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

General: Based on interview, it was found that classrooms are placed over ratio in the morning time when the ratio is met but staff continue to accept the children into the classroom. Staff report being over ratio for approximately five (5) minutes at a time before children are moved to another classroom or a staff member joins them. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2

Open Not marked corrected in the state record

Category: ratio. Open / not marked corrected.

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

Based on review of documentation, a check of the Kentucky Applicant Registry and Employment Screening (KARES) report revealed that one(1) staff member (DOH 04/01/24) is currently employed, however, is not showing eligible on the KARES report. Supervision In Compliance Staffing Requirements In Compliance General Administration In Compliance 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 review of documentation, staff evaluations were not available for review. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 4 Inspection Report Employee Records Not In Compliance

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on review of documentation, four (4) staff members (DOH 11/28/23, 06/05/23, 07/05/23, 05/04/23) did not have proof of educational qualifications in their personnel 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, five (5) staff members (DOH 04/19/23, 01/08/24, 05/04/23, 03/02/21, 10/08/22) did not have evidence of a negative tuberculin skin result, nor a physician’s statement clearing this individual of active tuberculosis.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, nine (9) staff members (DOH 06/05/23, 07/05/23, 05/04/23, 02/06/23, 04/19/23, 01/08/24, 12/27/23, 03/02/21, 09/03/21) did not have evidence of completing Cabinet-approved CPR training; this training is to be completed within the first 90 days of hire.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on review of documentation, the following was found: 1)Twelve (12) staff members (DOH 04/19/23, 01/08/24, 12/27/23, 11/28/23, 06/05/23, 07/05/23, 05/04/23, 02/06/23, 03/02/21, 04/13/23, 01/04/22, 09/03/21), did not have evidence of completing Cabinet-approved Orientation training; this training is to be completed within the first 90 days of hire. 2) Eight (8) staff members (DOH 05/04/23, 02/26/23, 04/19/23, 08/10/15, 03/02/21, 04/13/23, 09/14/22, 09/03/21) did not have evidence of completing Cabinet-approved Pediatric Head Trauma training; this training is to be completed within the first year of hire. 3) Thirteen (13) staff members (DOH 04/19/23, 05/04/23, 02/06/23, 05/12/22, 08/10/15, 03/02/21, 10/14/17, 10/11/21, 04/13/23, 05/17/21, 01/04/22, 09/14/22, 09/03/21) did not have the fifteen (15) hours of early care and education training recorded on ECE-TRIS for the July 1, 2022 – June 30, 2023, training year. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Kitchen Requirements In Compliance Food Service In Compliance Meal Planning/Center Provides Meals In Compliance Meal Planning/Center Does Not Provide Meals In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 4 Inspection Report Children's Records 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, one (1) child had an immunization record that was not current, and one (1) child enrolled longer than thirty (30) days did not have an immunization record.

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, two (2) children’s files reviewed did not list a preferred hospital and one (1) child's file reviewed did not list a physician. 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, a current staff schedule was not available for review at the time of the survey.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on review of documentation, professional development plans for current staff were not available for review. Posted Documentation In Compliance Animals Not Applicable

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, at approximately 11:30 a.m. the surveyor entered the Preschool Room located in the basement of the main building of the YMCA and found four (4) children running around on a large area rug located inside the classroom. The surveyor did not see a staff person in the area where the children were observed. The surveyor then heard an adult voice coming from a separate area located to the left of the room. The surveyor noted there was one staff person in that area with additional children. The staff person was in the bathroom helping the children change out of their swim suits. Due to the location of the bathroom the staff person could not see the four (4) children observed inside the classroom. Thus, the children were not within scope of vision and range of voice. It should be noted that the door to the classroom was locked and could not be opened without the assistance of YMCA facility staff or Child Care Staff. While the surveyor was being assisted by one of the YMCA facility staff, one of the childcare staff and two children came through a door located beside the classroom. The staff person opened the door and indicated she had left the room with the two children to get plates for lunch. It could not be determined how long the children were left unsupervised. Staffing Requirements In Compliance General Administration In Compliance

Open Not marked corrected in the state record

Category: supervision. Open / not marked corrected.

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

General: Based on observation in the Preschool classroom at approximately 10:58 a.m., the surveyor observed eighteen (18) children and four (4) adults. Three (3) of the four (4) adults were behavior therapists employed by Bluegrass Behavioral Services for Children (BBSC). One (1) of the therapists identified five (5) children ages two- to four-years-old that were "signed out" into their care. The surveyor found there was only one (1) two-year-old child present who was brought into the classroom to receive therapy. In short, the three (3) therapists working with their clients in the classroom do not meet the qualifications of a qualified staff member; therefore, do not count in staff-to-child ratios. The one (1) qualified staff member working in the classroom had thirteen (13) children ages three- to four-years-old. Therefore, the classroom was over-ratio by one (1) child. General Administration Not In Compliance

Open Not marked corrected in the state record

Category: ratio. Open / not marked corrected.

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

General: Based on observation, the surveyor found the following: 1. In the Nursery 1-B classroom, a radio cord was hanging from a mounted shelf within reach of the children in care. The children present were eight- to twelve-months old. 2. A mop bucket was located in front of the entrance to the Preschool classroom. 3. A plunger was located next to the toilet in the Preschool classroom's restroom. The plunger was within reach of the children in care; therefore, this promotes the risk of spreading germs. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 7 Inspection Report

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 13. Reports.

General: Based on interview, the surveyor found the public school provides transportation services to transport school-age children to and from field trips on Tuesdays and Thursdays. Based on review of documentation, the child-care center is not licensed for transportation services. 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 three (3) staff members hired respectively on 9/12/2022, 10/8/2022, and 5/30/2023, did not have proof of education on file.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, the surveyor found the following: 1. Four (4) staff members hired respectively on 8/8/2022, 10/8/2022, 5/9/2023, and 5/22/2023, did not have TB documentation available for review. 2. Two (2) staff members hired on 3/2/2021 and 5/17/2021, had TB documentation on file that was no longer current as of 3/25/2023 and 6/17/2023 respectively. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 7 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. Four (4) staff members hired respectively on 8/10/2015, 10/14/2017, 3/4/2020, and 5/17/2021, did not complete fifteen (15) hours of cabinet-approved early care and education training during the June 1, 2021-6/30/2022, training year. 2. One (1) staff member hired 9/14/2022, completed the six (6) hour orientation training on 2/28/2023, which exceeds the required three (3) month period of completion. 3. Four (4) staff members hired respectively on 3/2/2021, 3/14/2022, 2/28/2022, and 6/6/2022, have not completed one and one-half (1 ½) hours of cabinet-approved pediatric abusive head trauma training. 4. Two (2) staff members hired respectively on 2/28/2022 and 3/2/2021, have not completed six (6) hours of cabinet-approved orientation training. The staff members have been employed more than three (3) months. It should be noted that this regulatory violation was cited during the renewal inspection conducted on 6/22/2022 for two (2) staff members (hired: 2/28/2022 and 3/2/2021), not completing orientation training and pediatric abusive head trauma 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 4. Premises Requirements.

General: Based on observation, the surveyor found the following: 1. Several paper towels were stuck inside the floor vent in the restroom located in the Pre-K classroom. 2. An accumulation of dust was embedded within the ceiling exhaust vent in the restroom located 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 4. Premises Requirements.

General: Based on observation, the surveyor found excessive gashes, peeled paint, and holes in the walls in the Pre-K classroom, Two-year-old classroom, and Infant classroom. Additionally, the surveyor observed three (3) water-stained ceiling tiles in the Nursery II 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 12. Toilet, Diapering, and Toiletry Requirements.

General: Based on observation, the surveyor found a build-up of water scale and grime in the hand-washing sink located in the Two-year-old classroom. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 4 of 7 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 3. General Requirements.

General: Based on observation, The surveyor found the following: 1. In the Nursery 1-B classroom at approximately 10:40 a.m., the surveyor observed a staff member change a toddler’s diaper and then return the toddler to the play area without washing the toddler’s hands. 2. In the Nursery 2 classroom at approximately 10:43 a.m., the surveyor observed a staff member change a toddler’s diaper and then return the toddler to the play area without washing the toddler’s hands. 3. In the Nursery 2 classroom at approximately 10:45 a.m., the surveyor noted all eleven (11) children present in the classroom did not wash their hands prior to eating lunch.

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 in the Nursery 2 classroom, at approximately 10:43 a.m., a staff member did not wash her hands after changing a toddler’s diaper. Next, the staff member walked directly to the door to retrieve lunch plates from the cook. The staff member collected the plates and placed them on the table in front of the children

Open Not marked corrected in the state record

Category: recordkeeping. 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 diapering area located in the Preschool classroom was not free from non-diapering items, such as a backpack and clothing. During interview, the staff member stated that two (2) children enrolled in the classroom are still in diapers and a few other children are in pull-ups. First Aid/Medication In Compliance Outdoor Play Area In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 5 of 7 Inspection Report Equipment Not In Compliance

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on observation, the surveyor found the following: 1. Excessive tape residue was located on the back of a shelving unit located in the Nursery 2 classroom. 2. Excessive tape residue was located on two (2) tables located in the Preschool classroom. 3. Excessive paper particles were located on a blue area rug located in the Nursery 2 classroom.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the surveyor found a large tear in the seam of an adult-sized chair in the Nursery 1-B classroom. Transportation Not Applicable Kitchen Requirements In Compliance Food Service Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 9. Food and Drink Requirements for All Child-Care Centers.

General: Based on observation, the surveyor found a can of Good Start formula in the Nursery 1-B classroom. During interview, the surveyor found the formula belongs to a child enrolled in the classroom. The staff member stated that she prepares bottles for the child. The formula is not pre-measured by the parent.

Open Not marked corrected in the state record

Category: ratio. Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 9. Food and Drink Requirements for All Child-Care Centers.

General: Based on observation in the Preschool classroom at approximately 10:54 a.m., the surveyor observed a male child lying down on a bean bag and drinking from a sippy cup. The child was never directed to sit at a table. 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 An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 6 of 7 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 8. General.

General: Based on review of documentation, the statement of deficiency/plan of correction from the previous licensure survey was not posted in the facility. Animals Not Applicable

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:280 · 922 KAR 2:280 - Section 4. Procedures and Payments.

General: Based on review of documentation, one staff hired on 6/1/21, did not have evidence of initiating the process for a background check through the KARES system. This staff member did not have an application for KARES and had yet to submit fingerprints in order to obtain the background check. The staff was not present the day of survey.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:280 · 922 KAR 2:280. Section 4. Procedures and Payments.

General: Based on review of documentation, one staff hired on 6/1/21, did not have an application for KARES and had yet to submit fingerprints in order to obtain the background check. The staff was not present the day of survey. Supervision In Compliance Staffing Requirements In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 5 Inspection Report General Administration Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the Preschool classroom had a surge protector hanging on the wall with loose cords; this poses a safety risk to the children in the classroom. In addition, the Preschool classroom had balloons in the classroom which can pose a safety hazard to the children. 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 review of documentation, three staff hired on 6/1/21, 5/17/21, and 5/17/21, did not evidence of an annual evaluation on file at the facility. 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, four staff did not have proof of education on file at the facility. The hire dates for these staff were 9/28/21, 5/17/21, 5/24/22, and 6/6/22.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, the following was found: 1.) One staff hired on 2/28/22, did not have evidence of negative TB results on file at the facility. 2.) One staff hired on 10/14/17, did not have negative TB results on file at the facility that had been obtained within the last two years. The results on file expired 6/11/22.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, nine staff did not have evidence of completing the required CPR/FA training on file at the facility. The hire dates for these staff were 9/3/21, 6/1/21, 3/2/21, 9/28/21, 2/28/22, 10/7/21, 6/15/20, 11/12/21, and 11/12/21. A review of ECE-TRIS confirmed this finding. 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

Category: recordkeeping. Open / not marked corrected.

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

General: Based on review of documentation, the following was found: 1.) Three staff hired on 8/10/15, 10/14/17, and 6/15/20, did not complete the required 15 hours of annual training. 2.) Two staff hired on 3/2/21, and 6/15/20, did not complete the required PAHT training within the first year of employment. 3.) Three staff hired on 10/11/21, 5/17/21, and 8/31/21, did not complete the required Orientation training within the first three months of employment. 4.) Eight staff did not complete the required Orientation training. These staff have been employed for more than three months. Hire dates for these staff are 9/3/21, 6/15/20, 2/26/22, 10/7/21, 11/12/21, 11/12/21, 2/28/22, and 3/2/21. A review of ECE-TRIS confirmed these findings. 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 following was found: 1.) The Preschool classroom had three stained ceiling tiles. In addition, the baseboard had come unattached from the wall. 2.) The Pre-K Summer Camp classroom had one stained ceiling tile and several holes in the bathroom wall.

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 lid to the toilet in the Pre-K Summer Camp classroom was broken and in disrepair. Also, the screws at the base were exposed causing a safety hazard. 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 trash can in Preschool classroom for the soiled diapers was in disrepair and missing a lid; therefore, it was not covered. First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment Not In Compliance

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on observation, the Preschool classroom had the cots stacked upright with sheets and blankets touching; this is an unsanitary method of storage, as it promotes the spread of germs and bacteria. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 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 13. Toys and Furnishings.

General: Based on observation, the changing table in the Preschool classroom was missing a door; therefore, was in disrepair. Transportation In Compliance Kitchen Requirements Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation, the refrigerator in the Nursery 2 classroom used to store children's food did not have an indicating thermometer. 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

Open / not marked corrected.

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

General: Based on review of documentation, two children enrolled on 8/12/18, and 6/1/19, did not have physician contact information on file at the facility. 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 observation, this regulation was not met. The daily attendance sheet for the Pre-K classroom only had children signed in for Monday; there were no exit times listed. In addition, the attendance sheet for Tuesday had no children signed in or out. The attendance sheet for Wednesday did not have any children signed in.

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, three staff hired on 6/1/21, 5/17/21, and 5/17/21, did not have a professional development plan on file at the facility. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 4 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 2. Child Care Services.

General: Based on review of documentation, there was no evidence of an orientation policy for staff on file at the facility. 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 8. General.

General: Based on observation, the Pre-K classroom did not have an updated lesson plan posted. The one that was posted was for the previous week. Animals In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation and review of documentation, this regulatory requirement was not met. A staff member hired on 8/17/2020, did not have an out-of-state background check on file. The staff member previously lived in Florida within the past five years. The staff member was not working alone during the renewal survey. Supervision In Compliance Staffing Requirements In Compliance General Administration In Compliance Director Requirements In Compliance 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

Open / not marked corrected.

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

General: Based on observation and review of documentation, this regulatory requirement was not met. The following was found: 1. A staff hired on 1/31/20012, had a TB skin test on file that was expired. The TB skin test was dated 2/07/2019. TB skin tests are valid for two years. 2. A staff hired on 2/11/2019, had a TB skin test on file that was expired. The TB skin test was dated 5/09/2019. TB skin tests are valid for two years.

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 observation and review of documentation, this regulatory requirement was not met. The following was found: 1. Staff members hired on 5/13/2003, 8/10/2015, 5/10/2019, 3/04/2020, and 3/25/2020 did not complete the required Orientation I and II courses. These staff members have been employed for more than three months. 2. Staff members hired on 6/20/2016, 5/10/2019, 3/04/2020, 3/25/2020 did not completed the required PAHT training. These staff member have been employed for more than one year. The ECE-TRIS system was reviewed. 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, this regulatory requirement was not met. The following was found: 1. The preschool B room contained a stained and bulging ceiling tile next to a light. In addition, another stained ceiling tile was observed in this room. 2. Room 111 (nursery I room) contained a dusty vent on the wall next to the bulletin board. 3. The multi-purpose room I contained hole in a ceiling tile with a pipe exposed.

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, this regulatory requirement was not met. The following was found: 1. Room 112 (nursery II room) contained an area of chipped paint under the bulletin board. 2. Room 112 (nursery II room) contained some small holes in the drywall near the dramatic play area. 3. The two-year-old room contained a section of missing flooring. 4. The two-year-old room contained a wall under the window that was smudged and dirty with some areas of chipped paint. 5. The bathroom adjacent to the multi-purpose I room contained some small holes and tears in the drywall. Hygienic Practices In Compliance 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 Not In Compliance

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on observation, this regulatory requirement was not met. The following was found: 1. The bathroom in room 107 (pre-k room) contained 2 rusty bolts at the base of the toilet. 2. Room 112 (nursery II room) contained a broken piece of protective foam trim on a low shelf. 3. The bathroom in room 113 (preschool room) contained a toilet plunger and a toilet brush that were located next to the toilet. 4. The two-year-old room contained a closet, used to store cots, that the hinges were not attached to the door properly. The door opened unevenly due to the hinges not being properly attached. 5. The bathroom in the two-year-old contained a toilet plunger and toilet brush stored next to the toilet. Transportation In Compliance Food Service/Food Program In Compliance 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 observation and review of documentation, this regulatory requirement was not met. A child's file contained an expired immunization certificate. The immunization certificate on file was dated 4/30/2021. The child had been enrolled in excess of thirty days.

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 observation and review of documentation, this regulatory requirement was not met. A child's enrollment form was missing a physician's phone number. Written Documentation In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 4 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 10. Director Requirements and Responsibilities.

General: Based on observation and review of documentation, this regulatory requirement was not met. At the time of the survey conducted on 5/20/2021, room 111 (nursery I) contained a posted lesson plan that was no longer current. The lesson plan was dated 4/19/2021 to 4/21/2021. Animals 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, this regulatory requirement was not met. Two staff (hire dates: 6/12/20 and 7/20/20) did not have educational documentation on file.

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 interview, this regulatory requirement was not met. At the time of the survey, a State Fire Marshal inspection report was not presented for the surveyor to review. The staff person in charge stated that she would obtain a copy from the facilities manager. Director Requirements 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 10. Director Requirements and Responsibilities.

General: Based on observation, this regulatory requirement was not met. The following was found: 1. There were no provisions to keep the rolls of paper towels in the bathrooms clean and sanitary. The surveyor observed the rolls of paper towels sitting on a chair, sitting on a shelf and sitting on the sink counter. These areas had paper towel dispensers mounted on the wall; however, all the dispensers were empty. This method of storage promotes germs due to each staff person and child handling the roll to obtain a paper towel. 2. During a tour of the Preschool B Classroom, the surveyor observed clear tape being used to secure name labels on the top surface of classroom tables. The edges of the clear tape were curled up and dirt particles had collected to the sticky surface of the tape. 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

Open / not marked corrected.

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

General: Based on observation and review of documentation, this regulatory requirement was not met. The following was found: 1. One staff file (hire date: 5/10/19) contained results of a negative T.B. test that was no longer current. The test was dated 9/26/17, which exceeds the two year time frame. 2. One staff person did not have evidence of a negative TB skin test or physician's statement documenting he/she was free from tuberculosis prior to employment. The staff person was hired on 10/17/19; however, did not have a TB skin test until 6/30/20.

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 the Training Records Information System (TRIS), the following was found: Three staff (hire dates: 10/10/19 and 2 on 5/10/19) did not complete the six hours of cabinet-approved training within the first three 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, this regulatory requirement was not met. The following was found: 1. A staff person's purse was accessible to children in the younger school age classroom. The purse was hanging on a wall hook on the left side of the room. 2. A staff person's purse was accessible to children in the school age classroom in the gym. The purse was sitting on the floor beside a classroom table.

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, this regulatory requirement was not met. The following was found: 1. During a tour of the Nursery 2 Classroom, the surveyor observed that a large portion of the window screen was missing across the bottom and side and it was no longer connected to the metal frame 2. During a tour of the Preschool B Classroom, the surveyor observed a hopscotch area rug that had numerous dark spots/stains. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 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 4. Premises Requirements.

General: Based on observation, this regulatory requirement was not met. The following was found: 1. The surveyor observed a hole in the corner of the Preschool A Classroom ceiling. A ceiling tile had been removed and insulation was exposed. 2. The surveyor observed numerous areas of chipped paint on the walls throughout the Nursery 2 Classroom. 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 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, this regulatory requirement was not met. During a tour of the lower level of building #2, the surveyor toured a storage room adjacent to the younger school age classroom and observed a refrigerator door standing open. The refrigerator contained several gallons of milk and several cases of yogurt. No children or staff were present at the time in the lower level classrooms; therefore, the surveyor had no way of knowing how long the refrigerator door had been open. The thermometer inside the refrigerator indicated that the temperature was 18 degrees Celsius, which converts to 64 degrees Fahrenheit.

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, this regulatory requirement was not met. At the time of the survey it was observed that two bottles in the Nursery 1 Classroom refrigerator were not labeled with a child's name. 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, one child (enrollment date: 7/14/17) had an immunization certificate on file that was no longer current as of 7/25/20. The staff person in charge stated that she would contact the parent and request the updated records. Written Documentation In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 4 Inspection Report Posted 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 8. General.

General: Based on observation and review of documentation, this regulatory requirement was not met. The statement of deficiencies/inspection report issued as a result of a 11/6/19 complaint investigation was posted; however, the plan of correction statement was not included. Furthermore, the statement of deficiencies and plan of correction from the 5/29/19 renewal inspection was not posted.

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 and observation, this regulatory requirement was not met. The facility had a diagram posted in several different areas of the building; however, it was not accurate. The gym, which is currently being used as a classroom in half of the space, was not included on any of the diagrams posted.

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, this regulatory requirement was not met. The following was found: 1. The older school age classroom had a schedule of daily activities posted; however, no dates were listed. 2. The Nursery 1 Classroom had a schedule of daily activities posted that was dated June 22 – 26, 2020; therefore, it was no longer current. Animals In Compliance Emergency Regulation Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:400 · 922 KAR 2:400E. Emergency Regulation.

General: Based on review of documentation, observation, and the Training Records Information System (TRIS), one staff person (hire date: 10/17/19) did not have evidence of completing the required ECE 202 training class (Requirements for Reopening Child Care in Kentucky). The staff person was observed working in the two-year-old classroom during the inspection.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 12. Reports.

General: Based on observation, interview and review of documentation, this regulatory requirement was not met. Interviews found that on 10/2/19, and 10/22/19, a 15 month-old male child received injuries after falling down 12 concrete steps that lead out to the playground. Further interview with a staff person and the mother of the child, found that on 10/2/19, the mother of the child told the staff person at that time that she would be taking the child for medical attention. Documentation verifying the child was seen by a physician on 10/2/19, was provided by the mother. This information was not reported by the provider to the Cabinet within 24 hours of receiving verbal notification that the child had been taken for medical treatment. At the time of the investigation, the staff person in charge stated the facility had not been notified that the child was taken for medical treatment. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report 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, interview and review of documentation, this regulatory requirement was not met. At the time of the investigation, a tour of the outdoor playground and an inspection of the stairs leading to the outdoor playground was conducted. Observation of the stairs revealed there are 13 concrete steps that are 3.6 feet wide and 12 inches tall. The landing at the bottom is also concrete. Interviews with staff found that on 10/2/19, a 15-month-old male child obtained a bump on his forehead, a scrape on his nose and a bleeding lip after falling down the stairs that lead to the outdoor playground. Interviews with staff found they were in the process of getting all of the children down the steps and onto the playground. One staff person was at the top of the stairs with the children. While the other staff person would take one child at a time down the steps to the bottom. During the process of getting them down the stairs, another child pushed the child who was waiting his turn causing him to fall down the stairs. The child fell down the stairs a second time on 10/22/19. Interviews with staff indicated that the child did not wait for a staff person to help him and he tried going down the steps by himself leading to the fall. The child rolled almost to the bottom of the steps. The child received a bump on the head after the second fall.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation and review of documentation, a staff hired on 5/28/18 did not have written evidence of completing the National background check. The KARES system and the staff file were both reviewed. The staff member was not observed working alone with the children. Supervision In Compliance Staffing Requirements In Compliance General Administration Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, the staff in charge could not locate written documentation from the local zoning authority showing compliance with the local zoning requirements. 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 6. License Issuance.

General: Based on review of documentation, the general liability insurance on file was no longer current. The insurance certificate on file was dated 8/01/17 to 8/01/18. 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 review of documentation, the staff in charge could not locate written evidence of staff meetings.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on observation, an electrical outlet, with two plugs, was unprotected in the gymnastics room. During the renewal survey the two (2) year-old children were playing in this space. 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, five (5) staff did not have proof of education on file. These staff were hired on 4/01/19, 4/30/19, and three (3) staff hired on 5/10/19.

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, one (1) staff, hired on 4/01/19, did not have written evidence of negative TB documentation on file. Another staff hired on 6/01/16 had a TB test on file that was no longer current. The TB documentation was dated 3/16/17.

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 observation and review of documentation, the following staff did not complete fifteen (15) hours of cabinet-approved early care and education training during their completed training year: 1. A staff hired on 11/13/10 completed 11 hours of training. 2. A staff hired on 6/01/16 completed 0 hours of training. 3. A staff hired on 10/24/17 completed 8 hours of training. Seven (7) staff did not complete the six (6) hours of cabinet-approved orientation training within the first three (3) months of employment. These staff were hired on 2/11/19, 3/01/19, 9/19/18, 1/28/19, 3/18/19, 9/12/18, and 6/01/16. One (1) staff hired on 1/08/18 did not complete the Pediatric Abusive Head Trauma training within one (1) year of employment. The ECE-TRIS system and the staff files were both reviewed. Programming In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 4 Inspection Report Premises Not In Compliance

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on observation, the Pre-K room contained a brown staff purse on top of the shelf in the art center. The purse 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 4. Premises Requirements.

General: Based on observation, the bathrooms in the preschool and two year-old rooms contained dusty vents in the ceiling.

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 following areas were not smooth or were in disrepair: 1. The Pre-K room contained areas of chipped paint on the walls where the cots were stored. 2. The 2 year-old room contained chipped paint on the corner wall by the exit door. 3. The 2 year-old room contained tape residue on the wall next to the door to the room. Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment Not In Compliance

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on observation, the nursery II room contained a shelf with tape residue on the surface. Puzzles were stored on this shelf. Transportation In Compliance Food Service/Food Program In Compliance 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, one (1) child's file contained an immunization certificate that was no longer current. The immunization was dated 5/02/17. Another child's file contained an immunization certificate without an expiration date listed. Both children had been enrolled in excess of thirty (30) days. 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 5. Evacuation Plan.

General: Based on review of documentation, the facility did not have an updated emergency preparedness plan on file. The plan on file was dated 12/04/17.

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, eight (8) staff did not have current professional development plans on file. These staff were hired on 10/28/14, 5/13/03, 11/13/10, 7/01/15, 9/12/16, 10/24/16, 10/24/17, and 4/02/18. 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 8. General.

General: Based on observation, the facility did not have the statement of deficiency or plan of correction from the 6/01/18 renewal posted.

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 nursery II room did not have the proper methods of diapering posted by the diaper changing area. Animals 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 13. Animals.

General: Based on observation, two (2) classrooms contained fish and the staff could not locate written permission for the children to be in the presence of the fish.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on Review of Documentation, the following was found: 1. Staff person hired 7/1/16 had documentation of a CA/N check but no criminal records check on file or an "elibigle" status in the KARES system. The staff person was observed alone in the Nursery I classroom supervising five (5) children. A review of KARES records supports the information found during the survey. 2. Staff person hired 5/22/17 had documentation of a clear CA/N check but no criminal records check on file or an "elibigle" status in the KARES system. The staff person was not observed alone with children. A review of KARES records supports the information found during the survey. 3. Two (2) staff persons, both hired 5/29/18, had documentation of criminal records checks but no evidence of submitting fingerprints at an authorized collection site for NBCP on file or an "elibigle" status in the KARES system. The staff persons were not observed alone with children. A review of KARES records supports the information found during the survey. Supervision In Compliance Staffing Requirements In Compliance General Administration In Compliance 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 Review of Documentation, staff hired 6/3/16 and 5/22/17 did not have evidence of an annual evaluation on file in the facility. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 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, six (6) of the twenty (20) employee files presented for review did not contain evidence of a high school diploma, GED or Commonwealth Child Care Credential.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on Review of Documentation, staff person hired 5/29/18 did not have documentation of negative T.B. results on file in the facility that had been obtained within the past two (2) years.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on Review of Documentation, the following was found: 1. Eleven (11) of the fifteen (15) staff employed for more than one (1) year did not have fifteen (15) hours of annual training on file for the last full year of employment. A review of ECE-TRIS records supports the information found during the survey. 2. Five (5) of fifteen (15) staff employed for more than one (1) year of the did not have evidence of completing the Pediatric Abusive Head Trauma training within the first year of employment. A review of ECE-TRIS records supports the information found during the survey. 3. Six (6) of the twenty (20) staff files presented for review did not contain evidence of completing the required orientation training in the first three (3) months of employment. A review of ECE-TRIS records supports the information found during the survey. 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, a staff person's purse was sitting under one of the tables used by the children in the Pre-K classroom. The purse was accessible to the children in care.

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 following was found: 1. There were numerous crayon marks on all of the walls in the Twos classroom. 2. There was a quarter-size hole in the wall in the book area and a dime-size hole in the wall in the block area in the Nursery II classroom. 3. There was dime-size hole in the wall in the dramatic play area in the Preschool classroom. Hygienic Practices In Compliance 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 2 of 3 Inspection Report Transportation 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. Transportation.

General: Based on Review of Documentation, the inspection documentation on file for the bus used by the facility was not current. The inspection on file expired 5/9/18. Food Service/Food Program In Compliance 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, a child enrolled 2/12/18 did not have a current immunization certificate on file in the facility. 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, none of the eligible staff had evidence of a current annual professional development plan on file in the facility. 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 8. General.

General: Based on Observation, the statements of deficiencies and plans of correction from a complaint investigation conducted on 6/26/17 and from the previous re-licensure survey were not posted in the facility.

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 proper methods of diapering were not posted in the changing area in the Nursery I classroom. 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 6. License Issuance.

General: Based on interview, the facility Director failed to cooperate during the onset of an investigation but soon started to cooperate as the questioning by the surveyor continued. For instance, the surveyor initiated the investigation on 4/20/18 by speaking to the Director about the allegation of a staff person falsifying training certificates. The surveyor asked when the Director became aware the training certificates for three (3) staff had been falsified. The Director stated she became aware the same day that a representative from ECE- TRIS became aware which was on 3/28/18 via e-mail. The surveyor then presented a training certificate that had been falsified with the alleged perpetrator’s name and the director commented that she was not sure that it was that particular staff person who had falsified the training certificate. She stated that it was not the staff person’s hand-writing and the staff person in question had hand-writing that was more “bubbly”. The Director proceeded to say she had a sample of the staff person’s hand-writing and started to look through papers on her desk. Next, the Director stood up, closed her office door and confessed that she had been the one who had falsified the training certificates for three (3) staff. She stated she did not know why she had done it, but stated she had been having a lot of anxiety. She also stated her supervisor and staff were aware of what she had done.

Open Not marked corrected in the state record

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 06/08/2018 AND AS OF 06/21/2018, THE PLAN OF CORRECTION HAS NOT BEEN RECEIVED. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report 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 interview and review of documentation, the facility Director falsified a total of twelve (12) Quorum training certificates for three (3) staff. The Director submitted the false training certificates to ECE –TRIS on 3/28/18. The Director admitted to falsifying the certificates during an interview that was conducted on 4/20/18.

Open Not marked corrected in the state record

Category: recordkeeping. 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 07/19/2017 AND AS OF 08/03/2017, THE PLAN OF CORRECTION HAS NOT BEEN RECEIVED. Premises In Compliance Children's Records 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, this regulatory requirement was not met. At the time of the investigation it was found that the parents had been filling out one blanket form giving permission for the children to "participate in field trips and/or activities such as swimming, gymnastics, library, etc. with the YMCA Child Development Center". The form was filled out when each child enrolled and did not specify the date, time or location of the trip. The center then posted information for the parents giving details for individual field trips. The staff person in charge stated that she was not aware of this regulatory requirement and stated that she would revise the forms.

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, there were three (3) staff who did not have documentation of an annual evaluation on file. The hire dates for these staff were 2/8/12, 6/20/03, and 9/9/10. 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 6. License Issuance.

General: Based on Review of Documentation and interview, there was a staff person hired 6/21/16 who did not have the results of a child abuse and neglect check on file. There was documentation the the check had been submitted and the staff person in charge stated she was unaware of what had happened to the results. She also stated the staff person does not work alone. There were two (2) staff who had criminal records checks on file but the checks were not dated prior to employment and there was no documentation of when the checks had been submitted. A staff person hired 12/19/16 had a criminal records check dated 1/23/17 and a staff person hired 9/28/16 had a criminal records check dated 10/3/16. The bus driver did not have a child abuse and neglect check or a criminal records check on file. There were two (2) maintance staff employeed by the YMCA working on the playground while children were present; they did not have a background checks on file at the center. Also, there were two (2) YMCA staff in the center observed interacting with children at the time of the survey who did not have child abuse and neglect checks on file; they did have completed criminal records checks. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 5 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, there were five (5) staff who lacked documentation of meeting the education requirement. The hire dates for these staff were 11/6/14, 3/20/17, 12/21/16, and 12/19/16 for two (2) staff.

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, there was one (1) staff who did not have documentation of being free TB on file; hire date 6/9/14. Also, there were three (3) staff who did not recieve the documentation prior to employment. A staff person hired 12/19/16 had documentation dated 1/5/17. A staff person hired 10/25/16 had documentation dated 10/28/16. A staff person hired 9/28/16 had documentation dated 9/29/16.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on Review of Documentation and interview, the staff who opened the center at 6:30 AM on Tuesdays and Thursdays did not have current first aid training. The next staff person with training arrived at the center at 7:00 AM. The staff person in charge stated the opening staff person was trained in first aid at the same time as she was in CPR, however, the card did not reflect the first aid training.

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

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

General: Based on Review of Documentation, there were three (3) staff who had no evidence of completing the required orientation training; hire dates were 9/1/16, 9/4/16, 12/19/16. There was also one (1) staff who completed the training but not within the first three (3) months of employment. The staff was hired 12/19/16 had the training was completed 3/30/17. There was one (1) staff hired 8/13/15 who completed pediatric abusive head trauma training on 1/17/12 but had not renewed the training after five (5) years. There was one (1) staff hired 5/1/2015 who completed pediatric abusive head trauma training on 1/9/17; not within her first year of employment. There were three (3) staff who did not have documentation of completing the required fifteen (15) hours of training for their current training year; hire dates were 11/6/14, 9/9/10, and 5/1/2015.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 12. Transportation.

General: Based on Review of Documentation, the person desginated as the bus driver did not have a driving history check on file. Programming In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 5 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 3. General Requirements.

General: Based on Observation of the area adjacent to the kitchen and two (2) year old room, there were bottles of Pine Sol cleaner and black plastic garbage bags stored in cabinets accessible to children.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on Observation, in the Nursery 2 room there multiple areas of chipping paint and tape residue on the yellow wall and the orange wall. In the Two-Year -Old there were areas of chipping paint throughout the room and tape residue on the green wall in the dramatic play area.

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, in the bathroom in the Pre k room the caulk around the sink faucet was peeling away and there was a build up of grime.

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 water temperature at the handwashing sink in the Nursery 2 room was 125 degrees Fahrenheit. The water temperature was tested with a calibrated thermometer. 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 diaper changing mat in the Preschool room was torn. First Aid/Medication In Compliance Outdoor Play Area In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 5 Inspection Report Equipment Not In Compliance

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on Observation, in the Nursery 2 room there was a shelf near the classroom door that had paint damage that appeared to be from tape that had been removed. In the Nursery 1 room the adult rocking chair cushion was torn, the bouncy seat cloth cover was torn and frayed on the back, and the iniside of the refrigerator had food spills and hair. In the Pre k room the vinyl seats in the book area were torn at the edges. Transportation In Compliance Food Service In Compliance Children's Records Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on Review of Documentation, there were four (4) children's files that did not include name and/or contact information for a physician. The enrollment dates for these children were 6/4/15, 10/3/16, 8/10/16, and 10/19/16. 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 5. Evacuation Plan.

General: Based on Review of Documentation, there was no emergency preparedness plan written or submitted for 2016.

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 only staff schedule available was for 4/11/17. There was no staff schedule written for the day of the survey. The staff person in charge stated that a new schedule is done daily and all except for the the 4/11/17 had been thrown away and deleted from the computer.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on Review of Documentation, there was no documentation of current professional development plans on file. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 4 of 5 Inspection Report

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 only recorded earthquake drill and tornado drill was for February 2017. There were none for the previous year.

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 names of the children who participated in the fire drill was not documented for the 3/20/17 fire drill.

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 only recorded earthquake drill and tornado drill was for February 2017. There were none for the previous year. 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, the center's rates were not posted.

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 daily activities plan in the Preschool room and the Nursery 2 room were not current. The plan in the Preschool room was dated 4/3/17. The plan in the Nursery 2 room was dated 9/20/16. Animals 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, there were no current professional development plans on file for the staff. The staff person in charge acknowledged this finding.

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 Interview, a new director has been hired effective 04/26/16. Her criminal records check and child abuse and neglect check have been submitted but the results have not been received yet. A staff person in charge stated that the previous director left at the end of January.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110. Section 6. Reports.

General: Based on Interview, the director left her position at the end of January 2016. There was no one listed as director for approximately three (3) months. A new director was hired on 04/25/16. No one at the facility notified licensing of the director change yet because all of the new director's paperwork had 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 Review of Documentation, there were no annual performance evaluations on file for the staff. The staff person in charge acknowledged this finding.

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, staff hired on 04/11/16 did not have education documentation on file. The director acknowledged this finding.

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, staff hired on 02/08/12 and 08/07/13 did not have current documentation from a health care professional stating they were free from active tuberculosis. Director acknowledged this finding.

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, staff hired on 11/06/14, 08/12/13, 09/12/11, 08/28/14, 09/09/10, 03/20/15 and 10/14/13 did not have the required fifteen (15) hours of cabinet approved training on file. This information was verified through ECE-TRIS. The director acknowledged this finding.

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, a staff purse was found on the floor in the preschool classroom. There were adult scissors found in an unlocked drawer in the one (1) year old room. These scissors were accessible to the children. The kitchen door was propped open and the sink cabinet was unlocked with numerous cleaning supplies found inside. The children walk past this kitchen door to get to a classroom. The director acknowledged these findings.

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 exhaust vent in the preschool room bathroom was covered in lint. The director acknowledged this finding.

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, there were several walls with chipping paint in the two (2) year old room. The director acknowledged this finding.

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 water temperature in the toddler classroom measured 140 degrees Fahrenheit. This temperature was measured with a calibrated thermometer. The staff person in charge stated that she has no idea why it would be that high but would have someone look into it.

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 changing pad in the toddler classroom was torn. The director acknowledged the finding.

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on Observation, there were several torn books in the toddler classroom. The director stated those books would be removed from the room.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on Observation, the lincoln log house on the playground has a large broken section located at the base of the house.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 12. Transportation.

General: Based on Review of Documentation, there was no written record stating that pretrip inspections were conducted in 2015. The staff person in charge stated that they were done but the paperwork could not be located at the time of the survey.

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, children enrolled on 05/31/15, 01/04/15 and 03/07/16 did not have a preferred hospital listed on their enrollment forms. The staff person acknowledged this finding.

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 Review of Documentation, there was not a written chain of command on file for the facility. The staff person in charge stated that the director left in January and nothing has been updated since she left.

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, there were several children only signed out on the attendance records over the past two (2) weeks at the facility. There was no sign in time. The staff person in charge stated that it is very difficult to get parents to remember to sign in and out daily.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on Review of Documentation, the last earthquake and tornado drill documented was October 2014. The staff person in charge stated that they have been done and documented but is not for sure where they are located.

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 Review of Documentation, there is no written orientation procedure on file. The staff person in charge stated that she was unaware of this regulation.

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 Review of Documentation, the current rates for the facility were not posted. The staff person in charge stated that the rates were listed in the parent packet but not posted.

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, the daily activities posted in the preschool classroom and in the school age classroom were dated for the week of 04/25/16. The director acknowledged this finding.

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 school-age summer camp classroom did not have posted a daily planned program of activities for the children. Equipment

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on Observation, the school-age summer camp program did not have a current posted menu for the week. The posted menu was dated July 20-24. The survey was conducted on August 19th. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 2 of 3 Web site: http://chfs.ky.gov/ Inspection Report Posted Documentation

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 school-age summer camp classroom did not have a daily activities schedule posted, including the times of the the activities that will be conducted with the children.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on Observation, the first aid kit located in building #2 did not contain a flashlight.

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

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

General: Based on Review of Documentation, the copy of the regulations on site for the staff to access was outdated. The copy of the regulations on site was dated 2009.

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, one (1) staff member that is the cook and a substitute did not have an evaluation on file. This staff was hired on 9/12/11.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on Review of Documentation, a volunteer was observed in the Nursery II room (Room 112) and she did not have written evidence of a CAN check or a criminal records check. The volunteer was not observed working alone. The staff in charge indicated that the volunteer is usually at the facility about three (3) days a week for a few hours. A staff hired on 6/8/15 did not have written evidence of a criminal records check. This staff was not observed alone with the children. A staff hired on 5/26/15 did not have written evidence of a CAN check on file or an out of state criminal records check from North Carolina where the staff had previously lived within the last five (5) years. This staff was not observed working alone with the children.

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, seven (7) staff members did not have proof of education on file. The staff were hired on the following dates: 10/14/13, 5/14, 9/19/14, 6/1/15, 5/28/15, 6/8/15, and 5/26/15.

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 bus driver did not have negative TB documentation on file. This staff member was hired on 6/22/99. Another staff member hired on 10/14/13 had a TB skin test on file that was no longer current. The TB skin test was dated 5/3/13.

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 Nursery II room (Room 112) had a lesson plan posted that was outdated. The lesson plan was dated 5/25-5/29. The Preschool room (Room 113) had a lesson plan posted that was also outdated. The lesson plan was dated 6/1-6/5.

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 gymnastics room contained a large hole in the wall located towards the back of the room. The hole was approximately one (1) foot tall by 1.5 feet wide. The school-age and Pre-K children use the gymnastics room daily.

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on Observation, a tube of Monkey Butt Diaper Cream was observed in a locked drawer in the Nursery II room (Room 112) without a child's name on it. The tube of diaper cream contained drug facts on the label. Outdoor Play Area

Open Not marked corrected in the state record

Category: health medication. Open / not marked corrected.

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

General: Based on Observation, eight (8) cribs were observed in the Nursery I room (Room 111) and the manufactured date listed on the cribs was November of 2010. These cribs do not meet the Consumer Product Safety Commission standards. The cribs did not indicate that they were compliant with 16 C.F.R. part 1219 or 16 C.F.R. part 1220.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on Observation, the two (2) year-old room (Room 116) contained a set of mats for nap time that were approximately 1 to 1.5 inches thick. The staff in charge indicated that she had already placed an order for new mats that were the correct thickness.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 12. Transportation.

General: Based on Review of Documentation, the facility did not have any written routes on file in regards to field trips. In addition, the facility did not have any written monthly evaucation drills for the bus.

Open Not marked corrected in the state record

Category: transportation. Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 12. Transportation.

General: Based on Observation, the staff in charge indicated that the first aid kit used in the school-age room is taken on the bus for field trips. The first aid kit was missing a flashlight.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120. Section 12. Transportation.

General: Based on Review of Documentation, the staff in charge was umable to locate any vehicle inspection lists from when the bus was inpsected prior to field trips.

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 refrigerator in the Nursery I room (Room 111) did not contain a thermometer or other appropriate temperature measuring device. One (1) of the refrigerators in the kitchen did not contain a thermometer as well as one (1) of the freezers in the kitchen.

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, a bottle was observed, inside the refrigerator, in the Nursery I room without a cover or lid.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on Observation, the facility had two (2) percent milk in the refrigerator in the kitchen and the staff indicated that was to be served to the two (2) year-olds and above. Low fat one (1) per cent or fat-free skim milk is to be served to the children ages twenty-four (24) months to school-age.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on Observation, the posted lunch menu was dated 6/1-6/5. The posted lunch menu was outdated.

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, two (2) children's files were missing a physician's contact phone number.

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, one (1) staff member, hired on 9/12/11, that is the cook and a substitute did not have a current professional development plan on file. The PD plan was dated 10/12/11. Another staff member, hired in May of 2014, did not have a date listed on her professional development plan.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:110 · 922 KAR 2:110. Section 6. Reports.

General: Based on Interview, it was found that the new director has been employed as the director as of 2/23/15. The new director indicated through interview she assumed that a request had been submitted for a change of director by someone in the main office of the YMCA. A review of information from the Division of Regulated Child Care on 3/10/15 found that a request for a change of director for the facility had not be received. Director Requirements

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 Interview, based on interviews with more than one (1) staff person it was found that the director has been left alone with children on at least two (2) occassions while the staff person in the room took a break. An interview with the newly named director and a review of files found that the director recently moved to Kentucky from Minnesota. However, an application for the results of a criminal records check from Minnesota has not been submitted. Therefore the results of the criminal records check was not on file. Employee Records

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 Interview, based on interviews with more than one (1) staff person it was found that the director has been left alone with children on at least two (2) occassions while the staff person in the room took a break. An interview with the newly named director and a review of files found that the director recently moved to Kentucky from Minnesota. However, an application for the results of a criminal records check from Minnesota has not been submitted. Therefore the results of the criminal records check was not on file.

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 Interview, it was found that there are children who attend the facilty that leave the facility for a period of time each day to attend preschool programs located within the local schools. These children then return to the facility for child care later in the day. A review of records found that the time these children leave for preschool is not being documented and the time these same children return to the facility is not being documented. An interview with the staff person in charge found that she was unaware the children needed to be signed out and then signed back in upon their return. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 2 of 3 Web site: http://chfs.ky.gov/

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, there were five (5) staff who did not have evidence on file to verify they had completed fifteen (15) hours of annual training.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on Observation, at the time of the survey the staff person in charge had her one (1) year old daughter in the office for long periods of time as well as various other places in the facility that were other than the child's classroom. An interview with the staff person in charge found that she is still breast feeding her daughter. However, when she was not breast feeding her daughter the child was either in the office or being carried by the staff person in charge while she went to various places in the facility. The child was only placed in her classroom for very short periods of time. General Administration

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 Interview, a current copy of the regulations was not on file and available to staff.

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, of the fifteen (15) staff files presented for review there were three (3) staff who have been employed for a year or more that had no documentation to verify an annual performance evaluation had been conducted within the last year. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 5 of 26 Web site: http://chfs.ky.gov/ Inspection Report

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 Review of Documentation, there were several uncoverd outlets observed throughout the facility.

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, there were two (2) staff who are substitutes that were hired 2/18/13 and 3/14/11 that did not have the results of a child abuse and neglect check on file at the time of the survey.

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, there was one (1) staff person hired 2/19/14 who did not have the results of a T.B. skin test read until 2/20/14. There was an additional staff person who was hired as a substitute on 2/18/13 who had the results of a T.B. skin test dated 4/1/14. it was also found that the staff person who drives the facility bus did not have the results of a current T.B. skin test or a statement from a health professional indicating the individual is free from the symptoms of T.B.

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, there was one (1) substitute hired 3/14/11 who did not have the results of a child abuse and negelct check on file nor did this substitute have a copy of a high school diploma or GED or other qualifying documentation. There was also no evidence to verify the substitute had completed six (6) hours of orientation training. There was an additional substitute hired 2/18/13 who did not have the results of a child abuse and neglect check on file. It was also found that the substitute hired 3/14/11 did not have documentation available for review to verify they had completed fifteen (15) hours of training for the 2013-2014 training year. 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 2:120 · 922 KAR 2:120. Section 12. Transportation.

General: Based on Review of Documentation, there was not a current driver history record through the transportation agency that issued the driver's license for the staff person hwo drives the facility bus. Programming

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, during a tour of the school age room there was not a posted planned program of activities.

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 room 111 (Nursery I) there were two (2) water stained ceilings in the corner where the refrigerator is located. During a tour of Room #113 there were several areas of chipping and peeling paint with drywall exposed in the carpeted area.

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on Observation, during a tour of Room # 113 there was a red vinyl couch in the book area that had a hole in the seat.

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922 KAR 2:120 · 922 KAR 2:120. Section 12. Transportation.

General: Based on Observation, it was found that first aid supplies located on the bus that will be used to transport children for summer field trips did not have liquid soap, a flashlight, first aid book and thermometer. 825 - Transit/School Bus Not Applicable 922 KAR 2:120. Section 12. Transportation. (5) Transportation provided by licensed public transportation or a school bus shall comply with subsections (1) and (2) of this section.

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

General: Based on Review of Documentation, information regarding the preferred hospital for each child was not documented.

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

General: Based on Review of Documentation, 2012 was the last documented evidence of an annual professional development plan for staff. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 24 of 26 Web site: http://chfs.ky.gov/ Inspection Report

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

General: Based on Observation, it was found that at the time of the survey there was not a daily schedule posted in the school age room.

Open Not marked corrected in the state record

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

General: Based on Observation, it was found that at the time of the survey there was not a daily schedule posted in the school age room.

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

General: Based on Interview, it was found there are two (2) children who will not turn two (2) years old until July 2013. An interview with staff found that these two (2) children are transitioning into the two (2) year old room. However, there was no documentation on file to verify that these children are in a transition period. It was also found that there children are placed in the two (2) year old room if the staff to child ratio is over in Nursery II.

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

General: Based on Observation, the refrigerators in the Nursery and Nursery II classrooms did not contain thermometers or other appropriate temperature measuring devices.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on Review of Documentation, 1. Employee with hire date 2/3/12 did not have documentation of a negative T.B. results prior to employment. The certificate on file was dated 2/28/12. 2. Employee with hire date 2/8/12 did not have documentation of a negative T.B. results prior to employment. The certificate on file was dated 2/9/12. 128 - CPR/First Aid Coverage 922 KAR 2:110 - Section 5 (3) At least one (1) person on duty and present with the children shall be currently certified by a cabinet-approved training agency in the following skills: (a)Infant and child cardiopulmonary resuscitation; and (b) Infant and child first aid. 1) CPR In Compliance An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 8 of 41 Web site: http://chfs.ky.gov/ Inspection Report 2) First Aid In Compliance 131 - Adequate Substitute(s) 922 KAR 2:110 - Section 5 (6) Child-care centers shall have available in case of need: (a) One (1) qualified substitute staff person for a Type II child-care center; or (b) Two (2) qualified substitute staff persons for a Type I child-care center 1) Type I In Compliance 131 - Adequate Substitute(s) 922 KAR 2:110 - Section 5 (6) Child-care centers shall have available in case of need: (a) One (1) qualified substitute staff person for a Type II child-care center; or (b) Two (2) qualified substitute staff persons for a Type I child-care center 2) Type II Not Applicable 139 - Training 922 KAR 2:110 - Section 5 (14) A staff person with supervisory authority over a child shall complete the following: (a) Six (6) hours of cabinet-approved orientation within the first three (3) months of employment; (b) Nine (9) hours cabinet-approved child development training within the first year of employment; and (c) Fifteen (15) hours of cabinet-approved training during each subsequent year of employment. 1) Orientation In Compliance 2) 9 hours-first year In Compliance 3) 15 hours annually In Compliance 317 - Driver requirements 922 KAR 2:120 - Section 12 (18) A driver of a vehicle transporting a child for a center shall: (a) Be at least twenty one (21) years old; (b) Complete the background checks as described in 922 KAR 2:110; (c) Hold a current driver’s license which has not been suspended or revoked during the last five (5) years; (d) Not have had any convictions concerning vehicle operation in the past twelve (12) months; and (e) Not caused an accident which resulted in the death of a person. 1) Be 21 years old or over In Compliance 2) Background checks In Compliance 3) Drivers license In Compliance 4) No convictions for vehicle operation In Compliance 5) No accident causing death In Compliance Programming 169 - Program of Activities Followed 922 KAR 2:120 - Section 2 (4) The child-care center shall provide a daily planned program of activities: (a) Posted in writing in a conspicuous location with each age group and followed; 1) Posted In Compliance 2) Followed In Compliance

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