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

General: Based on review of documentation, staff hired 08/23/20, and 02/26/21, did not have the required fifteen (15) hours of cabinet-approved training on file. ECE-TRIS was reviewed and 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 In Compliance Posted Documentation In Compliance Animals Not Applicable

922 KAR 2:090 · Correction status not published

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

General: Based on review of documentation, the following was found: 1) Staff hired 09/07/22, had education documentation on file but it was not legible. 2) Staff hired 11/08/22, had education documentation on file but it did not list which school the staff person attended. 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 10. Director Requirements and Responsibilities.

General: Based on review of documentation, one staff person eligible for an annual performance review did not have documentation of a review on file at the facility. This staff person had 8/23/20, listed as their hire date. Employee Records Not In Compliance

922 KAR 2:090 · Correction status not published

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

General: Based on review of documentation and the Training Records Information System (TRIS), one staff person (hire date: 8/14/19) did not complete the required 15 hours of cabinet-approved training hours between 7/1/2020 and 6/30/21. 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 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 Not Applicable

922 KAR 2:090 · Correction status not published

922 KAR 2:280. Section 5. Checks of Other States.

General: Based on observation and review of documentation, a staff member hired on 11-06-2020, did not have a Criminal Records check, Child Abuse and Neglect check, and the Sexual Offender Registry check or proof of request for two additional states lived in previously. 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 An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Food Service/Food Program Not Applicable Food Service In Compliance Children's Records In Compliance Written Documentation In Compliance Posted Documentation In Compliance Animals Not Applicable Emergency Regulation In Compliance

922 KAR 2:280 · Correction status not published

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

General: Based on a review of documentation, the following was found: 1. One staff member did not have written evidence of completing the six hours of cabinet-approved orientation training within the first three months of employment. The ECE-TRIS system was reviewed and confirmed. 2. A substitute staff member completed only six hours of cabinet-approved early care and education training within her completed training year. The ECE-TRIS system was reviewed and confirmed. 3. One staff member completed 14.50 hours of cabinet-approved early care and education training within her completed training year. The ECE-TRIS system was reviewed and confirmed. 4. One staff member completed one hour of cabinet-approved early care and education training within her completed training year. The ECE-TRIS system was reviewed and confirmed. 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 observation and review of documentation, the facility did not have a written plan outlining the course of action in the event of a natural or manmade disaster posted in a prominet place. The facility had a diagram posted for evacuation, but not a written plan that had been submitted to the local Emergency Management Office. Animals Not Applicable An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 4

922 KAR 2:090 · Correction status not published

922 KAR 2:090. Section 9. Records.

General: Based on observation and review of documentation, the following was found: 1. Two children did not have a physician’s phone number on file. 2. Two children did not have a physician’s name or phone number on file. In addition, neither file listed a preferred hospital. Written Documentation Not In Compliance

922 KAR 2:120. Section 12. Transportation.

General: Based on review of documentation and interview, the child-care center did not have transportation records for the months of January and February that reflect times on and off of the vehicle that is used to transport the school-age children from public school. Food Service/Food Program Not Applicable Food Service In Compliance Children's Records Not In Compliance

922 KAR 2:120 · Correction status not published

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

General: Based on review of documentation and ECE-TRIS, the surveyor found a staff person hired on 11/1/17 only completed thirteen (13) hours of early care and education training. Additionally, this staff person did not complete the six (6) hour orientation training until 4/11/18, which is not within ninety (90) days of hire. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area Not Applicable Equipment In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Transportation Not In Compliance

922 KAR 2:090 · Correction status not published

922 KAR 2:090. Section 9. Records.

General: Based on review of documentation, the surveyor found immunization documentation for a child enrolled on 8/13/18 did not have a date; therefore, the surveyor could not verify if the child's immunizations were up to date. A child enrolled on 8/6/18 had immunization documentation on file that was no longer current as of 2/20/19 Written Documentation In Compliance Posted Documentation In Compliance Animals In Compliance

922 KAR 2:090 · Correction status not published

922 KAR 2:090. Section 9. Records.

General: Based on Review of Documentation, three (3) children's files did not contain immunization certificates. Another child's file contained a vaccination record from California and it did not contain an expiration date. All of the children had been enrolled in excess of thirty (30) days.

922 KAR 2:090 · Correction status not published

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

General: Based on Review of Documentation, one (1) staff member hired on 8/14/17 did not complete orientation training within the first three (3) months of employment. This staff member completed orientation training on 2/12/18. Two (2) other staff members did not completed fifteeen (15) hours of cabinet-approved early care and education training within their completed training year. A staff hired on 4/26/16 completed 12.50 hours of training and a substitute staff member hired on 8/12/15 completed twelve (12) hours of training. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Outdoor Play Area In Compliance Equipment In Compliance Transportation 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, the zoning letter (dated 4/7/09) on file for the YMCA indicated that they had a zoning capacity for up to fifty (50) children. The facility is licensed for a capacity of 112 children. The facility was not in compliance with the local zoning requirements. Director Requirements In Compliance Employee Records Not In Compliance

922 KAR 2:090 · Correction status not published

922 KAR 2:110. Section 3. Records.

General: Based on interview with the staff person in charge, the surveyor found that the YMCA Executive Director was filling in for the day as a bus monitor. The staff person in charge stated that this person has been the bus monitor on at least three (3) occasions. The staff person in charge stated that she did not have a personnel file for this person. It is important to note that this person was not left alone with the children in care during the inspection. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report

922 KAR 2:110 · Correction status not published

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

General: Based on Review of Documentation, the surveyor found that a staff person hired on 1/30/17 did not have TB skin documentation on file. Furthermore, a staff person hired on 9/21/16 had TB skin documentation on file that was dated 9/28/16 which is after the staff person's date of hire.

922 KAR 2:110 · Correction status not published

922 KAR 2:110. Section 2. General.

General: Based on Review of Documentation, the surveyor found that the past statement of deficiencies/ plan of corrections during the current licensure year were in a notebook labeled "The North Lexington YMCA DRCC Notebook". The staff person in charge stated that the notebook is available to the parents for review. However, the surveyor found that the notebook was not clearly identified in such a way that parents would know that they were allowed to review the contents of the notebook. Animals Not Applicable

922 KAR 2:110 · Correction status not published

922 KAR 2:110. Section 3. Records.

922 KAR 2:110. Section 6. Reports.

General: Based on Interview, at the time of the visit conducted on 1/10/17 it was found that the facility has been transporting children from school to the facility since 1/2/17. Howvever a review services offered by the facility found that the facility is not currently licensed for transportation. A review of records found that a written request was received by the Division of Regulated child care from the facility on 12/28/16; however this service had not yet been approved. Director Requirements In Compliance

922 KAR 2:110 · Correction status not published

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

General: Based on Review of Documentation, staff persons hired 10/27/14 and 10/4/14 did not have evidence of an annual evaluation on file in the facility. The staff person in charge aknowledged this deficincy during the exit interview.

922 KAR 2:110 · Correction status not published

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

General: Based on Review of Documentation, 1. Staff person hired 10/21/15 had the results of a CA/N check dated 11/16/15. There was no evidence on file that the application for the check had been submitted within the first five (5) days of employment as required. The staff person in charge acknowledged the deficiency during the exit interview. 2. Staff person hired 10/21/15 had the results of a criminal records check dated 11/2/15. There was no evidence on file that the application for the check had been submitted prior to employment as required. The staff person in charge acknowledged the deficiency during the exit interview.

922 KAR 2:090 · Correction status not published

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

General: Based on Review of Documentation, 1. Staff persons hired 11/24/15 and 10/21/15 did not have evidence of completing the required orientation training in the first three (3) months of employment. The director acknowledged the deficiency during the exit interview. A review of ECE-TRIS records supports the information found during the survey. 2. Staff persons hired 10/27/14 and 10/4/14 did not have evidence of fifteen (15) hours of annual training on file for the last full year of employment. The staff person in charge stated that she was unaware that these staff persons had not met the training requirements. A review of ECE-TRIS records supports the information found during the survey. 3. A staff person hired 10/4/14 did not have evidence of completing the Pediatric Abusive Head Trauma training within the first year of employment. A review of ECE-TRIS records supports the information found during the survey. 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

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

General: Based on Observation, there were several water stains on the ceiling tiles in the Pre-K classroom and the adjoining bathroom.

922 KAR 2:120 · Correction status not published

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

General: Based on Observation, two (2) foster grandparents hired on 07/16/13 and 10/02/13 did not have the results of a criminal records check on file.

922 KAR 2:090 · Correction status not published

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

General: Based on Review of Documentation, staff member rehired on 05/07/13 did not have education documentation on file.

922 KAR 2:110 · Correction status not published

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

General: Based on Review of Documentation, staff member rehired on 05/07/13 had a TB skin test documentation on file that was more than two (2) years old.

922 KAR 2:110 · Correction status not published

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

General: Based on Review of Documentation, staff member hired on 10/01/13 had documentation of Orientation I & II on file that was dated 02/12/14.

922 KAR 2:110 · Correction status not published

922 KAR 2:120. Section 10. Toilet, Diapering, and Toiletry Requirements.

922 KAR 2:120 - Section 5

Toddler: Based on Observation, in interviews with staff it was determined that children being cared for in the classroom ranged in age from eighteen (18) months to thirty-four (34) months.

922 KAR 2:120 · Correction status not published

922 KAR 2:110 - Section 2

General: Based on Review of Documentation, it was found that a foster grandparent that volunteer's at the child care facility approximately thirty (30) hours a week did not have written evidence on file indicating that this individual was free from TB. The volunteer agency had a written policy that indicated that volunteers must have a TB skin test.

922 KAR 2:110 · Correction status not published