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Home › KY › Lexington › YMCA CKY: Glendover
License #L356019 · Center · Licensed
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This investigation inspection recorded no violations or advisories.
This renewal application inspection recorded no violations or advisories.
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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
This renewal application inspection recorded no violations or advisories.
General: Based on observation, this regulatory requirement was not met. The children's backpacks were stored on the floor in the cafeteria. Some of the backpacks were piled on top of each other. This method of storage promotes the spread of germs and is unsanitary. Director Requirements Not In Compliance
General: Based on review of documentation, this regulatory requirement was not met. A staff member hired on 08/17/22, did not have an evaluation on file. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Employee Records Not In Compliance
General: Based on review of documentation, this regulatory requirement was not met. The following was found: 1. Two staff members both hired on 08/07/23, had their TB skin tests completed on 8/10/23. 2. A staff member hired on 05/22/23, had her TB skin test completed on 08/09/23. Therefore, these TB skin tests were not completed prior to employment. 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, three staff with hire dates of 8/15/22, 10/8/21, and 8/23/20, did not have documentation of negative TB results on file at the facility.
General: Based on review of documentation, two staff with hire dates of 8/17/22, did not have cleared background checks in KARES. Both staff were still "In Process" in KARES and present the day of inspection.
General: Based on review of documentation, one staff hired on 3/16/18, did not have evidence of a professional development plan on file at the facility. Posted Documentation In Compliance Animals In Compliance
General: Based on observation, the first aid kit did not contain a working flashlight on the day of inspection. Outdoor Play Area In Compliance Equipment In Compliance Transportation In Compliance Kitchen Requirements In Compliance Food Service In Compliance Meal Planning/Center Provides Meals Not In Compliance
General: Based on review of documentation, one staff hired on 8/17/22, had a listed address in West Virginia as a previous residence within the past five years. There was no evidence of a Child Abuse and Neglect check or sex offender check from West Virginia on file at the facility. 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
This investigation inspection recorded no violations or advisories.
This renewal application inspection recorded no violations or advisories.
General: Based on observation, interview and review of documentation during a tour of the facility, two unlicensed spaces were being used – Classroom 152 (Art room), and Classroom 156 (Music room). The staff person in charge stated that a request was made to add these two spaces but an inspection was never conducted. The surveyor contacted the director and the director explained that he mistakenly submitted the addition of space request to the wrong portal and has since resubmitted. Director Requirements In Compliance Employee Records In Compliance Programming In Compliance Premises In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation 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 observation, interview and review of documentation, this regulatory requirement was not met. A staff member hired on 9/02/19, did not have written evidence of completing an out-of-state child abuse and neglect registry check for Colorado. The staff member had lived in Colorado within the past five years. This staff member was not observed working alone with the children during the follow-up inspection. Supervision In Compliance Staffing Requirements In Compliance
General: Based on observation and review of documentation, this regulatory requirement was not met. There was no written evidence that any of the staff had current CPR and first aid training. The after-school program operates from 2:35 PM until 6:00 PM, Monday through Friday.
General: Based on observation, this regulatory requirement was not met. Based on observation, a group (group #2) of twenty-five (25) children were being supervised by one (1) staff person in the cafeteria. The children were six to seven (6-7) years-old. Since the youngest child in the group was six (6) years-old, one (1) staff can only supervise fifteen (15) children alone. General Administration Not In Compliance
General: Based on observation, this regulatory requirement was not met. The facility did not have written evidence of a current State Fire Marshal inspection.
General: Based on observation, this regulatory requirement was not met. A weekly snack menu was not posted. Children's Records Not In Compliance
General: Based on Interview, it was found that the facility did not have personnel files for the director and two (2) employees available for review.
General: Based on Review of Documentation, it was found that the facility did not have written documentation of fire drills being conducted during the months of January, February, March, April and May 2018 available for review. Posted Documentation In Compliance Animals Not Applicable
General: Based on Observation, it was found that one (1) staff person was supervising twenty (20) children ages six and seven-years-old. The staff person in charge stated that she thought all school age children fell under the one to twenty-five ratio. During interview, it was found that this group operates out of ratio daily from 2:35 p.m. until some of the children are picked up. General Administration In Compliance Director Requirements Not In Compliance
General: Based on Review of Documentation, the following was found during a review of staff files and the ECE-TRIS system: 1) an employee hired on 11-2-16 completed only 5 1/2 hours of additional training during the first year of employment; 2) employees hired on 8-18-17 and 3-16-18 have not yet completed the six (6) hour cabinet-approved orientation training; 3) an employee hired on 11-1-17 completed the six (6) hour cabinet-approved orientation training on 4-11-18. This date is not within the first three (3) months of employment as required; 4) an employee hired on 8-18-17 completed zero (0) hours of additional training during the first year of employment; 5) an employee hired on 4-21-17 completed only six and a half hours of additional training during the first year of employment; 6) an employee hired on 8-18-17 has not yet completed the Pediatric Abusive Head Trauma training. 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 3 of 4 Inspection Report Children's Records Not In Compliance
This investigation inspection recorded no violations or advisories.
General: Based on Review of Documentation, it was found through a review of ten (10) children's files that four (4) files did not contain the physician's contact information or list the preferred hospital. The dates of enrollment for the children were two (2) with an enrollment date of 08/04/2017 and two (2) with an enrollment date of 08/16/2017. Written Documentation Not In Compliance
General: Based on Review of Documentation, it was found that a staff person with a hire date of 11/02/2016 and a staff person with a hire date of 08/22/2017 did not have evidence of a child abuse and neglect check. The staff person with the hire date of 08/22/2017 was found to be alone supervising seventeen (17) school age children. It was also found that two (2) staff with hire dates of 11/15/2016 and 10/26/2016 did not have evidence of out of state background checks for the state of Ohio and for the state of Illinois. These staff were not observed to be working alone.
General: Based on Review of Documentation, it was found that medication administered on 08/17/2017, 08/18/2017 and 08/22/2017 did not contain a parent's signature.
General: Based on Review of Documentation, it was found through a review of twelve (12) staff files that two (2) staff files contained no evidence of the staff being free of TB. The dates of hire for the staff were 11/02/2016 and 08/08/2006.
General: Based on Review of Documentation, six (6) staff (hire dates: 9/28/15, 3/25/16, 3/9/16, 4/27/16, 10/2015 and 5/2016) did not have educational documentation on file.
General: Based on Review of Documentation and interview, the following was found: 1. One (1) staff person had a mailed copy of her child abuse/neglect check (CAN) on file that was dated 8/23/16; however, the results had not been obtained. This staff person was observed working alone with twenty-three (23) school age children on one (1) side of the library during the visit. This staff person had 8/23/16 written as their hire date on the front page of their CAN check; however, the words "interview date" had been written beside of the date listed. 2. One (1) staff person had a mailed copy of her CAN check on file that was dated 9/28/15; however, the results had not been obtained. This staff person was observed working alone with twenty-four (24) school age children on the other side of the library during the visit. This staff person had 9/28/15 written as their hire date on the front page of their CAN check. 3. One (1) staff person did not have evidence or results of a criminal records check (CRC) or CAN check on file. This staff person was observed working alone with twenty-two (22) school age children on one (1) side of the playground during the visit. This staff person did not have an employee file or any identifying documentation on site for the surveyor to review. The staff person in charge asked the staff person for their hire date during the visit. The staff person responded that she was hired on 4/27/16. 4. One (1) staff person did not have evidence or results of a CRC or CAN check on file. This staff person was observed working alone with different school age during the visit. She was identified as a "floater" and was observed escorting children back and forth from the classroom to the bathrooms in the hallway. This staff person did not have an employee file or any identifying documentation on site for the surveyor to review. The staff person in charge asked the staff person for their hire date during the visit. The staff person responded that she was hired 10/2015. 5. One (1) staff person did not have evidence or results of a CRC on file. The staff person in charge asked the staff person for his hire date during the visit. The staff person responded that he was hired 3/25/16. 6. One (1) staff person did not have evidence or results of a CRC or CAN check on file. The staff person in charge asked the staff person for her hire date during the visit. The staff person responded that she was hired 3/9/16. 7. The staff person in charge did not have an employee file or any identifying documentation (including a CRC or CAN) on site for the surveyor to review. The staff person in charge identified her hire date as 5/2016 and stated, "some of these staff, including myself, started working at a different location, but recently switched to this location. I don't think our paperwork has been transferred to this location yet".
General: Based on Observation, the surveyor observed a total of eighty nine (89) children and seven (7) staff in the cafeteria. The surveyor observed five (5) groups of children sitting at their designated table according to their age and grade. There were one (1) to two (2) staff assigned to each group. During record review the surveyor found that only one (1) staff person (staff person in charge) had the results of a child abuse/ neglect (CA/N) check on file. Record review found that some of the staff were new hires and some were re- hires with hire dates listed as 8/6/15 or 8/7/15. All CA/N checks had been requested but the results were not on file.
General: Based on Observation, the surveyor observed a total of eighty nine (89) children and seven (7) staff in the cafeteria. The surveyor observed five (5) groups of children sitting at their designated table according to their age and grade. There were one (1) to two (2) staff assigned to each group. During record review the surveyor found that only one (1) staff person (staff person in charge) had the results of a child abuse/ neglect (CA/N) check on file. Record review found that some of the staff were new hires and some were re- hires with hire dates listed as 8/6/15 or 8/7/15. All CA/N checks had been requested but the results were not on file.
General: Based on Review of Documentation, two (2) children's files (Enrollment date: 8/10/15) did not contain preferred hospital information or physician contact information. 1080 - Documentation for Off Premise Trip Not Applicable 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 Interview, on 11/14/14 a child was able to be picked up by her grandmother and taken from the school for at least five (5) minutes without the staff's knowledge. A child was taken from the playground and back to the grandmother's house nearby. The grandmother returned with the child about (5) minutes later and nobody at the after school program had realized she had been gone. Staffing Requirements
General: Based on Review of Documentation, the facility failed to maintain a personnel file for an employee that had been employed for more than one (1) year. In an interview with staff it was determined that the staff person began employment with the agency in August of 2013 and had worked at another site before being place at this facility in August of 2014. The employee's personnel file was not available for review at this site.
General: Based on Review of Documentation, there was no documentation made available at the time of the survey regarding current liability insurance. The insurance on file expired 8/1/14.
General: Based on Observation, the complete statement of deficiencies and plan of correction from the previous re-licensure survey was not posted in the facility. The first fourteen (14) pages of the document were not posted in the facility.
General: Based on Review of Documentation, staff person hired 10/5/12 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, the only drill documented that had the names of the children who were present was for 4/22/13. This was the only documentaion that was presented for review at the time of the survey.
General: Based on Interview, it was found that a child fell from a bench and injured her wrist on 4-29-13. At 8:47 p.m. on 4-29-13, the site supervisor was notified of the child being taken to the emergency room where it was found that she had two (2) broken bones in her wrist. The facility did not notify the Division of Regulated Child Care office of the incident until the morning of 5-1-13. Director Requirements
General: Based on Review of Documentation, staff with hire date 3/9/2 did not have her TB skin test read until 4/2/12. 128 - CPR/First Aid Coverage 922 KAR 2:110 - Section 5 (3) At least one (1) person on duty and present with the children shall be currently certified by a cabinet-approved training agency in the following skills: (a)Infant and child cardiopulmonary resuscitation; and (b) Infant and child first aid. 1) CPR In Compliance 2) First Aid In Compliance 131 - Adequate Substitute(s) 922 KAR 2:110 - Section 5 (6) Child-care centers shall have available in case of need: (a) One (1) qualified substitute staff person for a Type II child-care center; or (b) Two (2) qualified substitute staff persons for a Type I child-care center 1) Type I In Compliance 2) Type II In Compliance 139 - Training 922 KAR 2:110 - Section 5 (14) A staff person with supervisory authority over a child shall complete the following: (a) Six (6) hours of cabinet-approved orientation within the first three (3) months of employment; (b) Nine (9) hours cabinet-approved child development training within the first year of employment; and (c) Fifteen (15) hours of cabinet-approved training during each subsequent year of employment. 1) Orientation Not In Compliance Findings: General: Based on Review of Documentation, staff with hire date 3/20/12 did not have proof or completing the required orientation training. 139 - Training 922 KAR 2:110 - Section 5 (14) A staff person with supervisory authority over a child shall complete the following: (a) Six (6) hours of cabinet-approved orientation within the first three (3) months of employment; (b) Nine (9) hours cabinet-approved child development training within the first year of employment; and (c) Fifteen (15) hours of cabinet-approved training during each subsequent year of employment. 2) 9 hours-first year In Compliance 3) 15 hours annually In Compliance 317 - Driver requirements 922 KAR 2:120 - Section 12 (18) A driver of a vehicle transporting a child for a center shall: (a) Be at least twenty one (21) years old; (b) Complete the background checks as described in 922 KAR 2:110; (c) Hold a current driver’s license which has not been suspended or revoked during the last five (5) years; (d) Not have had any convictions concerning vehicle operation in the past twelve (12) months; and (e) Not caused an accident which resulted in the death of a person. 1) Be 21 years old or over Not Applicable 2) Background checks Not Applicable An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 8 of 38 Web site: http://chfs.ky.gov/ Inspection Report 3) Drivers license Not Applicable 4) No convictions for vehicle operation Not Applicable 5) No accident causing death Not Applicable Programming 169 - Program of Activities Followed 922 KAR 2:120 - Section 2 (4) The child-care center shall provide a daily planned program of activities: (a) Posted in writing in a conspicuous location with each age group and followed; 1) Posted In Compliance 2) Followed In Compliance
General: Based on review of documentation, two staff hired on 3/16/18 and 2/10/21, did not have evidence of an annual evaluation on file at the facility. Employee Records Not In Compliance
General: Based on review of documentation, two staff with hire dates of 8/23/20 and 10/8/21, did not have staff files at the facility the day of inspection. Therefore, identifying information was not available for these staff members, including documented date of hire, name, address, date of birth, proof of education qualifications, TB documentation, and background check results. Both staff were present the date of inspection.
General: Based on review of documentation, three staff with hire dates of 8/15/22, 8/23/20, and 10/8/21, did not have proof of education on file at the facility.
General: Based on review of documentation, there was no evidence to support that any current staff member was certified in CPR/First Aid. Therefore, there was no CPR/First Aid coverage at the facility. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 4 Inspection Report
General: Based on review of documentation, two staff with hire dates of 3/16/18 and 8/23/20, did not complete the required 15 hours of annual training for the year. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication Not In Compliance
General: Based on observation, the children were served only animal crackers for snack on the day of inspection. Snack should consist of two components. Meal Planning/Center Does Not Provide Meals In Compliance Children's Records In Compliance 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 observation and review of documentation, this regulatory requirement was not met. A staff member hired on 8/14/19 did not have written evidence of a completed national criminal background check. The staff member did not have a file on site. The KARES system was also reviewed for this facility and this individual was not on the KARES report. The staff member was not observed working alone with the children during the renewal survey.
General: Based on observation and review of documentation, this regulatory requirement was not met. The following items were found in regard to training: 1. A staff hired on 4/08/16 completed four (4) hours of training. 2. A staff hired on 3/16/18 completed six (6) hours of training. 3. A staff hired on 8/18/17 completed six (6) hours of training. 4. A staff hired on 8/16/18 completed six (6) hours of training. 5. A staff hired on 8/21/18 completed six (6) hours of training. 6. Staff hired on 8/18/17, 3/16/18, 8/16/18, and 8/21/18 did not have pediatric abusive head trauma training. 7. A staff hired on 9/04/18 did not have orientation training. ECE-TRIS was reviewed. 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 3 of 5 Inspection Report Equipment Not In Compliance
General: Based on observation and review of documentation, this regulatory requirement was not met. A staff member hired on 8/14/19 did not have written evidence of a completed national criminal background check. The staff member did not have written evidence of the submission of finger prints for the national background check to be conducted. The staff member did not have a file on site. The KARES system was also reviewed for this facility and this individual was not on the KARES report. The staff member was not observed working alone with the children during the renewal survey. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 5 Inspection Report Supervision In Compliance Staffing Requirements Not In Compliance
A PLAN OF CORRECTION WAS DUE ON 09/25/2019 AND AS OF 10/09/2019, THE PLAN OF CORRECTION HAS NOT BEEN RECEIVED. Director Requirements In Compliance Employee Records Not In Compliance
General: Based on observation and review of documentation, this regulatory requirement was not met. One (1) staff member did not have a file on site. This staff was hired on 8/14/19. Another staff did not have a written hire date on file. This staff was also hired on 8/14/19. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 5 Inspection Report
General: Based on review of documentation, this regulatory requirement was not met. Three (3) staff members did not have proof of education on file. One staff member was hired on 12/21/18 and two (2) were hired on 8/14/19.
General: Based on observation and review of documentation, this regulatory requirement was not met. A staff member hired on 8/14/19 did not have negative TB documentation on file or a physician's statement stating the individual is free of TB.
General: Based on observation, this regulatory requirement was not met. Four (4) plastic laundry baskets, used to store the children's backpacks and personal belongings, were cracked. Transportation Not Applicable Food Service/Food Program In Compliance Food Service Not In Compliance
General: Based on review of documentation, this regulatory requirement was not met. Seven children's files were misssing the physician name and phone number. Five (5) children's files were missing a preferred hospital. Written Documentation Not In Compliance
General: Based on observation and review of documentation, this regulatory requirement was not met. The facility did not have written evidence that a current emergency preparedness plan had been submitted to the local emergency management officials. The last documented plan was dated 9/19/17. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 4 of 5 Inspection Report
General: Based on observation and review of documentation, the written staff schedule located in the binder was not current. The staff schedule did not include all of the current staff that were working in the after-school program. In addition, staff that no longer work in the program were not removed from the schedule.
General: Based on observation and review of documentation, this regulatory requirement was not met. There was no written evidence of montly fire drills. Posted Documentation Not In Compliance
General: Based on observation, this regulatory requirement was not met. The posted daily activites sheet was no longer current. The activities were dated 5/20/19 to 5/24/19. Animals Not Applicable
General: Based on Review of Documentation, the following was found: 1) the file for an employee hired on 4-21-17 listed Florida, Texas and Kansas as places she has lived within the last five (5) years. The facility did not have evidence of out of state background checks being conducted on this employee; 2) the file for an employee with an unknown hire date contained evidence of the federal background check being requested and her fingerprints being taken, however, the final results had not yet been received by the facility; 3) the file for an employee with an unknown hire date contained evidence of the federal background check being requested by another facility. The results had not been received and the employee was not linked to the facility through the KARES system. Each of these three (3) employees was observed to be working alone with children for the duration of the survey. It was also found that each of the employees had been working alone with children since school started on 8-15-18. It should be noted that this facility was cited for staff working alone without the proper background checks being completed during the 2016 and 2017 relicensure surveys. Supervision In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 4 Inspection Report Staffing Requirements Not In Compliance
General: Based on Review of Documentation, it was found that the file for one (1) eligible employee did not contain evidence of an annual evaluation being completed.
General: Based on Observation, the following was found: 1) an employee hired on 4-21-17 was observed to be working alone with twenty (20) children ages six and seven-years-old for the duration of the survey. During interview, it was found that this employee has worked alone with this group of children since school started on 8-15-18. Record review found that this employee listed Florida, Texas and Kansas as places she has lived within the last five (5) years. The facility did not have evidence of out of state background checks being conducted on this employee; 2) an employee with an unknown hire date was observed to be working alone with thirteen (13) children ages five and six-years-old for the duration of the survey. During interview, it was found that this employee has worked alone with this group of children since school started on 8-15-18. Record review found that the results of the required federal background check had not yet been received; 3) an employee with an unknown hire date was observed to be working alone with sixteen (16) children ages eight and nine-years-old for the duration of the survey. During interview, it was found that this employee has worked alone with this group of children since school started on 8-15-18. Record review found that the results of the required federal background check had not yet been received. It should be noted that this facility was cited for staff working alone without the proper background checks being completed during the 2016 and 2017 relicensure surveys. 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, it was found that three (3) employees with unknown hire dates did not have evidence of a high school diploma, GED or Commonwealth Childcare Credential available for review.
General: Based on Review of Documentation, it was found that three (3) employees with unknown hire dates did not have evidence of a TB skin test or screening available for review. The file for an employee hired on 11-1-17 contained evidence of a TB skin test being read on 11-2-17. This date is not prior to date of hire as required by the regulation.
General: Based on Review of Documentation, it was found that ten (10) out of ten (10) children's records reviewed did not include a parent's signature or authorization to seek emergency medical care. One (1) child's record did not contain a physician's telephone number. Written Documentation Not In Compliance
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 Observation, it was found that there was no thermometer in the refrigerator used to store the children's milk.
General: Based on Review of Documentation, it was found that the facility did not have a daily schedule posted. Animals Not Applicable
General: Based on Review of Documentation, it was found through a review of twelve (12) staff files that seven (7) staff files did not have documentation of the fifteen (15) hours of cabinet-approved early care and education training. A review of ECE-TRIS confirmed this. It was also found that two (2) staff files did not have evidence of the one and one-half (1 1/2) hours of pediatric abusive head trauma training. A review of ECE-TRIS confirmed this. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 5 Inspection Report Programming Not In Compliance
General: Based on Review of Documentation, it was found that there was no earthquake/tornado drill conducted for the second quarter of 2017. Posted Documentation Not In Compliance
General: Based on Review of Documentation, it was found that there was no documentation of current liability insurance. Director Requirements Not In Compliance
General: Based on Review of Documentation, it was found through a review of twelve (12) staff files that five (5) files did not have documentation of an annual staff evaluation.
General: Based on Review of Documentation, it was found that a staff person with a hire date of 11/02/2016 and a staff person with a hire date of 08/22/2017 did not have evidence of a child abuse and neglect check. The staff person with the hire date of 08/22/2017 was found to be alone supervising seventeen (17) school age children. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 5 Inspection Report
General: Based on Review of Documentation, it was found that there was no evidence of at least one (1) annual activity involving parental or family participation. Employee Records Not In Compliance
General: Based on Review of Documentation, it was found that a staff person with a hire date of 08/22/2017 did not have evidence of proof of education in their staff file.
General: Based on Review of Documentation, it was found that the facility did not have evidence of a program of activities. Premises In Compliance Hygienic Practices In Compliance First Aid/Medication Not In Compliance
General: Based on Review of Documentation, it was found from 03/29/2016 to the end of the school year in May of 2017, a child receiving a daily prescription medication did not have the time of each dosage and the amount documented. The staff stated that she did not know she had to fill it out for each day.
General: Based on Observation, it was found that the medication box used to store a prescription medication was not locked. Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 5 Inspection Report Food Service Not In Compliance
General: Based on Review of Documentation, it was found that the facility did not have a current snack menu. The most recent menu was from 02/2017. Children's Records Not In Compliance
General: Based on Review of Documentation, it was found through a review of twelve (12) staff files that seven (7) staff files did not have documentation of an annual professional development plan.
General: Based on Review of Documentation, It was found that there were no fire drills conducted for April or May of 2017. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 4 of 5 Inspection Report
General: Based on Review of Documentation and interview, the following was found: 1. Four (4) staff observed working at the facility during the visit did not have a staff file or any identifying paperwork available for the surveyor to review. The staff person in charge asked each staff person for their hire date during the visit. These dates were identified as 3/9/16, 4/27/16, 10/2015 and 5/2016. 2. The hire dates for three (3) employees were not available in the files. The staff person in charge asked one (1) of the staff what their hire date was and he responded, "3/25/16". The other two (2) staff had 8/23/16 and 4/4/16 written as their hire date on the front page of their child abuse/neglect check (CAN); however, had written "interview date" beside of the dates listed. The staff person in charge stated that some of these staff started working at a different location and recently switched to this location and indicated that their paperwork may not have transferred with them.
General: Based on Review of Documentation and interview, the following was found: 1. One (1) staff person had a mailed copy of her child abuse/neglect check (CAN) on file that was dated 8/23/16; however, the results had not been obtained. This staff person was observed working alone with twenty-three (23) school age children on one (1) side of the library during the visit. This staff person had 8/23/16 written as their hire date on the front page of their CAN check; however, the words "interview date" had been written beside of the date listed. 2. One (1) staff person had a mailed copy of her child abuse/neglect check (CAN) on file that was dated 9/28/15; however, the results had not been obtained. This staff person was observed working alone with twenty-four (24) school age children on the other side of the library during the visit. This staff person had 9/28/15 written as their hire date on the front page of their CAN check. 3. One (1) staff person did not have evidence or results of a criminal records check (CRC) or CAN check on file. This staff person was observed working alone with twenty-two (22) school age children on one (1) side of the playground during the visit. This staff person did not have an employee file or any identifying documentation on site for the surveyor to review. The staff person in charge asked the staff person for their hire date during the visit. The staff person responded that she was hired on 4/27/16. 4. One (1) staff person did not have evidence or results of a criminal records check (CRC) or CAN check on file. This staff person was observed working alone with different school age during the visit. She was identified as a "floater" and was observed escorting children back and forth from the classroom to the bathrooms in the hallway. This staff person did not have an employee file or any identifying documentation on site for the surveyor to review. The staff person in charge asked the staff person for their hire date during the visit. The staff person responded that she was hired 10/2015.
General: Based on Review of Documentation, this regulatory requirement was not met. One (1) staff eligible for an annual performance review did not have documentation of a review on file in the facility.
General: Based on Review of Documentation, seven (7) staff (hire dates: 4/4/16, 9/28/15, 3/25/16, 3/9/16, 4/27/16,10/2015 and 5/2016) did not have T.B. documentation on file. 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 Observation and review of documentation, this regulatory requirement was not met. At the time of the survey it was found that only two (2) staff out of fourteen (14) were certified in infant/child CPR and infant/child first aid. These two (2) staff (hire dates: 8/7/13 and 10/23/14) were absent on the day of the survey; therefore, no one was on duty at the facility on 9/7/16 who was certified in CPR or First Aid.
General: Based on Review of Documentation, the following was found: 1. Seven (7) staff files (hire dates: 4/4/16, 9/28/15, 3/25/16, 3/9/16, 4/27/16, 10/2015 and 5/2016) did not contain evidence of the six (6) hours of cabinet-approved training being completed within the first three (3) months of employment. 2. Two (2) staff files (hire dates: 8/7/15 and 10/23/14) did not contain the required fifteen (15) hours of training. The surveyor reviewed the Early Care and Education Training Records Information System (ECE-TRIS) website and the staff person's personnel file at the facility and found no evidence that this training had been 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, this regulatory requirement was not met. A review of the facility's postings revealed that a menu was posted that was dated February 2016; therefore, it was not current.
General: Based on Review of Documentation, 1. Staff person hired 8/21/13 had evidence of only six (6) hours of annual training on file for the last full year of employment. 2. Staff person hired 1/8/14 did not have evidence of completing the required orientation training in the first three (3) months of employment.
General: Based on Review of Documentation, staff with hire date 3/20/12 did not have the required educational documentation on file for review.