922 KAR 2:090. Section 9. Records.
General: Based on review of documentation, the surveyor discovered one (1) child’s (DOE: 09/02/25) file contained an immunization certificate that was no longer current as of 02/11/26.
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License #L383316 · Center · Licensed
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This change of space/change in capacity inspection recorded no violations or advisories.
General: Based on review of documentation, the surveyor discovered one (1) child’s (DOE: 09/02/25) file contained an immunization certificate that was no longer current as of 02/11/26.
General: Based on review of documentation, the surveyor discovered two (2) children’s (DOE: 09/02/25 and 09/02/25) files did not contain the name or contact telephone numbers for the children’s preferred hospital. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 29 of 32 Inspection Report
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Data synced from Kentucky Cabinet for Health and Family Services, Division of Child Care on Jul 11, 2026 · Source records · Report an error
General: Based on review of documentation, the surveyor discovered a child's (DOE: 09/03/24) file did not contain an immunization certificate; therefore, the child-care center failed to maintain a current immunization certificate for the child.
General: Based on observation, the surveyor found the following: 1.) Multiple ceiling tiles located throughout the Art and Lunch Room with discolored water spots. 2.) One (1) missing ceiling tile in the Art and Lunch Room Therfore, the ceiling was not kept in good repair
General: Based on review of documentation, the surveyor found the following: 1.) Ten (10) children's (DOE:09/03/24, 09/03/24, 09/03/24, 09/03/24, 09/03/24,09/03/24, 09/03/24, 09/03/24, 09/03/24, 09/03/24) files did not contain the contact telephone number for the child’s preferred hospital. 2.) Two (2) children's (DOE: 09/03/24, 09/03/24) files did not contain the telephone number for the child's preferred physician Therefore, the child-care center failed to maintain children's records.
General: Based on observation and review of documentation, the surveyor discovered the State Fire Marshal report to be dated 08/11/2021. Staff was unable to provide a current Fire Marshal Report for the surveyor to review during the visit; therefore, the child-care center failed to provide documentation of compliance.
General: Based on review of documentation, three staff members (DOH: 09/04/2014, 12/04/2015, and 09/01/20210), did not have evidence of a professional development plan on file at the facility. Posted Documentation In Compliance Animals Not Applicable
General: Based on review of documentation, a staff member (DOH: 09/01/2023), did not have a current TB test or statement from a health professional on file. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Kitchen Requirements In Compliance Food Service In Compliance Meal Planning/Center Provides Meals In Compliance Meal Planning/Center Does Not Provide Meals In Compliance Children's Records Not In Compliance
General: Based on review of documentation, two staff members (DOH: 12/04/2015 and 09/01/2021), did not have evidence of an annual evaluation on file at the facility. Employee Records Not In Compliance
General: Based on interview and review of documentation, it was found that the last evacuation plan was written 01/27/2022, but not submitted to the local emergency management organization. The staff in charge was unable to provide documentation at the time of the survey for the 2023 evacuation plan nor to verify the submission date to the local emergency management organization.
General: Based on interview and review of documentation, the child care center failed to maintain employee records in accordance with regulations. Review of staff files found the center failed to have a high school diploma, GED, or Commonwealth Child Care Credential on file for a staff member hired 9/1/21. Interview with staff-in-charge found she did not have any educational documentation on file for this staff member. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report
General: Based on observation, the child care center failed to maintain state regulations. Observation of the Gross Motor Skills area found one (1) unprotected electrical wall outlet on the back wall, accessible to children in care. Director Requirements In Compliance Employee Records Not In Compliance
General: Based on interview and review of documentation, the child care center failed to maintain employee records in accordance with regulations. Review of staff files found a statement from a health professional that the individual is free of active tuberculosis or a copy of negative tuberculin results was not presented for review at the time of survey for two (2) staff members hired 9/4/14 and 12/04/15 respectively. Interview with staff-in-charge found the documentation was not available 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 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 Not In Compliance
General: Based on observation and interview, the surveyor found climbing equipment that had been installed on a parking lot, and mulch surrounding the equipment. Per 922 KAR 2:120, section 1 (12) clarifies loose surfacing material may not be installed over concrete. Equipment In Compliance
General: Based on review of documentation, four staff eligible for an annual performance evaluation did not have current documentation on file at the facility. The documentation on file was dated 2019. Employee Records Not In Compliance
General: Based on review of documentation, four staff eligible for an annual professional development plan did not have current documentation on file at the facility. The documentation on file was dated 2019. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 4 Inspection Report
General: Based on observation, this regulatory requirement was not met. The following was found: 1. During a tour of Room #204 (three-year-old's), the surveyor observed two uncovered electrical outlets on the wall beside of the woodworking area. 2. The roll of paper towels that the children use in the bathroom across from the facility office, was being stored in an unsanitary manner; positioned on the sink counter. This method of storage promotes germs due to each child handling the roll to obtain a paper towel. Director Requirements Not In Compliance
General: Based on review of documentation, three children (enrollment dates: 8/2/21, 9/1/21, and 9/6/21) had immunization certificates that were no longer current as of 12/7/21, 9/22/21, and 7/23/21. Written Documentation Not In Compliance
General: Based on observation and interview, this regulatory requirement was not met. During a tour of the facility, the following was found: 1. Retractable ribbon dividers were being used to separate the four year old classroom from a space used by the church. The side used by the church had multiple stacks of adult- size chairs lined up against the wall approximately five - six feet tall. The dividers being used to separate the space would not prevent a child from accessing the area. 2. Numerous pieces of furniture were observed being stored in the gross motor room such as milk crates, tables, chairs, individual desks, book shelves, and office furniture. The staff person in charge stated that she was in process of getting all of these items moved to storage. Premises Not In Compliance
General: Based on observation, this regulatory requirement was not met. During a tour of the four year old classroom, the surveyor observed the following: 1. A dark stain was located on the ceiling by the door used to enter/exit the classroom and some of the drywall was flaking off in this area. 2. A light fixture junction box in the ceiling was observed uncovered. Outdoor Play Area Not Applicable Equipment In Compliance Kitchen Requirements In Compliance Written Documentation In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Posted Documentation Not In Compliance
General: Based on review of documentation and interview, this regulatory requirement was not met. The facility did not have a written emergency plan and diagram posted. The staff person in charge stated that she had not yet created a diagram of the building; however, she indicated that she was working on it.
General: Based on review of documentation, two children did not have current immunization documentation on file. Written Documentation In Compliance Posted Documentation In Compliance Animals In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Emergency Regulation Not In Compliance
General: Based on interview and ECE-TRIS, six staff did not complete the mandatory training on cleaning, sanitizing, health procedures, and mandatory reporting prior to the date of reopening.
This renewal application inspection recorded no violations or advisories.
General: Based on review of documentation, this regulatory requirement was not met. At the time of the survey it was found that there was no documentation that an annual evaluation had been conducted on one (1) staff person who had worked in excess of one (1) year at the facility (hire date: 9/8/14). Employee Records In Compliance Programming In Compliance Premises Not In Compliance
General: Based on review of documentation and interview, it was found that the program currently uses two (2) classrooms (Room #408 and #409) in addition to the fellowship hall, resource room and outdoor playground. A review of documentation from previous inspections found the facility was approved for the use of two (2) classrooms (Room #408 and #409), the fellowship hall and the outdoor playground. After reviewing the list of classrooms approved during past inspections and reviewing the list of classrooms currently being used by the program, it was found that the Resource Room had not been approved as part of the licensed space. The staff person in charge stated during interview that the four (4) year olds use the Resource Room three (3) days a week for art, music and physical education activities and indicated that they started using this space when the new school year began (August 2018). An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Director Requirements Not In Compliance
General: Based on review of documentation, this regulatory requirement was not met. At the time of survey, it was found that the facility did not have a written policy regarding the implementation of procedures taught at orientation training. The staff person in charge stated that she did not have such a policy. Posted Documentation In Compliance Animals In Compliance
General: Based on Review of Documentation, there were no current staff evaluations on file. Employee Records Not In Compliance
General: Based on Observation, the list of children's allergies was posted on a dry erase board in Room 409. This information was not kept confidential. Director Requirements Not In Compliance
General: Based on Review of Documentation, there were no current professional development plans on file for the staff.
General: Based on Review of Documentation, staff hired on 12/05/14 did not have the required fifteen (15) hours of cabinet approved training on file. This information was verified through ECE-TRIS. Programming In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Food Service In Compliance Children's Records Not In Compliance
General: Based on Observation, four (4) staff hired on 09/08/14 and staff hired on 12/05/14 and 09/04/15 did not have documentation on file from a health care professional stating they were free of active tuberculosis. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Food Service In Compliance Children's Records In Compliance Written Documentation In Compliance Posted Documentation In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Animals Not In Compliance
General: Based on Interview, there is no written consent signed by the parents allowing their children to be in the presence of the fish which are in the classroom.
General: Based on review of documentation and interview, the surveyor found that five (5) staff did not have an annual written professional development plan on file. The Director stated they have yet to complete professional development plans.
General: Based on review of documentation, two (2) staff (hire date: 9/8/14) did not complete the required fifteen (15) hours of early care and education training. Both staff were short two (2) training hours. The Director stated she thought she had enough hours; however, the surveyor found that some of the training was completed during the summer before her hire date. (2) One (1) staff (hire date: 9/4/14) completed the six (6) hour orientation on 1/28/15 which was past the three (3) month timeframe as required by the regulations. 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 Observation, the surveyor observed a plastic climbing structure positioned on the grass on the playground. The Director stated the church had acquired the climbing structure over the summer and had placed it on the playground. She stated she was going to ask that they remove the equipment from the playround.
General: Based on Observation, it was found that a first aid kit was being stored on a hook on the wall beside the door entering room 412 along with the children's coats and backpacks. The first aid kit was accessible to the children.
General: Based on Observation, it was found that the refrigerator in room 408 did not have an indicating thermometer or other appropriate measuring device. An interview with the director found that the refrigerator is used to store food items used for the children.
General: Based on Review of Documentation, it was there was no documentation to verify that a fire drill had been conducted for November 2014 that included the date, time and the names of the children who participated. It was also found that the names of the children who had participated was not documented for fire drills conducted in October and September 2014.
General: Based on Review of Documentation, there was one (1) staff person hired 11/24/14 who did not have the application for the results of a criminal records check and the child abuse and neglect check submitted at the time of the visit. This staff person was observed working at the facility at the time of the visit. However, this staff person was not observed working alone with the children.
This initial application inspection recorded no violations or advisories.
A PLAN OF CORRECTION WAS DUE ON 06/20/2025 AND AS OF 07/07/2025, THE PLAN OF CORRECTION HAS NOT BEEN RECEIVED. Findings: A PLAN OF CORRECTION WAS DUE ON 07/22/2025 AND AS OF 09/01/2025, THE PLAN OF CORRECTION HAS NOT BEEN RECEIVED.
General: Based on observation and review of documentation, the surveyor found that one (1) staff's (DOH:09/20/24) personnel file did not contain a statement from a health professional that the individual is free of active tuberculosis or a copy of negative tuberculin results. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 10 of 33 Inspection Report
General: Based on observation, the surveyor discovered that one (1) light fixture, located in the Art and Lunch area, had a covering appeared to be cracked and not fully secured. Therefore, the child-care center failed to keep the light fixture in good repair.
General: Based on review of documentation, a staff member (DOH: 09/01/2023), did not have evidence of a high school diploma, GED, or Commonwealth Child Care Credential on file at the facility. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report
General: Based on review of documentation, two children enrolled 8/15/2023, and 8/21/2023, did not have current immunization certificates on file at the facility. Written Documentation Not In Compliance
General: Based on interview and review of documentation, the child care center failed to maintain children’s records in accordance with regulations. Review of children’s files found an immunization certificate was not presented for review at the time of survey for two (2) children with enrollment dates of 3/5/22 and 8/11/22 respectively. Interview with staff-in- charge found this documentation was not on file at the time of survey.
General: Based on review of documentation, the child care center failed to maintain children’s records in accordance with regulations. Review of ten (10) children’s files found the written records for one (1) child with an enrollment date of 3/5/2022 failed to contain contact information to enable a person in charge to contact the child’s preferred hospital. Written Documentation In Compliance Posted Documentation In Compliance Animals Not Applicable
General: Based on review of documentation, observation and interview, this regulatory requirement was not met. One staff person hired on 11/15/21, was observed working with another staff person with the three-year-old group during the visit. This staff person had a completed criminal records check (CRC) on file dated 10/22/21; however, the facility has yet to initiate the process for obtaining a background check for this staff person in the Kentucky National Background Check Service (KARES). The staff person in charge acknowledged this finding and identified the staff person as a substitute. 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 review of documentation and interview, this regulatory requirement was not met. A review of staff files during the inspection found two staff that did not have the date of employment listed in their file. The staff person in charge thought for a moment and then verbally identified 9/1/21 and 11/15/21, as the hire dates. However, the dates of hire were not maintained in the personnel files.
General: Based on review of documentation, two staff (hire dates: 9/1/21 and 11/15/21) did not have educational documentation on file.
General: Based on review of documentation, this regulatory requirement was not met. The following was found: 1. Two staff (hire dates: 9/1/21 and 11/15/21) did not have T.B. documentation on file. 2. Two staff files (hire dates: 9/6/16 and 9/4/18) contained results of negative T.B. tests that are no longer current. The tests were dated 10/22/19 and 10/15/19, which exceeds the two year time frame. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 4 Inspection Report
General: Based on review of documentation and the Training Records Information System (TRIS), the following was found: 1. One staff person (hire date: 9/4/18) did not complete the required 15 hours of cabinet-approved training hours between 7/1/2020 and 6/30/21. 2. One staff person (hire date: 12/4/15) completed PAHT training on 10/18/16; however, did not renew the training due 10/18/21. Programming In Compliance Premises Not In Compliance
General: Based on observation, this regulatory requirement was not met. The surveyor observed dark stains on four ceiling tiles in the women's bathroom across the hall from the facility office. Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area Not Applicable Equipment In Compliance Transportation Not Applicable Kitchen Requirements In Compliance Food Service In Compliance Meal Planning/Center Provides Meals In Compliance Meal Planning/Center Does Not Provide Meals In Compliance Children's Records Not In Compliance
General: Based on review of documentation and interview, this regulatory requirement was not met. The surveyor found that the facility has yet to establish their emergency preparedness plan according to KRS 199.895. The staff person in charge stated that she was not aware of this regulatory requirement.
General: Based on review of documentation, this regulatory requirement was not met. The fire, earthquake and tornado drills documented by the facility included the date and time of the drills; however, the names of the children who participated were not included on the documentation. Posted Documentation In Compliance Animals Not Applicable
General: Based on observation, this regulatory requirement was not met. During a tour of Room #408 (4 year olds), the surveyor observed a can of Lysol Disinfectant Spray being stored in a pocket storage container on the bathroom door along with numerous other classroom supplies such as paint brushes, tape, and glue sticks. The Lysol Disinfectant Spray was accessible to the children in the classroom. 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 Not In Compliance
General: Based on Review of Documentation, child enrolled on 07/17/17 did not have a current immunization record on file. Written Documentation Not In Compliance
General: Based on Review of Documentation, there was no documentation showing that a quarterly tornado drill was conducted by the facility. Posted Documentation In Compliance Animals Not Applicable
General: Based on Review of Documentation, out of ten (10) children's files reviewed there was one (1) child enrolled 9/8/14 who did not have identifying information about the child, parents' home or place of employment, family physician, the preferred hospital in the event of an emergency, medical history, allergies or restrictions and authorization for emergency medical care. 1080 - Documentation for Off Premise Trip Not Applicable 922 KAR 2:110. Section 3. Records. (1) A child-care center shall maintain: (b) A written record for each child: 3. To contain: g. A permission form for each trip off the premises signed by the child’s parent in accordance with 922 KAR 2:120, Section 12; Written Documentation
General: Based on Review of Documentation, there was one (1) staff person hired 11/24/14 who did not have a personnel file with all required documents. This staff person was observed working at the facility at the time of the visit on 12/1/14.
General: Based on Observation, it was found that children in both classrooms did not have access to blocks. Interviews with staff indicated that the blocks had been put away in storage due to the rotation of toys and weekly themes.
General: Based on Observation, a box of garbage bags was found on a low shelf in the bathroom located between room 408 and 409 and on the floor in the bathroom located in room 412. The garbage bags were accessible to the children. Also in room 409 in an unlocked cabinet a can of Lysol disinfectan spray, a bottle of Mr. Clean and a bottle of Clorox Anywhere cleaner were observed. These items were accessible to the children.
General: Based on Interview, it was found that a child in room 409 has an Epi-Pen. It was also found that the Epi-Pen is stored in the child's backpack which hangs on a hook on the wall inside the classroom and is accessible to the children. It was also found that in a first aid kit hanging on a hook outside of room 412 contained individual packets of first aid ointment, bee sting cream and aspirin and non aspirin pain reliever. These items were not in a locked container and were accessible to the children. Outdoor Play Area
General: Based on Interview, it was found that the facility provides milk for lunch. However, the facility provides 2% milk which does not meet the requirments for children ages four (4) to five (5) years old. 990 - Bottle Preparation by Parent Not Applicable 922 KAR 2:120. Section 9. Food and Meal Requirements. (4) Formula or breast milk provided by the parent shall be prepared and labeled.
General: Based on Review of Documentation, it was found that an earthquake drill conducted in November 2014 did not have the names of the children who had participated.
General: Based on Review of Documentation, there was no documentation to verify that a fire drill had been conducted for November 2014.