. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 4 Inspection Report
General: Based on review of documentation, it was found that: 1) The information available for nine (9) employees hired after 4-1-18 did not include evidence of the employees being listed in the KARES system. The employees were found to be working with children, but they had not yet had their fingerprints taken as required; 2) The files for employees hired on 1-24-18 and 2-5-18 did not include evidence of completed central registry checks. The office staff person stated that the requests had been returned to the facility due to expired forms being used. The facility did not resend the requests; 3) The file for an employee hired on 1-15-18 included evidence of the employee having lived in Indiana during the past five (5) years. The file did not contain evidence of an out of state background check being completed; 4) The employee hired on 2-5-18 (no central registry check) was found to be working in a classroom with an employee hired on 8-15-18 that had not yet been fingerprinted; 5) The employee hired on 1-24-18 (no central registry check) was found to be working in a classroom with an employee hired on 8-14-18 that had not yet been fingerprinted. The other employees mentioned were not found to be working alone with children. Supervision In Compliance Staffing Requirements In Compliance General Administration In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 4 Inspection Report Director Requirements Not In Compliance
General: Based on review of documentation, it was found that the files for six (6) eligible employees did not contain evidence of an annual evaluation being completed.
General: Based on observation, it was found that an employee hired on 2-5-18 was working with the second grade children in the computer lab along with an employee hired on 8-15- 18. The employee hired on 2-5-18 did not have a completed central registry check on file. The employee hired on 8-15-18 had not yet been added to the KARES system or fingerprinted. In addition, an employee hired on 1-24-18 was found to be working with the third grade children in the music room with an employee hired on 8-14-18. The employee hired on 1-24-18 did not have a completed central registry check on file. The employee hired on 8-14-18 had not yet been added to the KARES system or fingerprinted. According to the employees, they frequently work together in the classrooms. Employee Records Not In Compliance
General: Based on review of documentation, it was found that the files for nine (9) employees did not contain a date of hire.
General: Based on review of documentation, it was found that the file for one (1) eligible employee did not contain evidence of an annual professional development plan being completed.
General: Based on review of documentation, it was found that the fire, earthquake and tornado drills were listed under the heading "Emergency Drills" with one date and time. The individual times were not listed, nor were the names of the children who participated recorded.
General: Based on review of documentation, it was found that the facility did not have evidence of a written policy that states that the procedures taught at the six-hour cabinet- approved orientation training will be implemented at the facility. Posted Documentation Not In Compliance
General: Based on observation, it was found that the statement of deficiencies issued and the plan of correction submitted for an investigation conducted on 8-22-18 was not posted in the facility. It was also found that the civil penalty notice issued on 4-26-18 was not posted in the facility. Animals Not Applicable
General: Based on Review of Documentation, this regulatory requirement was not met. The facility had a schedule of daily activities posted that was dated October 2017; therefore, it was no longer current. Animals Not Applicable
General: Based on Review of Documentation, this regulatory requirement was not met. Review of the policies and procedures found that the facility did not have a current chain of command. The chain of command had a staff person's name listed that is no longer employed at the facility. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 4 Inspection Report
General: Based on Review of Documentation and interview, this regulatory requirement was not met. Nineteen (19) staff eligible for an annual performance review did not have documentation of a review on file in the facility. The staff person in charge stated that this documentation was packed away in a box somewhere; therefore, it was not available for the surveyor to review.
General: Based on Review of Documentation, observation, and interview, this regulatory requirement was not met. One (1) staff file (hire date: 9/7/17) did not contain evidence or results of a criminal records check (CRC). This staff person was observed sitting at a desk in the main hallway during most of the visit. The staff person in charge identified this staff person as "the runner" and stated that she has eyes on the children while they are in the hallway transitioning from one location to another. It is important to note that another staff person is not always in the hallway with this staff person; therefore, she is alone with children. The staff person in charge stated that this staff person is also a school staff person; therefore, she must have a CRC on file at the central office. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 4 Inspection Report Employee Records Not In Compliance
General: Based on Review of Documentation and interview, this regulatory requirement was not met. A review of staff files during the inspection found seven (7) staff that did not have the date of employment listed in their file. The staff person in charge reviewed internal documentation and then identified 8/16/17, 9/1/17, 10/25/16, 9/7/17, 9/6/17, 7/13/17 and 10/10/17 as the hire dates.
General: Based on Review of Documentation, this regulatory requirement was not met. Three (3) staff files (hire dates: 9/26/16, 9/7/17 and 10/10/17 did not have evidence of proof of education. The staff person with a 9/26/16 hire date had a high school transcript in her file; however, it did not list a graduation date. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 4 Inspection Report
General: Based on Review of Documentation, the following was found: 1. One (1) staff file (hire date: 8/10/16) contained results of a negative T.B. test that is no longer current. The test was dated 8/20/15 which exceeds the two (2) year time frame. 2. Four (4) staff (hire dates: 9/26/16, 9/7/17, 9/6/17 and 10/10/17) did not have T.B. documentation on file.
General: Based on Review of Documentation, this regulatory requirement was not met. Five (5) staff (hire dates: 6/24/16, 6/28/16, 6/28/16, 8/10/16, and 10/25/16) did not have evidence of a current staff professional development plan on file in the facility. Posted Documentation Not In Compliance
General: Based on Review of Documentation, this regulatory requirement was not met. The facility had a diagram posted; however, it did not include a written emergency plan.
General: Based on Review of Documentation, it was found there was a staff person who lives in Ohio but is going to college in Kentucky. Further review found that there was not a criminal records check from the state of Ohio. The staff person was hired 8/10/16. During an interview with the staff person in charge it was found that this staff person is a "runner". The staff person was observed standing in the hallway with a walkie talkie making sure that children made it down the hall and to the front desk where there parents are waiting to pick them up. There were times when this staff person was observed alone in the hallway with the children. There was no documentation to verify that the application for the results of a criminal records check from Ohio had been submitted. There was an additional staff person who was a male who did not have the results of a child abuse and neglect (CAN) check on file. This staff person was not observed working alone with the children. There was no documentation to veirfy that the application for the results had been submitted. This male staff person's date of hire was 8/10/16. There was an additioanl female staff person with a hire date of 8/10/16 who did not ahve the results of a child abuse and neglect check (CAN) on file. There was no documentation to verify that the application for the results of the CAN check had been submitted. During an interview with the staff person in charge it was indicated that the application had been submitted but was returned for corrections and was submitted again. However, the results were not back and on file.
General: Based on Review of Documentation, there was one (1) male staff person with a hire date of 8/10/16 who did not have the results of a T.B. skin test or a statement from a health professional indicating that the individual is free from the symptoms of T.B.
General: Based on Review of Documentation, it was found that earthquake, tornado and fire drills are being documented as one (1) drill with the same time. In addtion the names of the children who participated were not documented for September 2016.
General: Based on Review of Documentation, it was found that earthquake, tornado and fire drills are being documented as one (1) drill with the same time. In addtion the names of the children who participated were not documented for September 2016.
General: Based on Review of Documentation, it was found that earthquake, tornado and fire drills are being documented as one (1) drill with the same time. In addtion the names of the children who participated were not documented for September 2016. Posted Documentation