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Home › KY › Middlesboro › Small Wonders Child Development Center, LLC
License #L383429 · Center · Licensed
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General: Based on observation, the surveyor found the toilet seat was loose on the toilet in the girls' restroom; therefore, the toilet seat was not kept in good repair. Staff-in-charge stated she would have this repaired. Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation In Compliance Kitchen Requirements Not In Compliance
General: Based on observation, the surveyor found, in the Early Pre-K Classroom, long loose threads from frayed edges of the carpeting running across the middle of the room in multiple areas; therefore, the carpeting was not kept in good repair. Staff-in-charge stated she would have the loose threads and frayed edges fixed. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 4 Inspection Report
General: Based on review of documentation, and review of ECE-TRIS, the surveyor found the following: 1. One (1) staff (DOH: 08/03/15) completed zero (0) hours of the required fifteen (15) hours of cabinet-approved early care and education training for the review period of 07/01/23- 6/30/24. 2. One (1) staff (DOH: 03/02/24) completed two and one-half (2 ½) hours of the required fifteen (15) hours of cabinet-approved early care and education training for the review period of 08/11/23-08/11/24. 3. One (1) staff (DOH: 01/09/23) completed zero (0) hours of the required fifteen (15) hours of cabinet-approved early care and education training for her second year review period of 02/28/24-06/30/24. Programming In Compliance Premises Not In Compliance
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Generated from this facility's specific inspection record
Data synced from Kentucky Cabinet for Health and Family Services, Division of Child Care on Jul 11, 2026 · Source records · Report an error
General: Based on review of documentation of the childcare center’s KARES roster, the surveyor found one (1) current staff (DOH: 08/03/15) listed as a pending employee with determination status “In Process.” The surveyor found through a review of individual's applicant history in KARES that the last determination date was 01/03/19. The staff member was not observed by the surveyor working with children during the surveyor's inspection. During interview, staff-in-charge stated that this staff member has attempted to get her fingerprints updated since 2024; however, IdentiGo has not provided her an appointment date. Supervision In Compliance Staffing Requirements In Compliance General Administration Not In Compliance
A PLAN OF CORRECTION WAS DUE ON 07/18/2025 AND AS OF 10/15/2025, THE PLAN OF CORRECTION HAS NOT BEEN RECEIVED. Findings: A PLAN OF CORRECTION WAS DUE ON 10/30/2025 AND AS OF 11/26/2025, 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
General: Based on interview and review of documentation, the surveyor found one (1) staff’s (DOH: 01/09/25) file did not contain documentation of education in the form of a high school diploma, GED, or Commonwealth Child Care Credential. During interview, staff-in-charge stated this staff person is a substitute who works primarily at another childcare center. The staff-in-charge stated she would obtain the staff's education documentation.
General: Based on review of documentation, the surveyor found two (2) staff’s (DOH: 01/09/25 and DOH: 02/17/25) files contained no documentation of negative tuberculin (TB) skin tests or statements from a health professional that these staff were free of active tuberculosis. During interview, staff-in-charge stated she would ask these staff to submit the documentation.
General: Based on review of documentation, the surveyor found no food service permit dated through the current year. The most recent expiration date on the childcare center’s food service permit provided was 12/31/23. Staff-in-charge provided for review a copy of their inspection report from the Department of Public Health dated 03/14/24; however, staff-in-charge was unable to locate a current food service permit for the surveyor to review the date of the inspection. Food Service In Compliance Meal Planning/Center Provides Meals In Compliance Meal Planning/Center Does Not Provide Meals In Compliance Children's Records In Compliance Written Documentation Not In Compliance
General: Based on review of documentation, the surveyor found one (1) staff’s (DOH: 08/03/15) file contained a professional development plan dated 08/01/22.
General: Based on review of documentation, the surveyor found that documentation for monthly fire drills and quarterly tornado, earthquake, and lockdown drills were not available for review the date of the inspection. During interview, staff-in-charge stated that the drills were completed; however, they were currently not at the childcare center as the director had them with her off-site. Posted Documentation In Compliance Animals In Compliance
This investigation inspection recorded no violations or advisories.
General: Based on observation, the surveyor found the following: Girls' Restroom: 1. There was a layer of dust on the exhaust fan. Pre-K Classroom: 1. There were multiple pieces of paper under the reading center's platform. Nursery: 1. There was a layer of dust located on the air vent. School age Classroom: 1. There was a layer of dust on two (2) air vent. Boys' Restroom: 1. There was a layer of dust on the exhaust fan. Two-Year-Old Classroom: 1. There was a brown substance on a ceiling tile located next to the air vent. Changing Room: 1. There was a layer of dust on the air vent. Staff member reported that she would have the areas cleaned and the ceiling tiles changed.
General: Based on observation, the surveyor witnessed the toilet seat was not tightly secured to the toilet; therefore, the toilet seat was not in good repair. Staff member stated that she would have the toilet seat tightened. Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Kitchen Requirements In Compliance Food Service In Compliance Meal Planning/Center Provides Meals In Compliance Meal Planning/Center Does Not Provide Meals Not Applicable Children's Records In Compliance Written Documentation In Compliance Posted Documentation In Compliance Animals In Compliance
General: Based on review of documentation and ECE-TRIS, the surveyor discovered the following: 1. A staff member (DOH: 08/03/2015) completed twelve (12) of the required fifteen (15) hours of cabinet-approved early care and education training completed between 07/01/2022 through 06/30/23. 2. A staff member (DOH: 05/22/2023) did not complete the required six (6) hours of cabinet-approved orientation completed within the first three (3) months of employment. Staff member reported that she would make sure staff completes trainings. Programming In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Premises Not In Compliance
This investigation inspection recorded no violations or advisories.
This change of location inspection recorded no violations or advisories.
General: Based on observation, the surveyor observed rips in the diaper changing pad located in the Infant/Toddler Classroom. Staff reported she would replace the diaper changing pad. First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Kitchen Requirements In Compliance Food Service In Compliance Meal Planning/Center Provides Meals In Compliance Meal Planning/Center Does Not Provide Meals Not Applicable Children's Records In Compliance Written Documentation In Compliance Posted Documentation In Compliance Animals Not Applicable
General: Based on review of documentation and ECE-TRIS, the surveyor discovered that a staff (DOH:08/03/2015) completed three and one-half (3 1/2) of the required fifteen (15) hours of cabinet-approved early care and education training completed between 7/1/2021 through 6/30/2022. Staff reported she thought the staff's fifteen (15) hours of training was completed. Programming In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Premises Not In Compliance
General: Based on observation, the surveyor discovered the following: 1. Debris was on a light cover in the Infant/Toddler Classroom. 2. Debris was on six (6) light covers in the Preschool Classroom. 3. A smoke detector was hanging by two (2) wires approximately three (3) inches from the ceiling. 4. A ceiling tile contained a brown substance that appeared to be a stain located by the window of the Preschool Classroom. 5. Debris was on five (5) light covers in the Early Preschool Classroom. Staff reported she would have the light covers cleaned and the smoke detector installed correctly. Hygienic Practices Not In Compliance
This investigation inspection recorded no violations or advisories.
General: Based on observation, the surveyor found the following: 1. A staff’s (DOH: 06/15/22) file did not contain documentation of a current TB skin test or a statement from a health professional stating that the adult was free from active tuberculosis. During interview, staff-in-charge stated that the staff person has had a TB skin test; however, the documentation was at the doctor's office and could not be sent over. 2. A staff’s (DOH: 06/03/22) file did not contain documentation of a current TB skin test or a statement from a health professional stating that the adult was free from active tuberculosis.
General: Based on review of documentation presented, the surveyor learned the following: 1. A staff’s (DOH: 12/27/2021) file contained no verification of a negative tuberculin result or a statement from a health professional that the individual is free from active tuberculosis. 2. A staff’s (DOH: 02/02/2022) file contained no verification of a negative tuberculin result or a statement from a health professional that the individual is free from active tuberculosis. 3. A staff’s (DOH: 02/01/2022) file contained no verification of a negative tuberculin result or a statement from a health professional that the individual is free from active tuberculosis. 4. A staff’s (DOH: 01/02/2022) file contained no verification of a negative tuberculin result or a statement from a health professional that the individual is free from active tuberculosis. 5. A staff’s (DOH: 09/13/2021) file contained a copy of a negative tuberculin result that was no longer current as of 10/15/2019. Staff reported the staff has been on leave due to sickness and maternity leave. During interview, staff confirmed that the documentation was not in the staff’s files at the time of the survey.
General: Based on review of documentation and ECE-TRIS, the surveyor found a staff’s (DOH: 10/21/2021) file did not contain documentation of the completion of the six (6) hours of cabinet-approved orientation training; therefore, the training was not obtained during the staff’s first three (3) months of employment. During interview, staff stated she would ensure that the staff completes the orientation training as soon as possible. Programming In Compliance Premises Not In Compliance
General: Based on interviews, the surveyor learned that a three-year-old child walked out of the classroom and out the front door, behind a staff person. The staff person was unaware the child was behind her exiting the child care center. The staff then saw the child on the sidewalk. Therefore, the center failed to ensure that the child was within scope of vision and range of voice. Staffing Requirements In Compliance General Administration Discussed
General: Based on review of documentation, the surveyor found the following: 1. A child’s (DOE: 06/01/21) file contained an immunization certificate that was no longer current as of 09/01/21. 2. A child’s (DOE: 03/03/20) file contained an immunization certificate that was no longer current as of 03/29/21. 3. A child’s (DOE: 08/11/21) file did not contain an immunization certificate. 4. A child’s (DOE: 08/16/21) file did not contain an immunization certificate. 5. A child’s (DOE: 08/09/21) file did not contain an immunization certificate.
General: Based on review of documentation and ECE-TRIS, the surveyor found the following: 1. A staff’s (DOH: 05/14/21) file did not contain documentation of completion of six (6) hours of cabinet-approved orientation training; therefore, the training was not completed within the first three (3) months of employment. 2. A staff’s (DOH: 01/14/21) file did not contain documentation of completion of six (6) hours of cabinet-approved orientation training; therefore, the training was not completed within the first three (3) months of employment. First Aid/Medication In Compliance Food Service In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 4 Inspection Report Children's Records Not In Compliance
General: Based on review of documentation, the surveyor found that a staff’s (DOH: 09/02/21) file did not contain documentation of background checks submitted through the Kentucky National Background Check Service. Based on review of the Kentucky National Background Check Service, the staff person was listed as ‘in process’ and had not submitted to fingerprints. During interview, staff-in-charge confirmed that the staff person had not submitted to fingerprints as of 09/08/21; therefore, the staff person was hired prior to clearance for employment. Staff-in-charge stated that she was unaware that the staff person had to submit to fingerprints prior to employment. Through interview with staff, the surveyor learned that the staff person has worked alone with children. The surveyor did not observe the staff person to work alone with children during the visit on 09/08/21. Staff-in- charge stated that the staff person did not have a completed Child Abuse/Neglect Background Check or completed Criminal Records Background Check on file. Supervision In Compliance Staffing Requirements In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 4 Inspection Report General Administration Not In Compliance
General: Based on observation during a tour of the center, the surveyor found the light in the Sensory Room flickers and then dims; therefore, the lighting in the Sensory Room was not in good repair.
General: Based on observation during a tour of the center, the surveyor found the following: 1. The lesson plan posted in the Two-Year-Olds Classroom was dated for 04/12/21 – 04/23/21; therefore, the lesson plan was not current. 2. The lesson plan posted in the Preschool Classroom was dated for 04/12/21 – 04/23/21; therefore, the lesson plan was not current. 3. The lesson plan posted in the Nursery/Toddler Classroom was dated for 04/12/21 – 04/23/21; therefore, the lesson plan was not current. During interview, staff reported that lesson plans are updated every week; however, they were not posted in the classrooms. Premises Not In Compliance
General: Based on observation during a tour of the center, the surveyor found the water temperature in the restroom and classroom sinks were measured to be at seventy-eight (78) degrees Fahrenheit; therefore, the sinks were not equipped with hot water at a minimum temperature of ninety (90) degrees Fahrenheit and a maximum of one hundred-twenty (120) degrees Fahrenheit. Hygienic Practices In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3 Inspection Report 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 review of documentation, one (1) staff (DOH: 11/24/15) file contained a TB skin test screening form that had been altered and/or falsified. The staff person's TB skin test screening form appeared to have been altered and/or falsified as the markings on the form were exactly the same as another staff person's screening form. Based on interview with a health department employee, the surveyor verified that the mentioned staff person had not been at the health department on the date that was documented on the TB skin test screening form and that a TB skin test screening form had not been completed at that health department. During interview, the director and Staff #1 both stated that they were not aware that the TB skin test screening form had been altered and/or falsified. Based on review of documentation and interview, it was confirmed that the TB skin test screening form had been altered and/or falsified.
This follow-up inspection recorded no violations or advisories.
This change of space/change in capacity inspection recorded no violations or advisories.
This investigation inspection recorded no violations or advisories.
General: Based on observation, the surveyor found that the light in the girls’ restroom was dim and not working properly; therefore, the room was not well lit. This deficiency was cited during a Renewal Inspection conducted on 01/24/2020. The written Plan of Correction on the Renewal Inspection stated that following: “The valance had just started going out the same week the surveyor showed up for inspection and we already had someone coming to repair it on 02/01/2020. It is now in working condition.” The Ongoing Compliance for this Plan of Correction stated the following: “Any needed repair will be done as soon as possible. We always try to address repairs in a timely manner. If they can be done the same day we do attempt to get someone out, however, at times it may be the following Saturday.” Hygienic Practices In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report First Aid/Medication In Compliance Outdoor Play Area In Compliance Written Documentation In Compliance Posted Documentation In Compliance Emergency Regulation Not In Compliance
Based on observation, the surveyor found that there were eleven (11) children present in the classroom for the two- and three-year-old children. During interview, the staff stated that she did not realize another child had entered the classroom. Therefore, the classroom was over the group size by one (1) child. This deficiency was cited due to the following E-Reg: 922 KAR 2:400E Section 3. Social Distancing Requirements for Child Care Programs. (1) A child care center shall have a maximum group size of ten (10) children per group. Based on observation, the temperature of the surveyor was not taken before the surveyor was permitted entry into the child care center. Based on interview, the staff stated that they have been screening individuals; however, they did not think of screening the surveyor upon entrance to the center. This deficiency was cited due to the following E-Reg: 922 KAR 2:400E Section 6. Screening and Illness Requirements. (1) Children and adults shall be screened for fever and contagious symptoms upon entry into the child care center.
General: Based on interview, the surveyor found the following: 1. Staff in the Infant/Toddler Room stated they sanitize the mouth contact toys by spraying them with a soap solution and wiping them off. 2. Staff in the Preschool Room confirmed that some of the children were not fully potty-trained. The staff stated they sanitize the mouth contact toys by spraying them with a bleach solution and wiping them off. First Aid/Medication Not In Compliance
General: Based on review of documentation and ECE-TRIS, the surveyor found that the childcare center does not have two (2) qualified staff in the case of need. The two (2) individuals identified as substitute staff do not meet qualification based on lack of verification of education and copy of a negative tuberculin result or statement from a health professional that the individual is free of active tuberculosis.
General: Based on review of documentation, the surveyor found that the proper methods for diaper changing and hand washing were not posted at the diaper-changing table located near the restrooms. Animals Not Applicable
General: Based on observation, the surveyor measured the water temperature at the sink in the girls’ restroom. The water temperature measured to be 140 degrees Fahrenheit. Hygienic Practices Not In Compliance
This change of space/change in capacity inspection recorded no violations or advisories.
General: Based on observation, the surveyor found that one (1) staff was providing care for seven (7) children whose ages ranged from two-years-old to eight-years-old. Staff confirmed that the child was in the group for the entirety of the day. A transition plan for the child was not available for review. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2
General: Based on interview, a former staff person confirmed that while working at the childcare center, she spanked her own child in the restroom. She confirmed that the child was signed into the center at the time.
This change of service inspection recorded no violations or advisories.
General: Based on review of documentation, the surveyor found the following: (1.) A written record of the December 2018 fire drill was not documented. (2.) A list of children who participated in the fire, earthquake, and tornado drills were not documented for the year of 2018.
General: Based on observation, the surveyor found the following: (1.) One (1) electrical outlet in the preschool room without a protective cover. (2.) A broom and a dust pan was accessible to the children in the indoor gross motor room. Employee Records Not In Compliance
General: Based on review of documentation and ECE – TRIS, the surveyor found that staff (DOH: 8/3/15) obtained three (3) of the required fifteen (15) hours of cabinet – approved early care and education training. Programming In Compliance Premises Not In Compliance
General: Based on observation, the surveyor found the toilet in the restroom contained urine, feces, and dirty toilet paper; therefore, the toilet was not kept in a clean condition. Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area Not Applicable Equipment In Compliance Transportation Not Applicable Food Service/Food Program In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3 Inspection Report Food Service Not In Compliance
This change of location inspection recorded no violations or advisories.
General: Based on review of documentation contained in ten (10) children’s files, the surveyor found that the file for a child (DOE: 06/12/17) contained an immunization certificate that was no longer current as of 09/30/17. Written Documentation Not In Compliance
General: Based on review of documentation, the surveyor found no verification that earthquake drills were conducted during the first, second and third quarters of 2017. Posted Documentation In Compliance Animals Not Applicable
General: Based on review of documentation, the surveyor found that the Type I childcare center has two (2) substitute staff persons. However, only one (1) staff person meets qualification based on the lack of fifteen (15) hours of cabinet-approved annual training.
General: Based on review of documentation, the surveyor found that the Type I childcare center has two (2) substitute staff persons. However, only one (1) staff person meets qualification based on the lack of fifteen (15) hours of cabinet-approved annual training.
General: Based on observation, during the surveyor's visit on 11/9/17, there were thirteen (13) children present at the daycare center but only eleven (11) had been signed in on the attendance sheet.
General: Based on review of documentation, the surveyor found the following: 1. A staff member’s (DOH: 11/2/17) file did not contain a negative TB skin test result. 2. A staff member’s (DOH: 9/25/17) file did not contain a negative TB skin test result. Programming In Compliance Food Service In Compliance Children's Records Not In Compliance
General: Based on review of documentation, the surveyor found that a child's (DOE: 1/26/17) file did not contain an immunization certificate. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Written Documentation Not In Compliance
General: Based on observation, two (2) staff members (DOH: 10/25/16 & 11/24/15) wiped a child's nose with a tissue during the surveyor's visit. Neither staff washed their hands after completing this action. Therefore, the staff hand washing guidelines were not followed. Food Service In Compliance Written Documentation Not In Compliance
General: Based on observation, there were a total of fourteen (14) children present during this surveyor’s visit; however, based on review of documentation, there was only one (1) child signed in on the attendance sheets.
General: Based on review of documentation of staff files, the following was found: 1) One (1) staff file (DOH: 8/23/17) did not contain the results of the criminal records check (CRC). 2) Two (2) staff files (DOH: 8/18/17 & 8/23/17) did not contain a completed child abuse and neglect (CA/N) background check. Based on interview, the director stated that the results of these checks had not yet been received. Further interviews revealed that both staff members were together in the pre-school classroom with no other staff present starting at 9:00am on 8/29/17, which was prior to the surveyor's arrival. Based on observation, both staff members were present in the pre- school classroom with no other staff until 12:30pm. Therefore, two (2) staff members without completed background checks were left alone in a classroom for three and a half (3 1/2) hours. 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 and interview, the surveyor determined that on 8/14/17 the center's menu documented that the children were served water, apple, and cheese puffs for snack. The children were not provided with all of the meal requirements for snack as they were only served a fruit and not served milk, protein, bread, or a vegetable in addition to the fruit. The Director stated that the cheese puffs were actually cheese crackers and staff had documented it incorrectly on the menu.
General: Based on review of documentation and interview, the following were found: 1. A staff file (DOH:8/24/17) did not contain documentation of a negative tuberculin skin test or a negative screening completed by a medical professional. 2. A staff file (DOH:8/18/17) did not contain documentation of a negative tuberculin skin test or a negative screening completed by a medical professional. The Director reported that the staff members had not yet obtained a turberculin skin test or a negative screening. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 4 Inspection Report Programming Not In Compliance
General: Based on observation and interview, the surveyor found that a staff member (DOH: 11/24/15) communicated with a two-year-old child in a loud and demeaning manner in regards to the child having an accident on himself. As the surveyor was entering the building, a staff member was heard repeatedly questioning a child by asking "Why are you wet?" in a loud deep voice. Upon entering the classroom where this staff and child were located, the surveyor observed the staff member standing over the child who was in front of the staff member. There were ten (10) other children present in the room as well as two (2) other staff that had observed the exchange. Upon interview, the staff member stated that the parent has requested that staff be stern with the child in regards to potty training. Premises Not In Compliance
This change of location inspection recorded no violations or advisories.
General: Based on observation and interview, the surveyor observed two (2) infants sleeping in cribs with loose bedding on them. Upon interview, staff reported that both children were eleven (11) months old. Staff in charge stated that the children's parents prefer that the children have a blanket while sleeping.
General: Based on observation, the following was found: 1. Two (2) staff (DOH: 10/7/16, 10/10/16) were left alone providing care to children in the infant/toddler room without completed background checks. 2. A staff (DOH: 11/24/15) did not have an out of state background check from the previous state of residence. The staff (DOH: 11/24/15) was observed working alone with children and has been employed for more than ninety (90) days. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 5 Inspection Report
General: Based on observation, one (1) infant was lying in a crib with a loose blanket. 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 Not In Compliance
General: Based on review of documentation, the center has a food service contract with Libby's Catering Service. The center does not have a current food service permit from the catering service. The center's food service permit expired on 12/31/15.
General: Based on review of documentation, three (3) children's files (dates of enrollment unknown) contained immunization certificates that were no longer current as of 02/09/16, 10/13/16, and 10/13/16. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 4 of 5 Inspection Report
This investigation inspection recorded no violations or advisories.
General: Based on observation, the surveyor found several items, i.e., a vacuum cleaner, three (3) diaper bags, a trash can and a small cabinet, cluttering the hallway. Therefore, the fire exits were not being kept clear.
General: Based on review of documentation, sign in sheets from 1/1/16 through 10/5/16 showed the center was closed on 1/20/16, 1/21/16, 1/22/16, 2/15/16, 3/14/16 and 9/13/16. The director did not notifiy the Division of Regulated Child Care (DRCC) of the centers temporary closures. Based on an interview with the Director, the surveyor was informed that she was not aware that she had to notifiy the DRCC when she decided to close the center. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Premises Not In Compliance
General: Based on observation, the surveyor found the following: 1. A staff member was drinking from a can of Rockstar Energy Drink in front of the children. 2. A vacuum cleaner had been placed in the hallway and was accessible to the children.
Based on review of documentation and interview, the child care center only has one (1) qualified substitute.
General: Based on review of documentation and interview, the child care center only has one (1) qualified substitute. 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 review of documentation, the child care center failed to provide documentation for submitting a timely criminal record check for one (1) employee (DOH:8/3/15), as pursuant to KRS 199.896 (19). The Criminal Record Check was not completed on or before the first date of employment. Based on interview, the staff member has not worked alone with children.
General: Based on review of documentation and interview, verification of quarterly earthquake and tornado drill for the months of July through September 2015 was not presented for surveyor review. Posted Documentation
General: Based on review of documentation and interview, the child care center director failed to maintain one (1) staff member's (DOH:8/3/15) Criminal Records Check and Child Abuse and/or Neglect Check for five (5) years as required. These documents were not presented for surveyor review. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 24 of 26 Web site: http://chfs.ky.gov/ Inspection Report
General: Based on review of documentation, an employee (DOH 07/20/15) record presented for review did not contain verification of educational requirements.
General: Based on observation, two (2) handwashing sinks were equipped with hot water measuring 130 degrees Fahrenheit. Therefore, the water temperature exceeded the requirement that hot water is at minimum of ninety (90) degrees Fahrenheit and at a maximum of 120 degrees Fahrenheit.
General: Based on review of documentation, the following was found: 1) A substitute (DOH 07/20/15) file presented for review on 07/17/15 did not contain the following required documentation: a completed criminal record check, a completed central abuse and neglect registry check, and negative tuberculin verification. 2) A substitute (DOH 07/20/15) file presented for review on 07/17/15 did not contain the following required documentation: a completed criminal record check, a completed central abuse and neglect registry check, and verification of educational requirements. Therefore, the center did not have qualified substitutes as required by regulations. 340 - Training Discussed 922 KAR 2:110. Section 5. Staff Requirements. (14) In accordance with KRS 199.896(15) and (16), 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 of cabinet-approved early care and education training within the first year of employment, including one and one-half (1 ½) hours of pediatric abusive head trauma training; and (c) Fifteen (15) hours of cabinet-approved early care and education training during each subsequent year of employment, including one and one- half (1 ½) hours of pediatric abusive head trauma training completed once every five (5) years. 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 presented, the surveyor found the following: 1. A staff’s (DOH: 08/03/2015) file contained a professional development plan that was last updated on 08/01/2020. 2. A staff’s (DOH: 11/15/2019) file contained a professional development plan that was last updated on 11/30/2020. During interview, staff confirmed that the professional development plans need to be updated. Posted Documentation In Compliance Animals In Compliance
General: Based on observation, the surveyor found the water temperature in both the girls’ and boy’s restroom sinks were one hundred twenty-five (125) degrees Fahrenheit. Therefore, the hot water was not kept at a minimum temperature of ninety (90) degrees Fahrenheit and a maximum of one hundred twenty (120) degrees Fahrenheit. During interview, staff stated she stated she would ask the landlord to have someone check the hot water heater.
General: Based on review of documentation presented, the surveyor found the following: 1. A staff’s (DOH: 12/27/2021) file presented for review did not contain a high school diploma, GED, or Commonwealth Child Care Credential. 2. A staff’s (DOH: 02/02/2022) file presented for review did not contain a high school diploma, GED, or Commonwealth Child Care Credential. 3. A staff’s (DOH: 2/01/2022) file presented for review did not contain a high school diploma, GED, or Commonwealth Child Care Credential. 4. A staff’s (DOH: 01/27/2022) file presented for review did not contain a high school diploma, GED, or Commonwealth Child Care Credential. During interview, staff confirmed that the staff’s education documents were not in the staff’s files. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 4 Inspection Report
General: Based on observation during a tour of the center, the surveyor found the following: 1. A coating of dust on the ceiling air vent in the boys' restroom. 2. A coating of dust on the ceiling air vent in the girls’ restroom. During interview, staff stated they would ask the landlord to have the air vents cleaned. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 4 Inspection Report
General: Based on observation during a tour of the center, the surveyor found what appeared to be urine and feces substances inside the toilet bowl. The surveyor observed to see if staff checked the restroom for cleanliness. During a period of approximately ten (10) minutes, staff did not check the restroom after a child had utilized the restroom. During interview, staff stated that the restroom issue will be discussed with all staff. 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 Not In Compliance
General: Based on review of documentation presented, the surveyor found the following: 1. A child’s (DOE: 06/05/2020) enrollment data did not contain information to enable a person in charge to contact the preferred hospital. 2. A child’s (DOE: 02/07/2022) enrollment data did not contain information to enable a person in charge to identify or contact the family physician or preferred hospital. 3. A child’s (DOE: 10/25/2018) enrollment data did not contain information to enable a person in charge to contact the preferred hospital. During interview, staff confirmed the information was not provided in the children's files. Written Documentation Not In Compliance
General: Based on review of documentation, the surveyor found that a staff’s (DOH: 05/14/21) file did not contain a completed Criminal Records Background Check (CRC). The staff’s file contained a completed Child Abuse/Neglect Background Check only dated 05/20/21. The staff’s file contained a receipt showing payment for the CRC. During interview, staff-in-charge stated that the CRC was completed for the staff person; however, she was unable to locate the documentation. Staff-in-charge stated that the staff person did not work alone with children. Based on review of the Kentucky National Background Check Service, the staff person was fingerprinted on 08/09/21 and had an eligible for hire date of 08/09/21. Director Requirements Not In Compliance
General: Based on review of documentation, the surveyor found that a staff’s (DOH: 09/02/21) file did not contain documentation of background checks submitted through the Kentucky National Background Check Service. Based on review of the Kentucky National Background Check Service, the staff person was listed as ‘in process’ and had not submitted to fingerprints. During interview, staff-in-charge confirmed that the staff person had not submitted to fingerprints as of 09/08/21; therefore, the staff person was hired prior to clearance for employment. Staff-in-charge stated that she was unaware that the staff person had to submit to fingerprints prior to employment. Through interview with staff, the surveyor learned that the staff person has worked alone with children. The surveyor did not observe the staff person to work alone with children during the visit on 09/08/21. Staff-in- charge stated that the staff person did not have a completed Child Abuse/Neglect Background Check or completed Criminal Records Background Check on file. Employee Records Not In Compliance
General: Based on review of documentation, the surveyor found that a staff’s (DOH: 09/08/21) file did not contain documentation of a current TB skin test or a statement from a health professional stating that the adult was free from active tuberculosis. During interview, staff-in-charge stated that the staff person has had a TB skin test; however, she was unable to locate the documentation during the surveyor's visit.
General: Based on review of documentation, the surveyor found the following: 1. A child’s (DOE: 08/11/21) file did not contain a contact telephone number for the child’s preferred hospital. 2. A child’s (DOE: 08/16/21) file did not contain a contact telephone number for the child’s preferred hospital. 3. A child’s (DOE: 08/05/21) file did not contain the name of each person who is designated in writing to pick-up the child. 4. A child’s (DOE: 06/01/21) file did not contain the name of each person who is designated in writing to pick-up the child or the contact telephone number for the child’s preferred hospital. 5. A child’s (DOE: 06/01/21) file did not contain the name of each person who is designated in writing to pick-up the child or the contact telephone number for the child’s preferred hospital. 6. A child’s (DOE: 01/04/20) file did not contain the name of each person who is designated in writing to pick-up the child, the preferred hospital name, or contact telephone numbers for the preferred hospital and family physician. 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 review of documentation, the surveyor found the following: 1. The daily attendance records for the week of 08/16/21 - 08/20/21 contained a total of twenty-six (26) children that did not have a 'time out.' The daily attendance records were recorded on a plain sheet of paper and did not contain a parent or the parent's designated persons signature at the end of each week. The daily attendance records did not contain the child-care employees initials daily for the children that arrive/depart by bus. 2. The daily attendance records for the week of 08/23/21 - 08/27/21 contained five (5) children that did not have a 'time in' and twenty (20) children that did not have a 'time out.' The daily attendance records were recorded on a plain sheet of paper and did not contain a parent or the parent's designated persons signature at the end of each week. The daily attendance records did not contain the child-care employees initials daily for the children that arrive/depart by bus. 3. The daily attendance records for the week of 08/30/21 - 09/03/21 contained twenty-three (23) children that did not have a 'time out.' The daily attendance records were recorded on a plain sheet of paper on 08/30/21 and 08/31/21. The daily attendance records contained one (1) parent signature at the end of the week. 4. The daily attendance records for 09/06/2021 and 09/07/21 contained one (1) child that did not have a 'time out.' 5. Twenty (20) children were present at the child-care center on 09/08/21; however, based on review of documentation, sixteen (16) children were signed in on the daily attendance records. During interview, staff-in-charge stated that the daily attendance records for 08/16/21 - 08/20/21, 08/23/21 - 08/27/21, 08/30/21 and 08/31/21 were recorded on plain sheets of white paper and she was planning on transferring those records over onto a DCC-94E form. Staff-in-charge showed the surveyor the DCC-94E form that she had paper clipped to the daily attendance records that were recorded on a plain sheet of white paper that she was planning on using to transfer the records over onto herself. Staff-in-charge stated that her Director recently passed away and she has also been working on a new building that the child-care center will be moving into soon. Staff-in-charge stated that some of the children that were not signed in on 09/08/21 were missing attendance records.
General: Based on observation during a tour of the center, the surveyor found: 1. An outlet cover was missing in the School-Age Classroom; therefore, the outlet was a safety hazard. 2. An electrical outlet cover, located in the School-Age Classroom, was broken on the upper left corner and had sharp edges; therefore, the outlet was a safety hazard. Director Requirements In Compliance Employee Records Not In Compliance
General: Based on review of documentation presented, the surveyor found no verification that a staff (DOH: 05/03/21) obtained a High School Diploma, GED or Commonwealth Child Care Credential. Interview with staff found that the educational verification was not available for review. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report Programming Not In Compliance
General: Based on observation, the surveyor found the following: 1. The surveyor observed bleach, Clorox Cleaner and toilet bowl cleaner in an unlocked cabinet located in the kitchen. The kitchen door was standing open; therefore, the chemicals were accessible to the children. 2. The surveyor observed Ajax, toilet bowl cleaner, bathroom cleaner, insecticide, plunger and toilet brush and holder, spray paint and gallons of paint in an unlocked utility closet. The items were accessible to the children. 3. The surveyor observed paint, carpet cleaner, laundry detergent and furniture polish in an unlocked laundry room. The laundry room door was open; therefore, the chemicals were accessible to the children.
General: Based on review of documentation, the surveyor found the following: 1. The surveyor found no verification that a staff (DOH: 1/24/2020) has obtained a copy of a negative tuberculin result or a statement from a health professional that the individual is free of active tuberculosis. 2. The surveyor found no verification that a staff (DOH: 12/11/19) has obtained a copy of a negative tuberculin result or a statement from a health professional that the individual is free of active tuberculosis. 3. The surveyor found no verification that a staff (DOH: 1/6/2020) has obtained a copy of a negative tuberculin result or a statement from a health professional that the individual is free of active tuberculosis. 4. The surveyor found no verification that a staff (DOH: 9/25/19) has obtained a copy of a negative tuberculin result or a statement from a health professional that the individual is free of active tuberculosis. 5. The surveyor found no verification that a staff (DOH: 11/15/19) has obtained a copy of a negative tuberculin result or a statement from a health professional that the individual is free of active tuberculosis. 6. The surveyor found no verification that a staff (DOH: 1/21/2020) has obtained a copy of a negative tuberculin result or a statement from a health professional that the individual is free of active tuberculosis.
General: Based on review of documentation, the surveyor found the following: 1. The surveyor found no verification of a staff’s (DOH: 1/24/2020) High School Diploma, GED or Commonwealth Child Care Credential. 2. The surveyor found no verification of a staff’s (DOH: 1/21/2020) High School Diploma, GED or Commonwealth Child Care Credential. 3. The surveyor found no verification of a staff’s (DOH: 12/11/19) High School Diploma, GED or Commonwealth Child Care Credential. 4. The surveyor found no verification of a staff‘s (DOH: 1/6/2020) High School Diploma, GED or Commonwealth Child Care Credential. 5. The surveyor found no verification of a staff (DOH: 9/25/19) High School Diploma, GED or Commonwealth Child Care Credential. 6. The surveyor found no verification to a staff’s (DOH: 11/15/19) High School Diploma, GED or Commonwealth Child Care Credential. 7. The surveyor found no verification of a staff’s (DOH: 1/21/2020) High School Diploma, GED or Commonwealth Child Care Credential.
General: Based on review of documentation during a tour of the childcare center, the surveyor found that a list of the children’s full names and dates of birth were posted in the School-age Room, Preschool Room and Infant Room. Therefore, the children's information was not maintained confidential. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 7 of 8 Inspection Report Posted Documentation Not In Compliance
General: Based on observation, the surveyor found the following: 1. The surveyor observed an approximate five (5) foot area of a black mold-type substance along the wall in a utility closet. The closet door was unlocked and accessible to the children. 2. The surveyor observed a piece of sheet rock on the floor in an empty classroom. Nails protruded upward out of the sheetrock. The classroom door was unlocked; therefore, the nails were accessible and presented a safety risk to the children. 3. The surveyor found that a staff person ate food from McDonald’s in front of the infant and toddler-age children. 4. The surveyor observed metal shelving propped against the wall in the hallway near the restrooms. The shelving was accessible to the children. 5. During a tour of the Sensory Room, the surveyor observed a child's mat on the floor in the closet. The mat was located under a closet shelf that was approximately three and one- half (3 ½) feet from the floor. An uncovered electrical outlet was on the wall near the mat and was accessible to the children. Employee Records Not In Compliance
General: Based on observation, the surveyor found the following: 1. Upon arrival to the childcare center, the surveyor observed that a staff person and a child left the Infant/Toddler Room and walked through the School-age Room to open the entry door. The surveyor went to the classroom and observed that the staff person had left six (6) infant and toddler-age children unsupervised for three to five (3-5) minutes when opening the door. 2. The surveyor found that one (1) staff person and one (1) child were in the Sensory Room. The surveyor observed the staff person using her cell phone; therefore, the staff was not properly supervising the child. 3. The surveyor found that one (1) staff person and one (1) child were in the Sensory Room. The classroom was so dark that the staff person could not see the child. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 8 Inspection Report Staffing Requirements Not In Compliance
General: Based on observation during a tour of the Infant/Toddler Room, the surveyor observed that one (1) staff person was providing care for seven (7) children. The age of the youngest child was five (5) months. Two (2) children exceeded the staff-to-child ratio. General Administration In Compliance Director Requirements Not In Compliance
General: Based on review of documentation and interview with a staff person, the surveyor learned that five (5) staff files and one (1) volunteer’s file were unavailable for review. The staff person stated that the files had been taken home; therefore, were unavailable. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 8 Inspection Report
General: Based on review of documentation, upon arrival to the childcare center, the surveyor found that no staff person with current first aid and CPR was present. Through interview, the surveyor learned that staff are current in first aid and CPR; however, no written documentation for verification was available for the surveyor's review. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 8 Inspection Report
General: Based on review of documentation and ECE-TRIS, the surveyor found that a staff (DOH: 10/13/19) completed six (6) hours of cabinet-approved orientation training on 1/16/2020; thus, not within the first three (3) months of hire. Programming Not In Compliance
General: Based on observation from 2:10 p.m. until 4:05 p.m., the surveyor observed that staff provided no programming activities with the children.
General: Based on observation, the surveyor found that staff were providing care for four (4) two-year-old children along with three to five-year-old children. Staff confirmed that the children were in the mixed-age group for the entirety of the day. Through interview, the surveyor learned that the four (4) two-year-old children do not have transition plans. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 4 of 8 Inspection Report Premises Not In Compliance
General: Based on observation, the surveyor found the following: 1. The surveyor found that the fire alarm was consistently beeping; therefore, the fire alarms were not in good working order. 2. The surveyor observed an approximate five (5) foot area of a black mold-type substance along the wall in a utility closet. The closet door was unlocked and accessible to the children. 3. The surveyor found that four (4) kitchen-size bags of trash were stacked near the childcare center’s rear door.
General: Based on observation, the surveyor found that the light in the girls’ restroom was dim and not working properly. The room was not well lit.
General: Based on observation, the surveyor found that eighteen (18) school-age children were present in the School-age Classroom. The surveyor reviewed the childcare center’s diagram and found that the classroom’s capacity is seventeen (17). Therefore, one (1) child exceeded the thirty-five (35) square feet per child regulatory requirement. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 5 of 8 Inspection Report
General: Based on observation, the surveyor found that the school-age children did not wash their hands within thirty (30) minutes of arriving to the childcare center.
General: Based on observation, the surveyor found a bottle of Melatonin on a shelf located in the closet of the Sensory Room. Through interview, staff confirmed that they have administered the medication to the child on the request of the child’s parent. Staff were unable to provide the surveyor with a written administration record to include the time of each dosage, date, and amount, the name of the staff giving the medication, name of the child and name of the medication. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 6 of 8 Inspection Report
General: Based on observation, the surveyor found a bottle of Melatonin on a shelf located in the closet of the Sensory Room. The medication was not stored in a separate locked place. Outdoor Play Area Not In Compliance
General: Based on observation during a tour of the playground, the surveyor observed wooden lattice, a two by four (2x4) board and plywood leaned against the exterior wall behind the door leading outside to the playground. The items were accessible to the children. Equipment In Compliance Transportation Not Applicable Food Service/Food Program In Compliance Food Service In Compliance Children's Records Not In Compliance
General: Based on review of documentation, the surveyor found that a child’s (DOE: 12/7/17) enrollment file contained an immunization certificate from the state of Tennessee. The immunization certificate did not have an expiration date. Written Documentation Not In Compliance
General: Based on observation, the surveyor found toilet paper on the floor of the restroom; therefore, the restroom was not clean.
General: Based on review of documentation, the surveyor found the following: (1.) Staff’s (DOH: 10/22/18) file did not contain a statement from a health professional that the individual is free of active tuberculosis or a copy of a negative tuberculin result. (2.) Staff’s (DOH: 1/7/19) file did not contain a statement from a health professional that the individual is free of active tuberculosis or a copy of a negative tuberculin result. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report
General: Based on observation, the surveyor found the following: (1.) Two (2) round dark blue rugs located in the preschool room contained debris; therefore, the premises was not kept clean. (2.) The carpet located in the indoor gross motor room was stained in several different areas. (3.) The indoor gross motor room contained debris on the carpet; therefore, the carpet was not kept clean.
General: Based on observation, the surveyor found a tear in the dry wall of the indoor gross motor room.
General: Based on observation, the surveyor found the temperature in the kitchen’s freezer was ten (10) degrees Fahrenheit; therefore, the temperature was not at the required zero degrees Fahrenheit or below. Children's Records In Compliance Written Documentation Not In Compliance
General: Based on review of documentation, the surveyor found that nine (9) children’s arrival times were documented on the daily attendance record; however, there were a total of eleven (11) children present.
General: Based on review of documentation, the surveyor found a fire drill for December 2018 was not documented. Staff reported the fire drill was not conducted. Posted Documentation In Compliance Animals In Compliance
General: Based on review of documentation, the surveyor found no written job description for the Director.
General: Based on review of documentation, the surveyor found that the childcare center’s liability insurance policy had an expiration date of 10/05/17. An updated insurance policy was not available for review. Director Requirements In Compliance Employee Records Not In Compliance
General: Based on review of documentation, the surveyor found that the file for a staff (DOH: 11/02/17) contained a criminal records background check. The payment date on the background check was 11/08/17; thus, it was not submitted prior to or on the date of hire. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 4 Inspection Report
General: Based on review of documentation and ECE-TRIS, the surveyor found the following: 1. No verification was found that a staff (DOH: 07/18/16) completed one and one-half (1 ½) hours of pediatric abusive head trauma training. 2. Verification of only eleven (11) hours of cabinet-approved early care and education training was found for a staff (DOH: 11/24/15). Programming In Compliance Premises Not In Compliance
General: Based on observation, the surveyor found that the toilet seat was not securely attached to the toilet bowl located in girls’ restroom. Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment Not In Compliance
General: Based on observation during a tour of the childcare center, the surveyor found that the size of the furniture in the school-age room was for preschool-age children. Per conversation with the Director, the surveyor learned that few school-age children are enrolled in the program. Furniture for school-age children was not available, although, a nine- year-old child was present during the renewal visit. Transportation Not Applicable An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 4 Inspection Report Food Service Not In Compliance
General: Based on observation during a tour of the kitchen, the surveyor found cookies and cereal were stored on the bottom base of a brown cabinet. The cookies and cereal were stored approximately three (3) inches from the floor rather than six (6) inches per regulation. Children's Records Not In Compliance
General: Based on review of documentation, the surveyor found the following: 1. No verification was found that earthquake drills were conducted during the first, second and third quarters of 2017. 2. Verification was found that tornado drills were conducted during the first, second and third quarters of 2017. However, the times of the drills were not recorded.
General: Based on review of documentation, the surveyor found verification that fire drills were conducted from January 2017 through November 2017; however, the times that the drills were conducted were not recorded. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 4 Inspection Report
General: Based on review of documentation of staff files, the following was found: 1) One (1) staff file (DOH: 8/23/17) did not contain the results of the criminal records check (CRC). 2) Two (2) staff files (DOH: 8/18/17 & 8/23/17) did not contain a completed child abuse and neglect (CA/N) background check. Based on interview, the director stated that the results of these checks had not yet been received. Further interviews revealed that both staff members were together in the pre-school classroom with no other staff present starting at 9:00am on 8/29/17, which was prior to the surveyor's arrival. Based on observation, both staff members were present in the pre- school classroom with no other staff until 12:30pm. Therefore, two (2) staff members without completed background checks were left alone in a classroom for three and a half (3 1/2) hours. Programming In Compliance Hygienic Practices Not In Compliance
General: Based on observation and interview, the surveyor observed that on 8/25/17 the center's lunch was catered by Pizza Hut. The Director reported that the center's lunch is catered once per week by Pizza Hut or Papa John's Pizza; however, the Director did not have documentation of the food service permit for Pizza Hut or Papa John's Pizza. Therefore, the surveyor could not verify that the food was being obtained from an approved source.
General: Based on review of documentation and interview, the surveyor determined the following: 1. On 8/14/17 the center's menu documented that the children were served milk, eggs, and oatmeal. The children were not provided with all of the meal requirements for breakfast as they were not served a fruit, vegetable, or 100% juice. 2. On 8/16/17 the center's menu documented that the children were served milk and cheerios. The children were not provided with all of the meal requirements for breakfast as they were not served a fruit, vegetable, or 100% juice. 3. On 8/18/17 the center's menu documented that the children were served milk, yogurt, and shredded wheat. The children were not provided with all of the meal requirements for breakfast as they were not served a fruit, vegetable, or 100% juice. The Director reported that on 8/18/17 the children were actually served banana instead of yogurt and she forgot to write the substitution in on the menu. The Director stated that the children are always served a fruit as well and staff that prepared the menu just failed to write it on the menu.
General: Based on review of documentation and interview, the surveyor found that a staff file (DOH: 11/24/15) did not contain an annual staff evaluation. The Director reported that an evaluation had not been completed. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 4 Inspection Report Employee Records Not In Compliance
General: Based on review of documentation and interview, the following were found: 1. A staff file (DOH: 8/24/17) did not contain record of a Child Abuse/Neglect background check or record of the Child Abuse/Neglect background check having been submitted. The staff member was working but was not observed working alone. 2. A staff file (DOH: 8/18/17) did not contain record of a Child Abuse/Neglect background check or record of the Child Abuse/Neglect background check having been submitted. The staff member was not observed working alone with the children. 3. A volunteer file (Start Date: 8/18/17) did not contain record of a Child Abuse/Neglect background check or record of the Child Abuse/Neglect background check having been submitted. 4. A volunteer file (Start Date: 8/18/17) did not contain record of a Criminal Record background check or record of the Criminal Record background check having been submitted. Upon interview, the Director reported that staff do not work alone with the children until all background checks are returned. The Director stated that the Volunteer only does the cleaning and helping prepare meals. The Director reported that the Child Abuse/Neglect background checks had all been submitted except for the volunteer's as she was not aware that it was needed for a volunteer. The Director stated she was also not aware that a Criminal Record background check was needed for a volunteer. The Director related that she did not have any documentation to show that the Child Abuse/Neglect background checks had been submitted other than a reciept from the post office.
General: Based on review of documentation and interview, the following were found: 1. A staff file (DOH:8/24/17) did not contain documentation of a high school diploma, GED, or Commonwealth Child Care Credential. 2. A staff file (DOH:8/18/17) did not contain documentation of a high school diploma, GED, or Commonwealth Child Care Credential. The Director reported that she had not yet obtained documentation of the staff member's education.
General: Based on observation, review of documentation, and interview, the surveyor found that the center was not maintained in a clean condition. The surveyor observed that there were six (6) trash cans outside the center that were full of trash and had multiple bags of trash stacked up on top of them. There was trash observed scattered on the ground surrounding the trash cans. Staff stated that the city will not pick up the center's trash because they are a commercial business. The Director reported she has attempted to arrange for trash pick-up and a dumpster through another service provider. Food Service Not In Compliance
General: Based on review of documentation and interview, the surveyor found that on 8/18/17 the menu was not amended in writing with any substitutions made to the menu. On 8/18/17 the center's menu documented that the children were served milk, yogurt, and shredded wheat. The Director reported that on 8/18/17 the children were actually served banana instead of yogurt and she forgot to write the substitution in on the menu. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 4 Inspection Report
General: Based on review of documentation and interview, the surveyor found that on 8/14/17 the center's menu documented that the children were served milk, peperoni pizza, and peas. The children were not provided with all of the meal requirements for breakfast as they were not served two (2) fruits, two (2) vegetables, or one (1) fruit and one (1) vegetable. The Director stated that the menu is prepared by another staff member and the staff member is documenting everything on the menu correctly. Written Documentation Not In Compliance
General: Based on review of documentation and interview, the following was found: 1. A staff file (DOH: 8/3/15) contained an annual professional development plan that was last updated on 8/4/16; therefore, the professional development plan had not been updated annually as required. 2. A staff file (DOH: 11/24/15) did not contain an annual professional development plan; therefore, the professional development plan had not been updated annually as required. The Director reported that the professional development plans had not been completed.
General: Based on review of documentation, the staff file (DOH: 10/10/16) did not contain verification of a high school diploma, GED, or commonwealth child care credential.
General: Based on observation, the following was found: 1. Two (2) staff (DOH: 10/7/16, 10/10/16) were alone supervising children without the results of a criminal records check or child abuse/neglect check. 2. One (1) staff (DOH: 11/24/15) was alone with children without a completed out of state background check.
General: Based on review of documentation and interview, the child care center did not have written proof of liability insurance. Through interview with the director, it was learned that the center was insured. The director did not locate documentation for review. Director Requirements Not In Compliance
General: Based on review of documentation, the director did not maintain documentation for staff meetings.
General: Based on observation, the director failed to provide for the comfort of each child when one (1) school age child was served a can of soda during lunch in front of other children. Soda was not offered to the remaining children. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 5 Inspection Report
General: Based on review of documentation, the director could not provide proof of annual activities involving parental or family participation. Employee Records Not In Compliance
General: Based on review of documentation, the following was found: 1. Staff's (DOH: 10/10/16) file did not contain proof of educational qualifications. 2. Staff's (DOH: 7/18/16) file did not contain a child abuse/neglect check. 3. Staff (DOH: 11/24/15) was a resident of Tennessee within the past five (5) years. A criminal records check was not completed for the staff's previous state of residence.
General: Based on review of documentation and ECE-TRIS, the following was found: 1. The staff (DOH: 8/3/15) file did not contain documentation of nine (9) cabinet-approved early care and education training within the first year of employment. 2. The staff (DOH: 8/3/15) did not obtain six (6) hours of cabinet-approved orientation within the first three (3) months of employment. Programming Not In Compliance
General: Based on observation, a toddler was combined with a school age child in the same classroom for more than one (1) hour. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 5 Inspection Report
General: Based on observation, a school age child was not given milk during lunch time. The child was served a can of soda instead. Therefore, the milk requirement was not met. Children's Records Not In Compliance
General: Based on review of documentation, the following was found: 1. The child care center did not obtain authorization by a parent for the center to seek emergency medical care for three (3) child (dates of enrollment unknown) in a parent's absence. 2. The child care center did not obtain a preferred hospital for the child's (DOE: 4/18/16) record. Written Documentation Not In Compliance
General: Based on review of documentation, the child care center did not maintain a written record of quarterly practiced earthquake or tornado drills.
General: Based on review of documentation, the child care center could not provide documentation for conducted earthquake or tornado drills. Posted Documentation In Compliance Animals Not Applicable
General: Based on review of documentation, interview, and a review of the ECE-TRIS website, there was no documentation to verify two (2) staff members (DOH: 8/3/15, 8/3/15) have yet completed six (6) hours of cabinet-approved orientation training as of the surveyor's inspection which was after the ninty (90) day required time frame.
General: Based on observation and interview, the surveyor found a tear in the vinyl covering of one (1) diaper changing pad located outside of the nursery classroom. The infants changing pad was not in good repair.
General: Based on review of documentation and interview, the child care center failed to maintain a current immunization certificate for three (3) children (DOE: 9/4/15, 9/6/15, 8/31/15 ) in care within thirty (30) days of the child’s enrollment.
General: Based on review of documentation, an employee (DOH 07/20/15) record presented for review did not contain evidence of negative tuberculin verification.
General: Based on review of documentation, the center did not have two (2) qualified substitute staff persons as required for a Type I child care center. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 8 of 27 Web site: http://chfs.ky.gov/ Inspection Report
General: Based on observation, with the exception of books, the school age area was not equipped with developmentally appropriate activities for the children.
General: Based on observation, the manufacture date of two (2) cribs was 11/30/09 and neither crib had additional documentation to certify compliance. Therefore, it could not be determined that the two (2) cribs met federal crib standard (16 CFR 1219-1220) compliance. During an interview, the director stated that she would purchase and assemble a compliant crib over the weekend. The director was informed that non-compliant cribs must be dismantled and removed from the child care center.
General: Based on observation, the temperature of the refrigerator could not be determined compliant as a temperature measuring device had not been placed inside the appliance.
General: Based on review of documentation, a diagram outlining a course of action to be taken in the event or a natural or manmade disaster was not posted in the center.
General: Based on review of documentation, daily lesson plans for each age group were not prepared, nor placed for each classroom. During an interview, the director confirmed that she purchased lesson plan materials from the Mother Goose Time curriculum; however, these materials were not yet prepared for center use at the time of the DRCC inspection on 07/17/15.