922 KAR 2:090 · 922 KAR 2:090. Section 8. General.

General: Based on interview and review of documentation, a staff member mishandled a four-year-old child during two incidents on 05/06/25. First, the staff member moved the child from one classroom to another by pulling his/her legs and arm. Later, the staff member pulled on the lower portion of the child's arm and dragged him/her. Therefore, the child's comfort and safety was compromised when he/she was mishandled by the staff member.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, paint was peeling on wall above the block shelf, in the Cedar classroom.

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 8. General.

General: Based on observation, outlet covers were missing in the following rooms: 1) Elm 2) Pine 3) Atelier 4) Multi- Purpose room in Angels Hall

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 10. Director Requirements and Responsibilities.

General: Based on review of documentation, it could not be verified that twelve (12) staff members (08/02/18, 08/16/12, 08/01/23, 08/02/21, 08/05/14, 02/05/18, 01/31/12, 09/18/23, 04/12/10, 09/20/23, 08/02/18, and 09/02/21) had current annual evaluations.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on review of documentation, it could not be verified that eight (8) staff members (DOH:05/01/24, 09/20/23, 09/26/24, 07/10/24, 06/01/23, 08/12/24, 08/01/24 and 12/17/24) had proof of education via a high school diploma, GED, Commonwealth Child Care Credential or an equivalent.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, it could not be verified that twenty three (23) staff members (DOH: 03/14/24, 05/18/22, 09/20/22, 05/30/17, 08/01/24, 01/01/01, 01/27/15, 05/01/24, 09/26/24, 08/01/23, 08/08/24, 08/02/18, 07/10/24, 09/02/21, 06/01/23, 08/12/24, 08/01/24, 08/02/18, 05/01/24, 06/10/24, 10/02/23, 12/17/24 and 08/01/23 ) were free from active tuberculosis (TB).

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, the following could not be verified through the use of ECE-Tris: 1) It could not be verified that two (2) staff members (DOH: 08/08/24 and 06/01/23) completed six (6) hours of cabinet approved orientation. 2) It could not be verified that four (4) staff members (DOH: 08/01/23, 09/20/22, 09/02/21 and 06/01/23) had current Pediatric Abusive Head Trauma (PAHT) training. 3) It could not be verified that nine (9) staff members (DOH: 09/02/21, 06/01/23, 01/30/24, 09/20/22, 05/18/22, 01/31/12, 08/03/18, 08/01/23, 08/02/21 completed fifteen (15) hours of annual training.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on observation, the following was found: Pine: 1) Lysol wipes were stored on a shelf between the restrooms and were accessible to children. 2) The closet door was open with teacher's personal belongings hanging on a hook thus leaving it accessible to children.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the diaper changing station in the Holly room had crumbs on the changing mat and underneath the mat, indicating it was not clean at the time of the inspection.

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 13. Toys and Furnishings.

General: Based on observation, a pink tricycle on the playground at Angela Hall, contained a crack in the plastic on the front and back of the tricycle.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 8. Kitchen Requirements.

General: Based on observation and interview, the interior temperature of the refrigerator in the Sassafras Room could not be verified due to the lack of a thermometer. Interview with a staff member in the room confirmed it was used for the children. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 24 of 31 Inspection Report

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 8. Kitchen Requirements.

General: Based on observation and interview, the interior temperature of the freezer in the Sassafras classroom could not be verified due to the lack of a thermometer. Interview with a staff member in the room confirmed it was used for the children.

Open Not marked corrected in the state record

Category: nutrition. Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 9. Records.

General: Based on review of documentation, it could not be verified that a child (DOE: 08/08/24) had authorization by the parent for the child-care center to seek emergency medical care for the child in the parent’s absence.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 9. Records.

General: Based on review of documentation, it could not be verified that ten (10) staff members (DOH: 08/16/12. 08/0123, 08/02/21, 08/05/14, 02/05/18, 01/31/12, 01/30/24, 09/18/23, 08/02/18 and 09/02/21) had a professional development plan.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 9. Records.

General: Based on review of documentation, the presented documentation did not indicate what children were present at the time of the drills.

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

922 KAR 2:280 · 922 KAR 2:280. Section 3. Implementation and Enforcement.

General: Based on interview and review of documentation, the following was found: 1. One staff member (DOH: 03/14/2024) did not have evidence of submission or completion of a KARES based background check. 2. The background check for one (1) staff member (DOH:08/20/2001) was expired. on 06/12/2018. Review of the Kentucky National Background Check Service (KARES) supports this evidence. Supervision In Compliance Staffing Requirements In Compliance General Administration Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 15. Statement of Deficiency and Corrective Action Plans.

A PLAN OF CORRECTION WAS DUE ON 07/30/2024 AND AS OF 08/26/2024, THE PLAN OF CORRECTION HAS NOT BEEN RECEIVED. Director Requirements In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 4 Inspection Report Employee Records Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on interview and review of documentation, a high school diploma, GED or qualifying documentation from a comparable educational entity or a Commonwealth Child Care Credential for two (2) staff members (DOH: 01/30/2024, and 08/07/2023). Interview with the staff in charge revealed the documentation was not available at the time of the survey.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on interview and review of documentation, the following was found: 1. Eleven staff members (DOH: 01/30/2024, 10/27/2023, 02/13/2024, 03/14/2024, 02/14/2024, 09/13/2023, 08/01/2023, 03/14/2024, and 08/07/2023) did not have a physician’s statements clearing them of active tuberculosis, or a negative tuberculin skin result in their personnel files. 2. One staff member (DOH: 02/01/2024) had a blank tuberculosis form in their file; therefore, the dates that the test were conducted and read could not be determined. 3. Two staff members (DOH: 09/02/2021 and 08/02/2021) had a negative tuberculin skin test on file that exceeded two (2) years; therefore, the tests were no longer current.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 7. First Aid and Medicine.

General: Based on interview and review of documentation, five staff members (5) (DOH: 10/27/2023, 11/29/2023, 08/07/2023, 09/11/2023, and 08/31/2022) did not have evidence of completing the required CPR/First Aid training on file at the facility. A review of ECE-TRIS records supports the information found during the survey.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on interview and review of documentation, the following was found: 1. Four staff members (DOH: 08/25/2022, 08/29/2022, 09/20/2022, and 08/31/2022) failed to complete fifteen (15) hours of cabinet-approved annual education training completed between July 1 and the following June 30. 2. Verification of six (6) hours of cabinet-approved orientation, completed in the first three (3) months of employment, was not presented for review for six (6) staff members (DOH: 10/27/2023, 11/29/2023, 08/01/2023, 08/07/2023, 09/11/2023, and 08/31/2022). 3. One staff member (DOH: 09/26/2023) had not updated their Pediatric Abuse and Head Trauma training after five (5) years. 4. Three (3) staff members (DOH:08/29/2022, 09/20/2022, and 08/31/2022) had not completed pediatric head trauma training (PAHT) within their first year of employment. A review of ECE-TRIS supported 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 An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 4 Inspection Report Children's Records In Compliance Written Documentation In Compliance Posted Documentation In Compliance Animals In Compliance

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

922 KAR 2:280 · 922 KAR 2:280. Section 3. Implementation and Enforcement.

General: Based on observation and review of documentation, staff hired 08/10/22, and 09/06/22, did not have the results of a KARES background check on file. Neither staff was working alone with children. Supervision In Compliance Staffing Requirements In Compliance General Administration In Compliance Director Requirements In Compliance Employee Records Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, staff hired 11/01/22, 08/01/22, and 01/05/23 did not have education documentation on file. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, staff hired on 08/10/22, did not have documentation on file from a health care professional stating that she was free of active tuberculosis.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 7. First Aid and Medicine.

General: Based on review of documentation, staff hired on 1/01/22, 08/01/22, 09/20/22, 08/08/22, 08/31/22, 06/02/14, 08/10/22, and 09/06/22, did not complete the required CPR/First Aid training. The staff have been employed for more than three months. The ECE-TRIS system was reviewed and confirmed this finding.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on review of documentation, the following was found: 1) Staff hired 04/30/18, and 09/02/21, did not have the required fifteen (15) hours of cabinet approved training on file. 2) Staff hired 08/01/22, 08/08/22, 08/31/22, 08/10/22, and 09/06/22, did not complete the required orientation training. The staff have been employed for more than three (3) months. 3) Staff hired 08/03/20, completed pediatric abusive head trauma training on 01/04/18; however, did not renew the training due 01/04/23. 4) Staff hired 09/01/08, completed pediatric abusive head trauma training on 12/29/17; however, did not renew the training due 12/29/22. The ECE-TRIS was reviewed and confirmed these findings. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment 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 Children's Records In Compliance Written Documentation In Compliance Posted Documentation In Compliance Animals In Compliance

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

922 KAR 2:280 · 922 KAR 2:280. Section 11. Status of Employment.

General: Based on observation, interview and review of documentation, the center failed to maintain the employment status of each employee who has submitted to a fingerprint- based criminal background check by reporting the status using the National Background Check Program web-based system. Observation revealed a staff member working in a classroom on 01/09/2023; review of the center's Kentucky Applicant Registry and Employment Screening (KARES) report revealed the individual was listed as 'Eligible Not Employed'. Therefore, the accurate employment status for the individual was not documented on the report. Supervision Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 2. Child Care Services.

General: Based on interview and review of documentation, a two-year-old child was left unsupervised on the playground when her classmates and teachers returned inside the building. The child was reunited with center staff within five (5) minutes of the group's departure from the playground after two (2) Sacred Heart staff members observed the child from a window of a building that sits in front of the playground. The referenced Sacred Heart staff members are not employed by the licensed child care program. Staffing Requirements In Compliance

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 15. Statement of Deficiency and Corrective Action Plans.

A PLAN OF CORRECTION WAS DUE ON 12/16/2022 AND AS OF 01/31/2023, THE PLAN OF CORRECTION HAS NOT BEEN RECEIVED.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 8. General.

General: Based on interview and review of documentation, the facility did not provide for the health, safety and comfort of a child as follows: 1) A child was hit and injured by a milk crate out on the playground. The students at the time were using the milk crates to build a structure right in front of the slide. The milk crates were to be used on the grassy area and not in front of the playground equipment. The injured child suffered a laceration to the forehead which required two (2) sutures. 2) There was an area of the playground accessible to children which contained some unsafe "loose parts", including but not limited to sticks, rocks, PVC pipe, automobile tire, bicycle tire, metal strainer, and a piece of carpet/turf. Director Requirements In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Equipment Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 13. Toys and Furnishings.

General: Based on interview and review of documentation, it was also found that the center has a loose parts area out on the playground that students use the materials to build structures. The picture provided shows some of these loose parts to be unsafe, including but not limited to sticks, rocks, PVC pipe, automobile tire, bicycle tire, metal strainer, and a piece of carpet/turf.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, the child care center failed to maintain employee records in accordance with regulations. Review of staff files revealed four (4) staff members hired 8/15/18, 9/5/17, 10/28/18 and 8/27/17 failed to have record of negative tuberculin result or a statement from a health professional that the individual is free of active tuberculosis on file.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation and interview, the child care center failed to maintain employee records in accordance with regulations. Review of staff files and ECE- TRIS report revealed one (1) staff member with a hire date of 3/15/19 had not completed state approved orientation training. Interview with staff in charge revealed this documentation was not on file at the time of survey. Programming In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Premises Not In Compliance

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on observation, the child care center failed to maintain the premises in accordance with regulations. Observation of the indoor gross motor space revealed a bottle of Ultra Cleaner labeled keep out of reach of children was located in an unlocked cabinet accessible to children.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the child care center failed to maintain the premises in accordance with regulatory requirements. Observation of the red classroom revealed a large crack in the ceiling plaster. 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 In Compliance Written Documentation In Compliance Posted Documentation In Compliance Animals In Compliance

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 10. Director Requirements and Responsibilities.

General: Based on observation, the child care center director failed to assure compliance with regulatory requirements. Observation of the Yellow Room bathroom revealed a metal rodent trap that contained what appeared to be rodent droppings. Continued observation revealed children used the bathroom and had access to the rodent trap. Employee Records Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation and interview, the child care center failed to maintain employee records in accordance with regulations. Review of staff files revealed one (1) staff member hired 5/31/16 failed to have records of negative tuberculin result or a statement from a health professional on file. Interview with director revealed this documentation was not on file at the time of survey. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation and interview, the child care center failed to maintain employee records in accordance with regulations. Review of staff files revealed three (3) staff members hired 5/31/16, 10/1/04 and 10/31/16 had not received Pediatric Abusive Head Trauma training (PAHT). Review of staff files revealed six (6) staff members with hire dates of 2/5/18, 9/13/17, 1/22/18, 10/30/17, 4/30/18 and 4/30/18 had not completed state approved orientation training. Interview with director revealed this documentation was not on file at the time of survey. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Food Service/Food Program In Compliance Food Service In Compliance Children's Records In Compliance Written Documentation In Compliance Posted Documentation In Compliance Animals In Compliance

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on review of documentation and interview the child care center failed to maintain employee records in accordance with regulatory requirements. Upon request, the child care director did not present verification that the out of state background check had been completed for the employee with the hire date of 09/06/2017. The document reviewed revealed the employee had resided in the state of West Virginia within the last five (5) years. Observation of the employee revealed she was not working alone. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation and interview, the child care center failed to maintain employee records in accordance with regulatory requirements. Upon request, the child care director did not present verification that the record of the employees with the hire dates of 08/27/2017, 08/28/2017, 09/05/2017 and 09/08/2017 contained a copy of a High school diploma: or a GED or qualifying documentation from a comparable educational entity; or Commonwealth Child Care Credential as described in 922 KAR 2:250 of educational qualifications. Programming In Compliance Premises Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the child care center failed to maintain the premises in accordance with regulations. Observation of Gold classroom revealed a plastic bag containing other loose plastic bags hanging from the cabinet in the classroom bathroom, accessible to children in care. Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation and interview, the child care center failed to maintain an outdoor play area in accordance with regulations. Observation of the outdoor play area revealed a large slide/climber set was installed directly over a dirt surface without adequate protective surface material. Continued observation revealed the protective surface failed to sufficiently cover the ground at the bottom of the slide as the dirt was very visible. Further observation revealed the protective surface surrounding the slide/climber failed to provide coverage for an adequate fall zone for the height of the slide/climber. During interview, the director acknowledged the dirt surface on the playground and she acknowledged the protective surface surrounding the aforementioned equipment failed to sufficiently cover the ground or provide for an adequate fall zone. Equipment Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the child care center failed to maintain equipment in accordance with regulations. Observation of the Gold classroom revealed a microwave on a shelf above the classroom sink used to heat up children’s lunches. Continued observation revealed the microwave door handle was broken, cracked and hanging loose from the microwave. Transportation Not Applicable Food Service In Compliance Children's Records In Compliance Written Documentation In Compliance Posted Documentation In Compliance Animals In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on Review of Documentation, and interview, the child care center failed to maintain employee records in accordance with regulatory requirements. Review of employee records for staff with hire dates, 08/15/16, 08/11/16, 09/06/16, 08/26/16 and 05/31/16 revealed no documented evidence that criminal records checks for previous state residence for each individual who indicated residence outside the state of Kentucky within the last five (5) years was conducted. In addition, review of employee record for staff with a hire date of 08/03/15 revealed no documented evidence of a completed child abuse or neglect check (CA/N). The CA/N check dated 03/24/15 and received by Division of Child Care (DCC) on 04/10/15 revealed no result of substantiated/unsubstantiated child abuse or neglect. Telephone interview with DCC on 12/15/16 revealed the CA/N request was received by DCC on 04/10/15 and was returned as the dates of the employee signature and witness did not match. DCC further stated the document was never returned for review or determination. Further review revealed an employee with a hire date of 08/15/16 failed to submit a child abuse or neglect check (CA/N) check to the cabinet within five (5) working days after the date of hire. The CA/N in the staff’s record revealed a date of submittal to the cabinet on 08/23/16. Exit interview with the child care center director revealed acknowledgement of deficient practices. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 4 Inspection Report

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on Review of Documentation, and interview, the child care center failed to maintain employee records in accordance with regulatory requirements. Review of record for staff with a hire date of 05/04/15 revealed no documented evidence of a current statement from a health professional that the employee is free of active tuberculosis or a copy of negative tuberculin results. Exit interview with the child care center site director revealed acknowledgement of deficient practice. Programming In Compliance Premises Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on Observation, and interview, the child care center failed to maintain premises in accordance with regulatory requirements. Observation of the Lavender Room in Angela Hall revealed a spray bottle which was labeled to contain “bleach”, on the changing table in accessible reach of each child during diapering. Further observation of the Red Room in Angela Hall revealed loose plastic bags in accessible reach of children in a closet that was covered by cloth curtains. Exit interview with the child care center director revealed acknowledgement of deficient practices.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on Observation, and interview, the child care center failed to maintain premises in accordance with regulatory requirements. Observation of the Red Room in Angela Hall revealed loose plastic bags in accessible reach of children in a closet that was covered by cloth curtains. Exit interview with the child care center director revealed acknowledgement of deficient practices.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on Observation, and interview, the child care center failed to maintain premises in accordance with regulatory requirements. Observation of the Green Room in Angela Hall, revealed a sink that was not equipped with hot water at a minimum temperature of ninety (90) degrees Fahrenheit and a maximum of one hundred-twenty (120) degrees Fahrenheit. When the surveyor tested the water it was “ice cold”. Interview with the staff in the classroom revealed the hot water is turned off in the classroom because it gets “scalding hot.” The staff also stated there was no temperature measuring device in the classroom to determine if the temperature was within the required standards when the hands of children were washed. The staff stated the hot water was turned on when each child required hand washing. Additional observation revealed staff failed to test the water temperature before each child washed his/her hands. Exit interview with the child care center director revealed acknowledgement of deficient practice. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 4 Inspection Report Hygienic Practices Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on Observation, and interview, the child care center failed to comply with hygienic practices in accordance with regulatory requirements. Observation of the Orange Room, Yellow Room, Lavender Room, and Red Room in Angela Hall revealed dirt and debris beneath the mat on the diaper changing station. Further observation revealed children were diapered on the table without cleaning beneath the mat. In addition, observation of the Lavender Room revealed a spray bottle which was labeled to contain “bleach”, on the changing table in accessible reach of each child during diapering. Exit interview with the child care center director revealed acknowledgement of deficient practices. First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment Not In Compliance

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on Observation, and interview, the child care center failed to maintain equipment in accordance with regulatory requirements. Observation of toys and equipment at the child care center revealed some toys and equipment were not in good repair. Observation of the Orange Room in Angela Hall revealed a stove set with loose protruding metal screws. In addition, observation of the small playground located at Angela Hall revealed a red and yellow Little Tikes car without a steering wheel or door and a small pull toy wagon without a wheel. Exit interview with the child care center director revealed acknowledgement of deficient practice.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on Observation, and interview, the child care center failed to maintain equipment in accordance with regulatory requirements. Observation of toys on the outdoor small playground area of Angela Hall revealed toys, which were broken and were not used according to the manufacturer’s safety specifications. Observation of the small playground located at Angela Hall revealed a red and yellow Little Tikes car without a steering wheel or door and a small pull toy wagon without a wheel. Exit interview with the child care center director revealed acknowledgement of deficient practice. Transportation Not Applicable Food Service Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 8. Kitchen Requirements.

General: Based on Review of Documentation, and interview, the child care center failed to maintain food service in accordance with regulatory requirements. Record review of the temperature measuring devices of the refrigerator in the Red Room of the Angela Hall, which revealed a temperature of forty-four (44) degrees Fahrenheit and the refrigerator in the Red Room of Salesia Hall, which revealed a temperature of fifty (50) degrees Fahrenheit exceeded the acceptable temperature of forty (40) degrees Fahrenheit per regulatory requirement 922 KAR 2:120 Section 8, Kitchen Requirements. In addition, there was no evidence of a temperature measuring device in the refrigerator located in the Blue Room of Angela Hall. Exit interview with the child care center director revealed acknowledgement of deficient practice. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 4 Inspection Report

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922 KAR 2:120 · 922 KAR 2:120. Section 8. Kitchen Requirements.

General: Based on Review of Documentation, and interview, the child care center failed to maintain food service in accordance with regulatory requirements by storing frozen food at a temperature of zero degrees Fahrenheit or below. Review of freezer’s temperature measuring device located in the Red Room of Angela Hall revealed four (4) degrees Fahrenheit and the device located in the Gold Room freezer of Salesia Hall revealed a measurement of thirty (30) degrees Fahrenheit. Both freezers exceeded the acceptable range of zero degrees Fahrenheit per 922 KAR 2:120, Section 8, Kitchen Requirements. Exit interview with the child care center director revealed acknowledgement of deficient practice. Children's Records In Compliance Written Documentation In Compliance Posted Documentation In Compliance Animals In Compliance

Open Not marked corrected in the state record

Category: nutrition. Open / not marked corrected.

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

General: Based on Review of Documentation and Interview, the director failed to assure compliance with regulatory requirements. Review of staff files revealed the center failed to have an annual written performance evaluation on file for staff members hired 3/24/10, 1/4/13, 5/29/13, 8/26/13, 8/28/13, and 6/2/14. Interview with director revealed these six (6) staff members were part-time employees who worked with children in care. Continued interview with director revealed she was not aware that written performance evaluations were required for part-time staff members who worked with children in care.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on Review of Documentation and Interview, the child care center failed to maintain employee records in accordance with regulations. Review of staff files revealed the center failed to have fifteen (15) hours of cabinet approved training on file for a staff member hired 9/8/14. Continued review of staff files revealed the center failed to have documentation of orientation on file for one (1) staff member hired 6/1/15. Interview with director and assistant office manager revealed the staff member hired 6/1/15 registered for orientation, but had not completed it yet.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 7. First Aid and Medicine.

General: Based on Observation, the child care center failed to comply with regulations regarding first aid and/or medication. Observation of the bathroom in the Lavender Room in Angela Hall revealed one (1) tube of diaper rash cream stored in a container in an unlocked cabinet above the toilet. Observation of the Purple Room in Salesia Hall revealed two (2) tubes of diaper rash cream stored in a container in an unlocked cabinet located between the bathrooms. Observation of the Red Room in Salesia Hall revealed four (4) cans of sunscreen, one (1) tube of sunscreen, and one (1) tube of diaper rash cream stored in a container in an unlocked cabinet located between the bathrooms. Observation of the Yellow Room in Salesia Hall revealed two (2) cans of sunscreen, one (1) tube of sunscreen, and one (1) bottle of bath oil spray stored in a container in an unlocked cabinet located between the bathrooms. Observation of the bathroom in the T2/Gold Room in Salesia Hall revealed one (1) can of sunscreen stored in an unlocked cabinet. Outdoor Play Area

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 6. Sleeping and Napping Requirements.

General: Based on Observation, the child care center failed to maintain equipment in accordance with regulations. Observation of the Rainbow Room in Angela Hall revealed two (2) mats were torn/ripped at the edges, exposing the inner foam.

Open Not marked corrected in the state record

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922 KAR 2:120 · 922 KAR 2:120. Section 8. Kitchen Requirements.

General: Based on Observation, the child care center failed to maintain food service in accordance with regulations. Observation of the Lavender Room in Angela Hall revealed the refrigerator temperature measured fifty (50) degrees Fahrenheit. Observation of the Multi-purpose Room in Angela Hall revealed the refrigerator was not equipped with an indicating thermometer. Observation of the Green Room in Salesia Hall revealed the refrigerator temperature measured forty-five (45) degrees Fahrenheit.

Open Not marked corrected in the state record

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922 KAR 2:120 · 922 KAR 2:120. Section 8. Kitchen Requirements.

General: Based on Observation, the child care center failed to maintain food service in accordance with regulations. Observation of the Yellow Room in Salesia Hall revealed food splatter on the inside of the microwave.

Open Not marked corrected in the state record

Category: nutrition. Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110. Section 3. Records.

General: Based on Review of Documentation, the child care center failed to maintain children’s records in accordance with regulations. Review of children’s files revealed the written records for children enrolled 8/11/15 and 9/8/15 failed to contain the name of each person who is designated in writing to pick-up the child. Continued review of children’s files revealed the written record for a child enrolled 7/29/15 failed to contain preferred hospital information.

Open Not marked corrected in the state record

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

General: Based on Observation, it was determined the director failed to provide for the health, safety and comfort of each child. Observation revealed a tube of sunscreen and a bottle of "Dry Erase Board Cleaner" both labeled "Keep Out of Reach of Children" located in an unlocked cabinet, accessible to children in the Red Room. Additionally in Room T3, a child was observed eating pretzels from the floor, after another child accidently spilled their snack. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 5 of 25 Web site: http://chfs.ky.gov/ Inspection Report

Open Not marked corrected in the state record

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

General: Based on Review of Documentation, it was determined the center failed to comply with regulatory requirements regarding employee records, specifically background checks. The center failed to provide documentation for review at time of survey to verify the completion of a criminal records check for any previous state of residence outside the state of Kentucky, as determined on the CAN check, for a staff member hired 9/10/13.

Open Not marked corrected in the state record

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

General: Based on Observation, it was determined the center failed to comply with regulatory requirements regarding hygienic practices, specifically child hand washing. Observation revealed the children in Room T3 failed to wash hands with liquid soap and warm water after eating afternoon snack.

Open Not marked corrected in the state record

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922 KAR 2:120 · 922 KAR 2:120. Section 6. Sleeping and Napping Requirements.

General: Based on Observation, it was determined the center failed to comply with regulatory requirements regarding equipment, specifically individual bedding storage. Observation revealed the sleeping mats located in the Rainbow Room were stored stacked atop each other with the children's mat sheets touching.

Open Not marked corrected in the state record

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922 KAR 2:120 · 922 KAR 2:120. Section 9. Food and Meal Requirements.

General: Based on Observation, it was determined the center failed to comply with regulatory requirements regarding food service, specifically snack requirements. Observation revealed the children in Room T3 were served pretzels and water for afternoon snack.

Open Not marked corrected in the state record

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

General: Based on Observation, the child care center failed to maintain their outdoor equipment. Observation of the playground revealed a brown climbing apparatus with steps leading up to it. Continued observation of the steps revealed a thirty (30) inch long strip of packaging tape, concealing wear and tear on the steps. The aforementioned brown packaging tape is torn is several areas. Interview with the director revealed she is aware of the steps being in disrepair.

Open Not marked corrected in the state record

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922 KAR 2:120 · 922 KAR 2:120. Section 5. Infant and Toddler Play Requirements.

General: Based on Interview, with the director and assistant director, the center was transitioning toddlers not yet twenty-one (21) months or older in with children that had recently turned two years old. Further interview with the director and assistant director revealed the center was unaware a transition procedure was needed that included a transition plan, listed a transitioning toddler on attendance records, including a specific day and time the toddler was with either age group along with the signature and approval of the toddler’s parent on the toddler’s transition plan. 420 - Infant Sleep Position Not Applicable 922 KAR 2:120. Section 6. Sleeping and Napping Requirements. (1) An infant shall sleep or nap on the infant’s back unless the infant’s health professional signs a waiver that states the infant requires an alternate sleeping position.

Open Not marked corrected in the state record

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

General: Based on Observation, a plunger and toilet brush were accessible in the restroom located in the Silver Room/T1. Continued observation revealed a toilet brush was accessible in the restroom located in Gold Room/T2. Further observation revealed a plunger was accessible in the restroom located in Blue Room/Room 103. Ongoing observation revealed toilet brushes were accessible in the restrooms located in Red Room/Room 102 and Yellow Room/Room 100.

Open Not marked corrected in the state record

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922 KAR 2:120 · 922 KAR 2:120. Section 2. Child Care Services.

General: Based on Observation and interview, at approximately 10:00 am eighteen children between the ages eighteen months and two years old were on the playground with four staff members. Continued observation revealed the children were not divided into groups and were allowed to play together. Further observation revealed at approximately 10:25 am a staff member was supervising eleven one year olds in the Green Room located in the Angelina Building while a second staff member was in the hallway retrieving a child's personal effect from a back pack.

Open Not marked corrected in the state record

Category: ratio. Open / not marked corrected.

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

General: Based on Review of Documentation for all staff members, a staff member with a hire date of 01/02/2012 had written evidence of having lived in a previous state. Interview with the center's director revealed the staff member had lived in the state of Kentucky for approximately four years.

Open Not marked corrected in the state record

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

General: Based on Observation, food crumbs were on the carpet in the Green Room located in the Angelina Building. Continued observation revealed a visible build-up of dust along the vent covers and a ceiling tile with a brown circular stain in the Blue Room located in the Angelina Building. Further observation revealed in Blue Room located in the Angelina Building the following: visible buildup of dust along the return vents: cobwebs hanging along the doorway leading to the outside playground, and three ceiling tiles with discolored circular areas. Observation of the Silver Room/T1 located in Salesia Hall revealed the dry was broken under the window seal and dust along the ceiling. Continued observation in Salesia Hall revealed the following rooms had a visible build-up of dust on the outside of the return vents were: Gold Room/T2, Orange Room/Room 101, Green Room/Room 105, and T3. Further observation in Salesia Hall revealed the paint was chipped down to the dry wall in areas in the following rooms were: Blue Room/Room 103 and Red Room/Room 102.

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on Observation, three fluorescent bulbs were not working in the Blue Room located in the Angelina Building. Further observation revealed three light bulbs were not working in the Silver Room/T1 located in Salesia Hall.

Open Not marked corrected in the state record

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

General: Based on Observation, after twelve children returned from taking a walk outside the two staff members in the room did not prompt/assist the children with washing their hands prior to sitting down for circle time.

Open Not marked corrected in the state record

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

General: Based on Observation, after twelve children returned from taking a walking trip outside the two staff members in the room assisted the children with removing their jackets. Further observation revealed each child's jacket was stacked in a fashion which allowed for direct contact. 645 - Toothbrush/Toothpaste Not Applicable 922 KAR 2:120. Section 10. Toilet, Diapering, and Toiletry Requirements. (15) Toothbrushes shall be: (a) Individually identified; (b) Allowed to air dry; and (c) Protected from contamination. (16) Toothpaste used by multiple children shall be dispensed onto an intermediate surface, such as waxed paper, to avoid cross contamination. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 14 of 26 Web site: http://chfs.ky.gov/ Inspection Report

Open Not marked corrected in the state record

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922 KAR 2:120 · 922 KAR 2:120. Section 7. First Aid and Medicine.

General: Based on Observation, three permission slips to administer diaper rash cream during a diaper change for three different children did not have an ending date.

Open Not marked corrected in the state record

Category: ratio. Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 7. First Aid and Medicine.

General: Based on Observation, seven tubes of diaper rash cream were located in a basket on the changing table. Further observation revealed each tube was labeled with a child's name along with drug fact information on each tube. Outdoor Play Area

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

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

General: Based on Observation, the grass was observed growing up through the ground covering.

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 6. Sleeping and Napping Requirements.

General: Based on Observation, the vinyl covering on four mats in the Purple Room located in Salesia Hall was torn allowing for the foam padding to be exposed.

Open Not marked corrected in the state record

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

General: Based on Observation, fifteen children were playing on a metal play structure that had a note posted on a set of steps that were broken. Further observation revealed yellow caution tape was placed along the front of the steps to prevent them from being accessed but portions of the tape had been torn about allowing the steps to be accessed.

Open Not marked corrected in the state record

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922 KAR 2:120 · 922 KAR 2:120. Section 2. Child Care Services.

General: Based on Review of Documentation and interview, the center did not have a written policy that specifies that the procedures that were taught at the orientation training shall be implemented by each child-care center staff member.

Open Not marked corrected in the state record

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

General: Based on Review of Documentation, one (1) staff person (hire date: 8/16/12) did not have evidence of a high school diploma, GED or Commonwealth Child Care Credential in their file.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110 - Section 5 (1)

General: Based on Review of Documentation, the surveyor found that the driver of the campus school bus (hire date: unknown) did not have TB skin documentation on file at the time of the inspection. 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 Not In Compliance Findings: General: Based on Review of Documentation, it was revealed that the driver of the campus school bus nor the bus monitor was currently certified in CPR. 2) First Aid Not In Compliance Findings: General: Based on Observation, it was revealed that the driver of the campus school bus nor the bus monitor was currently certified in First Aid. 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 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 2) Type II Not Applicable An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 8 of 40 Web site: http://chfs.ky.gov/ Inspection Report 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, one (1) staff file did not contain evidence of the six (6) hours of cabinet-approved orientation training being completed within the first three (3) months of employment. The employee was hired on 7/1/12. 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 In Compliance 3) Drivers license In Compliance 4) No convictions for vehicle operation In Compliance 5) No accident causing death 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. 2) Background checks Not In Compliance Findings: General: Based on Review of Documentation, the surveryor found that the driver of the campus school bus did not have a driving record on file at the time of the inspection. General: Based on Review of Documentation, the surveryor found that the driver of the campus school bus did not have a driving record on file at the time of the inspection. 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

Open Not marked corrected in the state record

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

General: Based on Review of Documentation, a staff person hired 8/21/11 and staff person hired 5/21/11 did not have a high school diploma, GED or Commonwealth Care Credential on file. The Director acknowledged the finding during interview and provided no further comment regarding this violation.

Open Not marked corrected in the state record

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