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

General: Based on review of documentation, the surveyor found that the staff-in-charge had documents of staff meetings being conducted and documented from 2021 through 2023; however, the surveyor was not provided with documentation of at least two (2) staff meetings be conducted and documented within the last year. During interview with staff-in-charge, she stated that she believed staff meetings had been conducted; however, she was unsure of where the documentation was located.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on review of documentation, the surveyor found that a staff’s (DOH: 03/23/22) 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.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, the surveyor found that the Type I child-care center has only one (1) qualified substitute staff person; therefore, the child-care center did not have the required two (2) qualified substitute staff persons for a Type I child-care center. During interview with staff-in-charge, she confirmed that the child-care center only had one (1) substitute staff person hired at this time.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the surveyor found that a light fixture located in the back left corner of the Preschool Classroom was loose and not secure to the ceiling; therefore, the light fixture was not kept in good repair.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the surveyor found the following: 1. The Preschool Classroom had a diaper changing station that was located in the middle of the classroom and was observed to be twenty-five (25) feet and eleven (11) inches away from the nearest hand washing station; therefore, the diaper changing station was not directly adjacent to the sink for hand washing purposes. During interview, staff-in-charge stated the diaper changing station would not be moved as there are times she is left alone in the Preschool Classroom to change diapers and supervise children on both sides of the classroom. 2. The hot water temperature in the sink located in the Preschool Classroom measured approximately seventy (70) degrees Fahrenheit; therefore, the hot water was not a minimum temperature of ninety (90) degrees Fahrenheit and a maximum of 120 degrees Fahrenheit.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the surveyor found the following: 1. The toilet seat moved easily and was not tightly secured to the toilet located in the first stall in the girls' restroom. 2. The toilet seat moved easily and was not tightly secured to the toilet located in the middle stall in the girls' restroom. Hygienic Practices In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the surveyor found the following on the playground: 1. There was a building accessible to the children on the playground. The building had a lock on the doors that was broken. When the surveyor checked to see if the lock was secured, the lock easily opened and the door to the building opened. The surveyor attempted to click the lock back into the locked position; however, the lock would not stay locked. 2. There were two (2) water tables and a plastic turtle that was filled with water that was observed to be uncovered and accessible to children. The surveyor observed these items to be filled with water to the top of the containers and easily accessible to children in the playground area. Therefore, the playground was not safe from foreseeable hazard.

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on observation, the surveyor observed there to be a wooden swing set that had two (2) swings located on a grassy area of the playground. The swing set that did not contain a protective surface that was equal to the height of the equipment.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the surveyor found the following on the playground: 1. The gate leading to the playground was observed to be leaning sideways and a piece of the fence was detached from lattice. 2. There was a gap between the gate and the fence that measured approximately six (6) and a half (1/2) inches wide. 3. There was a gap in the fence next to the playground entrance that measured approximately five (5) inches wide. Therefore, the fence was not stable and was not kept in good condition.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the surveyor found that the freezer attached to the refrigerator located in the Preschool Classroom had a temperature of ten (10) degrees Fahrenheit; therefore, the freezer did not have a temperature of zero (0) degrees Fahrenheit or below.

Open Not marked corrected in the state record

Category: nutrition. Open / not marked corrected.

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

General: Based on review of documentation, the surveyor found the following: 1. A child’s (DOE: 08/13/25) file contained an immunization certificate that was no longer current as of 07/03/25. 2. A child’s (DOE: 08/13/25) file contained an immunization certificate that was no longer current as of 08/08/25. 3. A child’s (DOE: 08/13/25) file contained an immunization certificate that was no longer current as of 09/08/25.

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

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

General: Based on review of documentation, the surveyor found the following: 1. A child’s (DOE: 08/13/25) file did not contain the contact telephone number for the child’s preferred hospital. 2. The following children (DOE: 08/13/25, 08/13/25, 08/13/25, 08/13/25, 08/13/25, 08/13/25, 08/18/25, 08/21/25 and 09/02/25) files did not contain the name of the child’s preferred hospital or contact telephone number.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, the surveyor found the following: 1. The child-care center failed to document the monthly required fire drills for January, April, and May of 2025. During interview with staff-in-charge, she stated that fire drills had been conducted with the children; however, she was not sure where the documentation was located that shows the names of children and staff who participated in the drills. 2. The child-care center failed to document the quarterly required earthquake and tornado drills for the second quarter of 2025. During interview with staff-in-charge, she stated that the drills were conducted with the children; however, she was not sure where the documentation was located that shows the names of the children and staff who participated in the drills. 3. The child-care center failed to document the quarterly required shelter-in-place drills for all of 2024 and 2025. During interview with staff-in-charge, she stated that the drills were conducted with the children; however, she was not sure where the documentation was located that shows the names of the children and staff who participated in the drills. Posted Documentation Not In Compliance

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on review of documentation, the surveyor found that the child-care center failed to post the required hand washing policy documents in the boys' and girls' restrooms. During interview with staff-in-charge, she informed the surveyor that she had not printed the documents yet due to her not being able to find cute designs for the document. The surveyor referred the staff-in-charge to the child-care aware website to access the required documentation for all postings needed in the child-care center. Animals In Compliance

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

A PLAN OF CORRECTION WAS DUE ON 04/22/2024 AND AS OF 05/08/2024, THE PLAN OF CORRECTION HAS NOT BEEN RECEIVED. Director Requirements In Compliance Employee Records Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, the surveyor found the following: 1. A staff member (DOH: 03/23/2022) did not have proof of education documentation in their personnel file. 2. A staff member (DOH: 08/13/2023) did not have proof of education documentation in their personnel file. 3. A staff member (DOH: 09/07/2023) did not have proof of education documentation in their personnel file. Staff-in-charge reported that she would have the staff members bring in their verification of education documentation. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, the surveyor found the following: 1. A staff member's (DOH: 08/15/2002) personnel file contained a negative tuberculin (TB skin test) dated 07/27/2021; therefore, TB skin test was no longer current. 2. A staff member's (DOH: 08/18/2011) personnel file contained a negative TB skin test dated for 07/27/2021; therefore, the TB skin test was no longer current. 3. A staff member's (DOH: 08/13/2023) personnel file did not contain a copy of a statement from a health professional stating that the individual was free of active tuberculosis or a copy of a negative TB skin test; therefore, the surveyor was unable to verify if the staff member was free of active tuberculosis. Staff-in-charge reported that she would have the staff members get updated TB skin tests.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation and ECE-TRIS, the surveyor discovered that a staff member (DOH: 08/18/2011) completed the required one and one-half (1 ½) hours of cabinet-approved pediatric abusive head trauma (PAHT) training on 01/07/2018; therefore, the training was not completed once every five (5) years. Staff-in-charge reported that she would have the staff member update their training. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable 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

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on review of documentation, the surveyor learned the following: 1. A child's (DOE: 08/01/2023) file contained an immunization certificate that was no longer current after 02/17/2024. 2. A child's (DOE: 08/09/2023) file contained an immunization certificate that was no longer current after 11/22/2023. 3. A child's (DOE: 03/28/2023) file contained an immunization certificate that was no longer current after 01/02/2024. 4. A child's (DOE: 04/17/2023) file contained an immunization certificate that was no longer current after 09/27/2023. Staff-in-charge reported that she would have the parents of the children provide updated immunization certificates. Written Documentation In Compliance Posted Documentation In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3 Inspection Report Animals Not Applicable

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

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

General: Based on review of documentation, the surveyor learned that a staff's (DOH: 03/23/2022) file did not contain a staff evaluation. Staff reported that she would locate the staff's evaluation. Employee Records Not In Compliance

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on review of documentation, the surveyor discovered the following: 1. A staff's (DOH: 08/09/2021) personnel file did not contain a high school diploma, GED, or Commonwealth Child Care Credential; therefore, the surveyor was unable to verify the staff's education. 2. A staff's (DOH: 03/23/2022) personnel file did not contain a high school diploma, GED, or Commonwealth Child Care Credential; therefore, the surveyor was unable to verify the staff's education. Staff reported that she will have the staff bring in their education documentation. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, the surveyor learned a staff's (DOH: 03/23/2022) file did not contain a copy of a statement from a health professional stating that the individual was free of active tuberculosis or a copy of a negative tuberculin (TB skin test) result for the staff person; therefore, the surveyor was unable to verify if the staff person was free of active tuberculosis. Staff reported that she would have the staff member complete the TB skin test.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation and ECE-TRIS, the surveyor discovered the following: 1. A staff (DOH: 03/23/2022) completed three and one-half (3 1/2) of the required fifteen (15) hours of cabinet-approved early care and education training completed between 03/23/2022-03/22/2023. 2. A staff (DOH: 03/23/2022) completed the required six (6) hours of cabinet-approved orientation on 04/18/2023; therefore, the six (6) hours of cabinet-approved orientation was not completed within the first three (3) months of employment in a child-care program. 3. A staff (DOH: 03/23/2022) completed the one and one-half (1 ½) hours of cabinet-approved pediatric abusive head trauma (PAHT) training on 04/16/2023; therefore, the PAHT training was not completed within the staff's first year of employment in a child-care program. 4. A staff (DOH: 09/12/2022) completed the required six (6) hours of cabinet-approved orientation on 01/05/2023; therefore, the six (6) hours of cabinet-approved orientation was not completed within the first three (3) months of employment in a child-care program. Programming In Compliance Premises Not In Compliance

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on observation, the surveyor discovered the following: 1. There was dirt/debris on the floor by a small couch located in the Toddler One Classroom. 2. There were multiple areas of food debris around the tables located in the Toddler I Classroom. Staff reported that she would have the areas cleaned.

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on observation, the surveyor discovered that the toilet seat was not tightly secured to the toilet in the girl's restroom. Staff reported that she would have the toilet seat tightened. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3 Inspection Report Hygienic Practices Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the surveyor discovered the following: 1. There were multiple holes in the diaper changing pad located in the Toddler Two Classroom. 2. There were rips in the diaper changing pad located in the Toddler One Classroom. Staff reported that she would replace the changing pads. First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Kitchen Requirements Not In Compliance

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on observation, the surveyor discovered an uncovered bottle with approximately seven (7) ounces of milk located in the refrigerator in the Toddler One Classroom. Staff reported that she will talk to staff about ensuring that bottles are covered when the bottles are not being used. 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 Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, the surveyor discovered a staff's (DOH: 03/23/2022) personnel file did not contain a professional development plan. Staff reported that she would have the staff member complete a professional development plan. Posted Documentation In Compliance Animals Not Applicable

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation presented, one (1) staff (DOH: 08/09/2021) file did not contain verification and/or documentation of education. Therefore, the education documentation was not maintained in the staff files. During interview, staff verified that the proof of education was not available for review.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation presented, the surveyor found no verification of a staff’s (DOH: 08/09/2021) negative tuberculin result or a statement from a health professional that the individual is free from active tuberculosis. During interview, staff verified that the tuberculin result was not available for review. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation and ECE-TRIS as well as interview with staff, the surveyor found the following: 1. Verification of zero hours (0) of early care and education annual training was found for a staff (DOH: 10/20/2017). 2. Verification of only five (5) hours of early care and education annual training was found for a staff (DOH: 08/15/2002. 3. Verification of only five and one-half (5 ½) hours of early care and education annual training was found for a staff (08/18/2011). During interview, staff verified that training hours were not completed for the date range of 07/01/2020 through 06/30/2021 for employees. Programming In Compliance Premises Not In Compliance

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on observation during a tour of the center, the surveyor found dead bugs in the ceiling light fixtures located in the boys’ and girls’ restrooms and in the preschool room. During interview, staff verified there were dead bugs in the fixtures and stated they will be cleaned as soon as possible. Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Kitchen Requirements In Compliance Food Service In Compliance Meal Planning/Center Provides Meals In Compliance Meal Planning/Center Does Not Provide Meals In Compliance Children's Records In Compliance Written Documentation In Compliance Posted Documentation In Compliance Animals In Compliance

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on observation, the surveyor observed two (2) children to leave the Preschool Classroom unsupervised and go to the restroom that is located by the classroom. During interview, the surveyor learned that the children are four (4) and five (5) years old. Staff-in-charge stated that she did not know why the children left the classroom. Staff-in- charge stated that the children know they cannot leave the classroom without supervision. Staffing Requirements In Compliance General Administration In Compliance Director Requirements Not In Compliance

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

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

General: Based on review of documentation, the surveyor found the following: 1. A staff’s (DOH: 08/18/11) file contained an annual written performance evaluation dated for 05/28/19; therefore, the evaluation was not completed annually. 2. A staff’s (DOH: 02/02/18) file contained an annual written performance evaluation dated for 05/28/19; therefore, the evaluation was not completed annually. 3. A staff’s (DOH: 08/01/16) file contained an annual written performance evaluation dated for 05/28/19; therefore, the evaluation was not completed annually. 4. A staff’s (DOH: 10/20/17) file did not contain an annual written performance evaluation; therefore, an evaluation was not completed annually. Through interview with staff-in-charge, the surveyor learned that up-to-date annual written performance evaluations were not available for review for the staff mentioned. Employee Records In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report Programming In Compliance Premises Not In Compliance

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on observation, the surveyor found the following: 1. A Trusted Comfort heater was turned on and located on the floor by a child’s cot in the Three Year Old Classroom. The surveyor did not observe a child to be in the cot. Warm heat was observed to be coming from the heater. 2. A Trusted Comfort heater was located on the floor under a table in the Three Year Old Classroom. The heater was observed to be turned off. 3. A Trusted Comfort heater was located on the floor next to a highchair in the Toddler Classroom. The heater was observed to be turned off. During interview, staff-in-charge stated that the heaters are child safe and do not get hot to the touch. Staff-in-charge stated that she would move the heaters to a place where they would not be accessible to the children.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the surveyor found the following: 1. A blue oval rug contained debris and stains in the Preschool Classroom; therefore, the rug was not kept clean. 2. The carpet contained stains in the Preschool Classroom; therefore, the carpet was not kept clean. 3. A cream square rug contained stains in the Preschool Classroom; therefore, the rug was not kept clean. 4. The floor contained debris in the Three Year Old Classroom; therefore, the floor was not kept clean. 5. A gray square rug contained debris in the Three Year Old Classroom; therefore, the rug was not kept clean. 6. A cream square rug contained stains in the Three Year Old Classroom; therefore, the rug was not kept clean. 7. A cream square rug contained stains and debris in the Toddler Classroom; therefore, the rug was not kept clean. 8. An oval rug contained debris and stains in the Toddler Classroom; therefore, the rug was not kept clean.

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on observation, the surveyor found an out of order sign on the door of the first stall in the boys' restroom. The surveyor observed the toilet to not be in working order. During interview, staff-in-charge stated that the toilet does not work properly and that maintenance has been working on the toilet. Hygienic Practices Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the surveyor found debris on the diaper changing table underneath the diaper changing pad in the Three Year Old Classroom; therefore, the diaper changing surface was not kept clean. First Aid/Medication In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3 Inspection Report 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 Not In Compliance

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on review of documentation, the surveyor found the following: 1. A staff’s (DOH: 08/01/16) file contained a professional development plan dated for 08/30/19; therefore, the plan was not completed annually. 2. A staff’s (DOH: 10/20/17) file did not contain a professional development plan; therefore, a plan was not completed annually. Through interview with staff-in-charge, the surveyor learned that up-to-date annual professional development plans were not available for review for the staff mentioned.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, the surveyor found no verification that earthquake and tornado drills were conducted during the first quarter of 2020. During interview, staff-in-charge stated that they have completed the earthquake and tornado drills; however, written verification of the drills was not available for review.

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on review of documentation, the surveyor found the following: 1. There was no verification that fire drills were conducted during the months of January, February, March, and December of 2020. 2. There was no verification that fire drills were conducted during the months of January and February of 2021. During interview, staff-in-charge stated that they have completed the fire drills; however, written verification of the fire drills was not available for review. Posted Documentation In Compliance Animals In Compliance Emergency Regulation Not In Compliance

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

922 KAR 2:415 · 922 KAR 2:415E. Emergency Regulation.

General: Based on review of documentation, the surveyor found that a staff’s (DOH: 02/23/21) file did not contain a completed Child Abuse/Neglect Background Check or a completed Criminal Records Background Check. During interview, staff-in-charge stated that the staff member has worked alone with children. The surveyor observed the staff member to work alone with children.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the surveyor found the following: 1. The surveyor found that staff had folded and stored a stepladder on the floor under the bulletin board in the Preschool Room. The stepladder was accessible to the children. 2. The surveyor observed a Dust Buster on the floor near the sink in the Preschool Room. The Dust Buster’s electric cord was plugged into an electrical outlet and was accessible to the children. 3. The surveyor observed an unsecured television on a shelf in the classroom for the three-year-old children. The television was easily moved. A child was sleeping on a cot/mat located on the floor directly in front of the shelf and television. The unsecured television presents a safety risk to the children in the area. Employee Records Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, the surveyor found the following: 1. The surveyor found that a staff’s (DOH: 10/20/17) negative tuberculin result was no longer current as of 10/20/19. 2. The surveyor found that a staff’s (DOH: 2/2/18) negative tuberculin result was no longer current as of 2/5/2020. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 4 Inspection Report

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation and ECE-TRIS, the surveyor found the following: 1. The surveyor found verification of only nine and one-half (9 ½) hours of cabinet-approved early care and education annual training for a staff (DOH: 2/12/19). 2. The surveyor found no verification that a staff (DOH: 11/13/18) obtained six (6) hours of cabinet-approved orientation training. 3. The surveyor found no verification that a staff (DOH: 11/13/18) obtained one and one-half (1 ½) hours of pediatric abusive head trauma training. 4. The surveyor found no verification that a staff (DOH: 2/2/18) obtained six (6) hours of cabinet-approved orientation training. 5. The surveyor found no verification that a staff (DOH: 10/20/17) obtained six (6) hours of cabinet-approved orientation training. Programming Not In Compliance

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on observation and review of documentation, the surveyor found that a one-year-old child, four (4) two-year-old children and three (3) three-year-old children are provided care in the Toddler Room. The surveyor found that the childcare center has a plan for transition; however, the written plan is not complete with the parent’s signatures and a procedure to list the specific day and time that the toddler is with either age group. Premises Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation during a tour of the Preschool Room, the surveyor found the following: 1. A canister of Lysol Wipes was located on the sink within reach of the children. The label on the canister indicated it should be kept out of the reach of children. 2. Empty plastic bags were stored in the unlocked drawers located under the sink. The empty plastic bags were accessible and within reach of the children. Hygienic Practices Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation during a tour of the Toddler Room, the surveyor found a tear in the vinyl covering on the diaper-changing pad. First Aid/Medication In Compliance Outdoor Play Area In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 4 Inspection Report Equipment In Compliance Transportation Not Applicable Food Service/Food Program In Compliance Food Service Not In Compliance

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on observation during a tour of the classroom for the three-year-old children, the surveyor found that the thermometer indicated that the interior temperature of the refrigerator was sixty (60) degree Fahrenheit. The food items inside the refrigerator was cold to the touch. Through interview, a staff person reported that the thermometer was broken; therefore, the surveyor was unable to determine the interior temperature of the refrigerator.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation during a tour of the Preschool Room, the surveyor found the following: 1. A cream-colored substance had spilled on the interior freezer base. 2. A pink substance and a white substance had spilled on the interior door and top shelf (respectively) of the refrigerator.

Open Not marked corrected in the state record

Category: nutrition. Open / not marked corrected.

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

General: Based on observation during a tour of the Preschool Room, the surveyor found that two (2) boxes of Capri Sun were stored on the floor beside a tan cabinet. Through interview, a staff reported that the Capri Sun was for the children’s use. The Capri Sun was not stored at a minimum of at least six (6) inches off the floor. Children's Records Not In Compliance

Open Not marked corrected in the state record

Category: nutrition. Open / not marked corrected.

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

General: Based on review of documentation, the surveyor found the following: 1. A child’s (DOE: 10/18/19) immunization certificate had an expiration date of 9/25/19; therefore, the child’s immunizations were no longer current. 2. A child’s (DOE: 4/17/19) immunization certificate had an expiration date of 11/9/19; therefore, the child’s immunizations were no longer current. 3. A child’s (DOE: 3/14/19) immunization certificate had an expiration date of 2/6/20; therefore, the child’s immunizations were no longer current. 4. A child’s (DOE: 4/9/19) immunization certificate had an expiration date of 9/17/19; therefore, the child’s immunizations were no longer current. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 4 Inspection Report Written Documentation Not In Compliance

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

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

General: Based on review of documentation, the surveyor found that staff had not recorded the time of day that the quarterly practiced tornado and earthquake drills were conducted during each quarter of 2019. Posted Documentation In Compliance Animals Not Applicable

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on review of documentation of the files presented to the surveyor for review, the following was found: 1. The file for a child (DOE: 08/06/18) did not contain contact information to enable a person in charge to contact their preferred hospital. 2. The file for a child (DOE: 05/20/18) did not contain contact information to enable a person in charge to contact their preferred hospital. 3. The file for a child (DOE: 08/29/18) did not contain contact information to enable a person in charge to contact their preferred hospital. 4. The file for a child (DOE: 05/21/18) did not contain contact information to enable a person in charge to contact their preferred hospital. 5. The file for a child (DOE: 07/23/18) did not contain contact information to enable a person in charge to contact their preferred hospital. 6. The file for a child (DOE: 03/15/18) did not contain contact information to enable a person in charge to contact their preferred hospital. 7. The file for a child (DOE: 07/30/18) did not contain contact information to enable a person in charge to contact their preferred hospital. 8. The file for a child (DOE: 07/17/18) did not contain contact information to enable a person in charge to contact their preferred hospital. 9. The file for a child (DOE: 08/03/18) did not contain contact information to enable a person in charge to contact their preferred hospital. 10. The file for a child (DOE: 06/05/18) did not contain contact information to enable a person in charge to contact their preferred hospital. Written Documentation Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation presented for review, the surveyor found the following: 1. Staff (DOH: 08/01/16) file did not contain an annual written performance evaluation. 2. Staff (DOH: 10/20/17) file did not contain an annual written performance evaluation. During interview with the director, it was confirmed that the documents were not in the files. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 4 Inspection Report Employee Records Not In Compliance

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on review of documentation presented for review, the surveyor found the following: 1. An employee (DOH: 02/12/19) record presented for review did not contain evidence of educational qualification. 2. An employee (DOH: 11/13/18) record presented for review did not contain evidence of educational qualification. During interview with the director, it was confirmed that the documents were not in the files.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, the surveyor was presented with a file for one (1) staff member (DOH: 08/01/16) that did not contain a copy of a negative tuberculin result or a statement from a health professional that the individual was free of active tuberculosis. Through interview with the director, it was confirmed that the statement was not present in the file.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation and ECE-TRIS, the files presented to the surveyor found the following: 1. No verification that two (2) staff (DOH: 02/02/18) and (DOH: 10/20/17) had completed Pediatric Abusive Head Trauma Training within the first year of employment. 2. Verification that one (1) staff (DOH: 02/02/18) had obtained only nine (9) hours of cabinet-approved early care and education annual training. 3. Verification that one (1) staff (DOH: 10/20/17) had obtained only thirteen (13) hours of cabinet-approved early care and education annual training. 4. No verification that four (4) staff (DOH: 11/13/18), (DOH: 10/18/18), (DOH: 02/02/18) and (DOH: 10/20/17) had obtained six (6) hours of cabinet-approved orientation training within the first three (3) months of employment. Programming In Compliance Premises Not In Compliance

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on observation, the surveyor found a bottle of Dawn dish detergent, which was marked "Keep Out of Reach of Children", on the sink in the Early Learning Center room where the children wash their hands; therefore, the bottle was accessible to the children. Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation In Compliance Food Service/Food Program In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 4 Inspection Report Food Service In Compliance Children's Records Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation of files presented to the surveyor for review, the following was found: 1. The most recent immunization certificate presented for surveyor review for one (1) child (DOE: 05/20/18) was no longer current after 12/14/18. 2. The most recent immunization certificate presented for surveyor review for one (1) child (DOE: 05/21/18) was no longer current after 12/02/18. 3. The most recent immunization certificate presented for surveyor review for one (1) child (DOE: 07/23/18) was no longer current after 02/09/19.

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

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

General: Based on review of documentation, the surveyor was presented with a binder designated for documentation of practiced earthquake, tornado, and file drills; however, the surveyor found that the docuemnation did not contain drills practiced after 09/15/18. Based upon interview, the director stated that all drills have been completed but they were not in the file; therefore, a written record of the practiced earthquake, tornado, or file drills could not be verified. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 4 Inspection Report

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on review of documentation, the surveyor was presented with a binder designated for documentation of practiced earthquake, tornado, and file drills; however, the surveyor found that the docuemnation did not contain drills practiced after 09/15/18. Based upon interview, the director stated that all drills have been completed but they were not in the file; therefore, it could not be verified that the practiced earthquake, tornado, or file drills had been conducted and/or documented. Posted Documentation In Compliance Animals In Compliance

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 14. Statement of Deficiency and Corrective Action Plans.

A PLAN OF CORRECTION WAS DUE ON 09/18/2018 AND AS OF 09/20/2018, THE PLAN OF CORRECTION HAS NOT BEEN RECEIVED. Director Requirements Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation and interview, the following were found: 1. There was stained glass located in the front windows and door of the Gross Motor Room. The glass was breakable and would be accessible to any children utilizing the space. The Director stated she did not know that the glass would need to be covered to protect it from being broken. 2. There were two (2) large glass statues located on shelves on both sides of the Gross Motor Room. The statues were not secure to the shelves and could therefore fall on any children utilizing the space. 3. There were glass candleholders on the fireplace mantle in the Gross Motor Space that could be knocked over and broken by children utilizing the space. 4. There was a glass mirror sitting on the mantle that was not secured to the wall. The mirror presents a safety risk to any children that would utilize the space, as the glass is breakable. The Director stated that she did not know if the statues, candleholders, or mirror would need to be removed from the room in order for it to be approved as a Gross Motor Room. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Premises Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation and interview, the surveyor found that two (2) large stained glass windows on both sides of the front door located in the Gross Motor Room had been removed for repair and temporarilty replaced with plywood. There were gaps between the plywood and the window frame allowing room for air and possibly vermin to enter the facility. The Director reported that the windows had been sent off to be repaired and she was unsure of when they would be completed.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation and interview, the following were found: 1. A staff file (DOH: 8/18/11) did not contain an annual evaluation. 2. A staff file (DOH: 8/1/16) did not contain an annual evaluation. 3. A staff file (DOH: 8/11/16) did not contain an annual evaluation. 4. A staff file (DOH: 8/11/16) did not contain an annual evaluation. 5. A staff file (DOH: 9/6/16) did not contain an annual evaluation. Upon interview, the Director was aware that staff evaluations were not in the file.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on observation and interview, the surveyor found that there were three (3) unprotected electrical outlets located behind the changing area in Toddler One Classroom. Staff reported that they had recently utilized the outlets and not replaced the protective covers. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 5 Inspection Report Employee Records Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation and interview, the surveyor found that a staff file (DOH: 10/20/17) did not contain an out of state criminal record check for a state that the staff member had previously resided in within the past five (5) years. The file did not contain documentation of the out of state criminal record check being submitted. Upon interview, the Director stated that she did not keep a copy of the out of state criminal record check but had given it to the staff member to submit. The Director explained that the staff member has not yet worked at the center or with the children as they are waiting on the results of the out of state criminal record check.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, review of ECE-TRIS, and interview, the following was found: 1. A staff file (DOH:8/15/02) presented for review contained documentation of only completing eight (8) hours of annual training from 8/15/16 - 8/14/17. Review of ECE-TRIS, confirmed that only eight (8) hours of annual training had been completed. 2. A staff file (DOH: 8/18/11) presented for review contained documentation of only completing eleven (11) hours of annual training from 8/18/16 - 8/17/17. Review of ECE-TRIS, confirmed that only eleven (11) hours of annual training had been completed. 3. A staff file (DOH: 8/11/16) presented for review contained documentation of only completing six and a half (6.5) hours of annual training from 8/11/16 - 8/10/17. Review of ECE- TRIS, confirmed that only six and a half (6.5) hours of annual training had been completed. 4. A staff file (DOH:8/11/16) presented for review contained documentation of only completing six (6) hours of annual training from 8/11/16 - 8/10/17. Review of ECE-TRIS, confirmed that only six (6) hours of annual training had been completed. 5. A staff file (DOH: 9/6/16) presented for review contained documentation of only completing twelve (12) hours of annual training from 9/6/16 - 9/5/17. Review of ECE-TRIS, documented that only three (3) hours of annual training had been completed. 6. A staff file (DOH: 8/18/11) contained documentation of completed Pediatric Abusive Head Trauma (PAHT) on 8/16/12. Review of ECE-TRIS, revealed that PAHT was completed on 8/16/12; therefore, PAHT has not been completed every five (5) years as required. 7. A staff file (DOH: 8/11/16) did not contain documentation of having completed Pediatric Abusive Head Trauma (PAHT) training. Review of ECE-TRIS, revealed that PAHT had not been completed. 8. A staff file (DOH: 8/11/16) did not contain documentation of having completed Pediatric Abusive Head Trauma (PAHT) training. Review of ECE-TRIS, revealed that PAHT had not been completed. 9. A staff file (DOH: 9/6/16) did not contain documentation of having completed Pediatric Abusive Head Trauma (PAHT) training. Review of ECE-TRIS, revealed that PAHT had not been completed. The Director stated that she was aware of the descrepancies in regards to training. Programming In Compliance Premises Not In Compliance

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on observation and interview, the surveyor observed a pair of adult non-safety scissors on the mantle of the faux fireplace in the Toddler Two Classroom which would be accessible to the children. Upon interview, staff stated that she had been using the scissors and did not think that the children could reach them. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 5 Inspection Report

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation and interview, the surveyor found the following: 1. The white rug located in the Toddler Two Classroom was badly stained and soiled. Staff stated the the rugs are cleaned multiple times through out the year. 2.The front of the cabinets under the sink in the Pre-school Classroom were soiled. 3. The front of the cabinets in the Toddler Two Classroom were soiled. Upon interview, staff reported that the cabinets are wiped down daily with a bleach solution. Hygienic Practices Not In Compliance

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on observation and interview, the surveyor found that the diaper changing pad located in the Toddler One Classroom contained multiple tears in the vinyl covering, thus preventing it from being adequatley sanitized. The Director reported that the teacher had just requested that a new diaper changing mat be ordered. First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Food Service Not In Compliance

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on observation and interview, the surveyor found that the mini refrigerator located in the Toddler One Classroom did not have a thermometer. Upon interview, the Director thought that a thermometer had been ordered; however, staff stated they had not requested a thermometer.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation and interview, the surveyor found that the thermometer in the freezer located in the Pre-school Classroom was reading at twelve (12) degrees Fahrenheit rather than the required zero (0) degrees Fahrenheit or less. Upon interview, the Director was not aware that the freezer was not maintained at the required temperature. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 5 Inspection Report Children's Records Not In Compliance

Open Not marked corrected in the state record

Category: nutrition. Open / not marked corrected.

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

General: Based on review of documentation and interview, the surveyor found that a child's file (DOE: 4/20/17) did not contain a current immunization record as the immunizations were due to be updated by 12/2/17. Upon interview, the Director was not aware that the immunizations were not up-to-date.

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

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

General: Based on review of documentation and interview, the following were found: 1. A child's file (DOE: 11/7/17) did not contain a preferred hospital name or telephone number. 2. A child's file (DOE: 3/30/17) did not contain a preferred hospital name or telephone number. 3. A child's file (DOE: 5/10/17) did not contain a preferred hospital name or telephone number. 4. A child's file (DOE: 3/25/17) did not contain a preferred hospital name or telephone number. Upon interview, the Director was not aware that the information was missing from the files. Written Documentation Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation and interview, the surveyor found that a staff file (DOH: 8/11/16) contained an annual professional development plan that was not dated; therefore, a valid annual professional development plan was not presented for review. Upon interview, the Director was not aware that the professional development plan had not been dated. Posted Documentation Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110. Section 2. General.

General: Based on observation and interview, the surveyor found that each deficiency statement and plan of correction completed within the past year was not posted in a conspicuous location where they were availble for public review. Upon interview, the Director reported that the documentation was stored in a binder in the classroom. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 4 of 5 Inspection Report Animals In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the surveyor found the two-year-old classroom's refridgerator did not contain a thermometer.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the surveyor found that the proper methods of diapering were not posted in the two year old classroom's diaper changing area. Animals In Compliance

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on review of documentation, staff (DOH: 8/18/11) did not have an annual written performance evaluation.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on interview, the director confirmed that staff (DOH: 9/6/16) has worked alone with children without a completed out of state criminal records check. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 5 Inspection Report Employee Records Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, the surveyor found that staff (DOH: 9/6/16) documented on their child abuse and neglect check that they have been a resident of Tennessee within the past five (5) years. The director confirmed that staff has worked alone with children without a completed out of state criminal records check.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, the surveyor found the following: (1.) According to staff's (DOH: 9/6/16) child abuse or neglect check, staff has been a resident of Tennessee within the past five (5) years. A criminal records check for the staff's previous state of residence was not completed. (2.) Staff's (DOH: 8/1/16, 8/11/16, 8/11/16, 9/6/16) file did not contain proof of educational qualifications. (3.) Staff's (DOH: 8/1/16, 8/11/16, 8/11/16, 9/6/16) file did not contain a statement from a healthcare professional to indicate that the staff is free of active tuberculosis.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, the surveyor found that staff's (DOH: 8/1/16, 8/11/16, 8/11/16, 9/6/16) file did not contain a high school diploma, GED, or Commonwealth Child Care Credential.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, the surveyor found the staff’s (DOH: 8/1/16, 8/11/16, 8/11/16, 9/6/16) file did not contain the results of negative tuberculin test. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 5 Inspection Report Programming Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the surveyor found that the two-year-old and infant classrooms did not have lesson plans. Premises Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the surveyor found one (1) container of Aquaphor Healing Ointment accessible to the children on a shelf underneath the diaper changing table. The label on the ointment read to keep out of reach of children. Hygienic Practices Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the surveyor found a soiled diaper in an uncovered trash can in the two-year-old classroom.

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on observation, the surveyor found a tear in the infant classroom's diaper changing pad. First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 5 Inspection Report Transportation Not Applicable Food Service Not In Compliance

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on observation, the surveyor found the following: (1.) The preschool room's freezer thermometer read ten (10) degrees fahrenheit, which is above the required temperature of zero (0) degrees fahrenheit or below. (2.) The two-year-old classroom's freezer did not contain a thermometer. Children's Records Not In Compliance

Open Not marked corrected in the state record

Category: nutrition. Open / not marked corrected.

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

General: Based on review of documentation, the surveyor found the children's (DOE: 8/15/16, 8/15/16) immunization certificates had no expiration date.

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

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

General: Based on review of documentation, the surveyor found the following: (1.) The child's (DOE: 8/15/16) file did not contain information regarding the child's medical history. (2.) The children's (DOE: 9/10/16, 8/15/16, 3/1/16, 8/13/16, 8/15/16, 3/1/16, 2/11/16, 2/24/16, 12/4/12) file did not contained a preferred hospital or telephone number. (3.) The child's (DOE: 2/11/16) file did not contain a preferred physician. Written Documentation In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 4 of 5 Inspection Report Posted Documentation Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation the surveyor found that the verification provided for proof of insurance showed a policy end date of 12/31/15.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 9. Statement of Deficiency and Corrective Action Plans.

A PLAN OF CORRECTION WAS DUE ON 18 Mar 16 AND AS OF 23 Mar 16, THE PLAN OF CORRECTION HAS NOT BEEN RECEIVED.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation the surveyor found the children’s coats, backpacks and other belongings hanging on hooks outside the classroom to be touching which could cause cross contamination.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation the surveyor found the following: 1.The file for a staff person (DOH: 8/20/93) did not contain documentation that fifteen (15) hours of approved training has been completed. A review of the staff persons training record on ECE-TRIS found no additional training documentation. 2.The file for a staff person (DOH: 8/18/11) did not contain documentation that fifteen (15) hours of approved training has been completed. A review of the staff persons training record on ECE-TRIS found no additional training documentation. 3.The file for a staff person (DOH: 9/19/14) did not contain documentation that fifteen (15) hours of approved training has been completed. A review of the staff persons training record on ECE-TRIS found the staff person has not completed the 1 and a half (1 ½ ) hours of pediatric abusive head trauma training or any additional training.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on observation the surveyor found that the lesson plan posted in the classroom had not been updated for the current week.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation the surveyor found a handheld vacuum laying in the floor by a wall in the classroom. The vacuum was accessible to the children.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation the surveyor found the thermometer located in the freezer measured a temperature of 10 degrees.

Open Not marked corrected in the state record

Category: nutrition. Open / not marked corrected.

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

General: Based on review of documentation contained in a child’s file(DOE: 8/20/15), the surveyor found that the child’s immunization certificate was no longer current as of 1/28/16. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 23 of 26 Web site: http://chfs.ky.gov/ Inspection Report

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

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

General: Based on review of documentation the surveyor found the following: 1.The file for a child (DOB: 10/12/11) did not provide a preferred hospital name or phone number for the preferred hospital. 2.The files for two (2) children (DOB: 1/29/11 & 08/20/15) did not provide a preferred hospital name.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation the surveyor found that no fire drills had been conducted for the month of November 2015.

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on review of documentation the surveyor found that the emergency prepardness plan was incomplete as it was not signed or dated. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 25 of 26 Web site: http://chfs.ky.gov/ Inspection Report

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation and interview, there was no posted lesson plan for the preschool children.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation during a tour of the outdoor play area, the surveyor found that the landscape fabric installed under the mulch was exposed in many areas and created a safety hazard to the children.

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on observation and review of documentation, the snack portion of the posted menu had not been completed for the date of the surveyor's inspection.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, none of the ten (10) children's files presented for surveyor review contained the preferred hospital and preferred hospital telephone number.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, verification of fire drills for the months of August, September, October, and November 2014 was not presented for surveyor review. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 24 of 25 Web site: http://chfs.ky.gov/ Inspection Report

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on review of documentation, verification of earthquake and tornado drills for the quarterly months of July through September 2014 was not presented for surveyor review. Posted Documentation

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 13. Animals.

General: Based on interview, the child care center failed to obtain written parental consent from all children's parents/guardians in the preschool classroom for the classroom's pet fish.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110. Section 2. General.

General: Based on observation, the director did not have a current copy of the administrative regulations. Based upon interview, the director had not printed new regulations or provided a copy to child care center staff as required.

Open Not marked corrected in the state record

Category: ratio. Open / not marked corrected.

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

General: Based on review of documentation, the director did not provide documentation of current staff evaluation for all four (4) child care center employees.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on review of documentation, documentation of current negative TB verification for an employee (DOH: 11/29/12) was not contained in the staff member's file.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, the child care center did not present documentation that the substitute (DOH: 12/04/12) was qualified as required by administrative regulations in that no training hours were presented for review nor available on ECE-TRIS system. 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

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, an employee (DOH:08/18/11) record presented for review contained evidence of only 14 hours of cabinet approved training as verified by ECE-TRIS and the file presented for review. 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

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on observation, the protective surfacing of mulch had eroded in high traffic areas at the swings, around the play structure, and the tire set, exposing the black plastic material beneath. With the material rising above the mulch, a fall hazard was present. The playground appeared to have an adequate amount of protective surfacing; however, the mulch needed to be maintained to ensure all areas have safe, adequate coverage.

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on review of documentation, the file presented for review for a child (DOE: 08/04/13) contained an immunization certificate that was no longer current after 07/11/13. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 23 of 26 Web site: http://chfs.ky.gov/ Inspection Report

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

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

General: Based on review of documentation, none of the ten (10) children's records presented for review contained the preferred hospital contact information required in the event of an emergency.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, the following issues were found: (1) The professional development plan for an employee (DOH: 11/29/12) had not been updated annually as required. (2) A current professional development plan for an employee (DOH: 08/18/11) was not presented for review. Based upon interview, the director was unable to locate this professional development plan. (3) A current professional development plan for an employee (DOH: 08/20/93) was not presented for review. Based upon interview, the director was unable to locate this professional development plan.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, the director did not provide written documentation of practiced quarterly earthquake and tornado drills.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, the director did not provide written documentation of practiced monthly fire drills.

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on interview, the director stated that she had thrown away documentation of fire, earthquake, and tornado drills that occurred prior to the beginning of the 2013-2014 school year in August. Therefore, the director failed to maintain written record of fire, earthquake, and tornado drill documentation for five (5) years as required by KAR 2:110, Section 3, Records.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110. Section 2. General.

General: Based on observation, the child care center did not have the most recent statement of deficiency issued by the cabinet posted as required by regulations.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110 - Section 4 (1)

Based on review of documentation, the surveyor found no documented staff meetings within the past year.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110 - Section 4 (1)

Based on review of documentation, the surveyor found that the most recent performance evaluation on file for a staff member (DOH: 8/20/08) was dated 1/17/10.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110 - Section 3

Based on review of documentation, the surveyor found that two (2) staff members (DOH: 8/20/93 and 8/20/08) did not have professional development plans on file. 107 - Maintenance of Background check/Out of State 922 KAR 2:110 - Section 3 (12) For the director, employee, volunteer, or any person with supervisory or disciplinary control over, or having direct contact with a child, results of the: (a) Criminal records check in accordance with KRS 17.165; (b) Child abuse and neglect check in accordance with 922 KAR 1:470; and (c) Background check from: 1. Previous state of residence, if the individual has been a resident outside of Kentucky in the previous five (5) years; or 2. Current state of residence, if other than Kentucky; 1) Criminal Records Check In Compliance 2) Child Abuse/Neglect Check In Compliance 107 - Maintenance of Background check/Out of State 922 KAR 2:110 - Section 3 (12) For the director, employee, volunteer, or any person with supervisory or disciplinary control over, or having direct contact with a child, results of the: (a) Criminal records check in accordance with KRS 17.165; (b) Child abuse and neglect check in accordance with 922 KAR 1:470; and (c) Background check from: 1. Previous state of residence, if the individual has been a resident outside of Kentucky in the previous five (5) years; or 2. Current state of residence, if other than Kentucky; 3) Previous State of Residence Not Applicable 4) Current State other than KY Not Applicable

Open Not marked corrected in the state record

Open / not marked corrected.

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

Based on review of documentation, the surveyor found that there was no evidence of a high school diploma, GED, or Commonwealth Child Care Credential on file for a staff member (DOH: 9/20/11).

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120 - Section 4 (18)

Based on observation during a tour of the playground, the surveyor found that the landscape fabric was protruding through the mulch in numerous places throughout the swing set area and in front of the steps to the climber/slide structure.

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110 - Section 3

Based on review of documentation, the surveyor found that the center did not have a written staff work schedule. 104 - Earthquake/Tornado Drills 922 KAR 2:110 - Section 3 (9) A written record of quarterly, practiced earthquake and tornado drills detailing the date, time, and children who participated; 1) Earthquake - conducted quarterly Not In Compliance Findings: Based on review of documentation, the surveyor found that an earthquake drill was not conducted during the quarter of July-September 2011. 5) Tornado - conducted quarterly Not In Compliance Findings: Based on review of documentation, the surveyor found that a tornado drill was not conducted during the quarter of April-June 2011. 104 - Earthquake/Tornado Drills 922 KAR 2:110 - Section 3 (9) A written record of quarterly, practiced earthquake and tornado drills detailing the date, time, and children who participated; 2) Earthquake - includes date In Compliance 3) Earthquake - includes time In Compliance 4) Earthquake - includes children who participated In Compliance 6) Tornado - includes date In Compliance 7) Tornado - includes time In Compliance 8) Tornado - includes children who participated In Compliance 105 - Fire Drills 922 KAR 2:110 - Section 3 (10) A written record of practiced fire drills conducted monthly detailing the date, time, and children who participated; 1) Date Not In Compliance Findings: Based on review of documentation, the surveyor found that there was no documented fire drill in February 2011. 2) Time Not In Compliance Findings: Based on review of documentation, the surveyor found that there was no documented fire drill in February 2011. Therefore, compliance with this requirement could not be determined. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 38 of 41 Web site: http://chfs.ky.gov/ Inspection Report 3) Children Not In Compliance Findings: Based on review of documentation, the surveyor found that there was no documented fire drill in February 2011. Therefore, compliance with this requirement could not be determined. 105 - Fire Drills 922 KAR 2:110 - Section 3 (10) A written record of practiced fire drills conducted monthly detailing the date, time, and children who participated; 4) Conducted monthly In Compliance

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.