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

General: Based on review of ECE-TRIS, the surveyor discovered that one (1) staff member (DOH: 10/09/23; first year start date: 11/15/22) had completed six (6) hours of the fifteen (15) required hours of cabinet-approved early care and education training for the timeframe of 11/15/22-11/15/23; therefore, the child-care center failed to ensure that training was completed as required. 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 An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report Kitchen Requirements In Compliance Food Service In Compliance Meal Planning/Center Provides Meals In Compliance Meal Planning/Center Does Not Provide Meals In Compliance Children's Records In Compliance Written Documentation In Compliance Posted Documentation In Compliance Animals In Compliance

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on review of documentation, the surveyor found that a staff’s (DOH: 09/14/22) file contained documentation of a background check submitted through the Kentucky Applicant Registry and Employment System (KARES) that verified the staff’s eligibility date as 08/30/22. The documentation verified that the staff person lived in Carbondale, IL and Tennessee in the last five (5) years. The staff’s file did not contain a completed out of state Child Abuse/Neglect Background Check (CAN), Criminal Records Background Check (CRC), or a check of the states sex offender registry. The surveyor did not observe the staff person working alone with children. During interview, staff-in-charge stated that the staff person has not worked alone with children. Supervision In Compliance Staffing Requirements In Compliance General Administration In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 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 review of documentation, the surveyor found the following: 1. A staff’s (DOH: 05/24/12) file contained an annual written performance evaluation dated 04/01/22; therefore, the evaluation was not completed annually. 2. A staff’s (DOH: 07/17/12) file contained an annual written performance evaluation dated for 04/01/22; therefore, the evaluation was not completed annually. 3. A staff’s (DOH: 11/14/18) file contained an annual written performance evaluation dated for 04/01/22; therefore, the evaluation was not completed annually. 4. A staff’s (DOH: 03/14/11) file contained an annual written performance evaluation dated for 04/13/22; therefore, the evaluation was not completed annually. During interview with staff-in-charge, the surveyor learned that the evaluations for the staff mentioned were not available for review. 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 ECE-TRIS, the surveyor found the following: 1. A staff (DOH: 03/17/17) obtained fourteen (14) hours of the required fifteen (15) hours of cabinet-approved early care and education training for the review period 07/01/21 - 06/30/33. 2. A staff (DOH: 11/14/18) obtained fourteen and one-half (14 1/2) hours of the required fifteen (15) hours of cabinet-approved early care and education training for the review period 07/01/21 - 06/30/22. 3. A staff (DOH: 05/10/21) obtained one and one-half (1 1/2) hours of the required fifteen (15) hours of cabinet-approved early care and education training for the review period 05/11/22 - 06/30/22. 4. A staff (DOH: 03/22/21) obtained six and one-half (6 1/2) hours of the required fifteen (15) hours of cabinet-approved early care and education training for the review period 03/23/22 - 06/30/22. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area 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 two (2) pieces of metal siding that were slightly sticking out on the bottom side of the child-care center building on the playground. Aluminum foil was observed to be wrapped around the pieces of siding. During interview, staff-in-charge stated that the aluminum foil was used to wrap around the pieces so they would not have sharp edges. Equipment In Compliance Transportation In Compliance Kitchen Requirements In Compliance Food Service In Compliance Meal Planning/Center Provides Meals In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3 Inspection Report Meal Planning/Center Does Not Provide Meals In Compliance Children's Records Not In Compliance

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

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

General: Based on observation, the surveyor found that a child's (DOE: 10/27/22) file did not contain the name or contact telephone number for the child's preferred hospital. Written Documentation Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, the surveyor found the following: 1. A staff’s (DOH: 05/24/12) file contained a professional development plan dated 04/01/22; therefore, the plan was not completed annually. 2. A staff’s (DOH: 07/17/12) file contained a professional development plan dated 04/01/22; therefore, the plan was not completed annually. 3. A staff’s (DOH: 11/14/18) file contained a professional development plan dated 04/01/22; therefore, the plan was not completed annually. 4. A staff’s (DOH: 03/14/11) file contained a professional development plan dated 04/13/22; therefore, the plan was not completed annually. During interview with staff-in-charge, the surveyor learned that the professional development plans for the staff mentioned were not available for review. Posted Documentation In Compliance Animals In Compliance

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 04/24/2019 AND AS OF 05/08/2019, THE PLAN OF CORRECTION HAS NOT BEEN RECEIVED. Director Requirements Not In Compliance

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation and interview, the surveyor was not presented with a 2018 annual evaluation for a staff (DOH: 8/8/08). Upon interview, staff stated that the employee was on maternity leave and the evaluation could not be completed until the employee returns. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 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 and interview, the surveyor was not presented with documentation of six (6) hours of annual training for a staff (DOH: 11/14/18). Review of ECE-TRIS confirmed that the staff member has not completed orientation. Upon interview, staff reported that they did not start working until the end of February 2019 even though their hire date is 11/14/18. Programming In Compliance Premises In Compliance Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area In Compliance Equipment In Compliance Transportation Not Applicable Food Service/Food Program In Compliance Food Service In Compliance Children's Records In Compliance Written Documentation In Compliance Posted Documentation In Compliance Animals In Compliance

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on observation and interview, the following was found inside the child care center: 1. There was a vacuum cleaner located inside the restroom used by the children in the Head Start 1 & 2 classroom. 2. There was a vacuum cleaner located inside the restroom used by children in the Head Start 3 & 4 classroom. The staff stated during interview that the vacuum cleaners were kept in the restrooms so it was not in the classrooms. However, the restrooms are used by the children at the center.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on observation and interview, there was a black substance located around the window sills of the two (2) windows located in the Head Start 3 & 4 classroom and around the window sill of one (1) window located in the Head Start 1 & 2 classroom. The staff stated during interview that the black substance could have been created from the moisture around the windows.

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 and interview, there was a sharp metal strip protruding outward at the bottom of the outside entrance door leading into the Head Start 1 & 2 classroom. The staff stated during interview that the children enter and exit from the Head Start 1 & 2 classroom.

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 in the Head Start 1 & 2 classroom: 1. There was a two-inch by one-inch hole in the wall located beside the kitchen area. 2. The paint was peeling from the wall in the classroom beside the exit door that leads into the classroom that is not currently being used. The staff stated during interview that she was aware of the hole in the wall and the peeling paint.

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 observation, the following was witnessed at the child care center: 1. There were two (2) staff (doh: 07/20/12 and 03/01/13) that were observed to wipe two (2) children's nose with a baby wipe while on the playground; however, neither staff washed their hands after wiping the children's nose. Both of the staff were wearing gloves. The staff stated during interview that it was hard to always wash their hands after wiping a child's nose if they are on the playground. 2. There was one (1) staff (doh: 03/01/13) that was observed to wipe a child's nose in the classroom; however, the staff person did not wash her hands after wiping the child's nose. The staff person was wearing gloves.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on interview, the staff at the child care center stated that they used the following method to sanitize mouth contact toys: 1. Wash the toys in soapy bleach water using a brush or wash cloth on the toys to clean them. 2. Rinse the toys in clean water. 3. Sanitize toys in sanitizing water for two (2) minutes. 4. Allow toys to air dry. This method does not meet the regulatory requirement for sanitizing mouth contact toys. First Aid/Medication

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, there were several areas of sharp metal protruding from the outer wall of the child care center. This part of the outer wall of the child care center is located inside the outdoor playground. The sharp metal poses a safety hazard to the children while on the playground.

Open Not marked corrected in the state record

Category: physical safety. Open / not marked corrected.

922 KAR 2:090 · 922 KAR 2:090. Section 5. Evacuation Plan.

General: Based on review of documentation, the child care center had a written evacuation plan; however, the plan has not been updated to assign new staff duties. The evacuation plan had staff named for specific duties that no longer work at the child care center. The staff that was no longer employed at the center was named as the Evacuation Manager and the Shelter in Place Coordinator on the evacuation plan. The staff person in charge acknowledged during interview that the evacuation plan needed to be updated with new staff.

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 observation, there were six (6) children present in the Head Start 3 & 4 classroom. Based on review of documentation, there were only five (5) children signed in on the attendance log. Based on interview with the staff, the surveyor learned that it is hard to get parents to sign their children in and out of the child care center.

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 surveyor found that the quarterly practiced tornado and earthquake drills were recorded as having been conducted at the same time. It could not be determined that both drills had been practiced.

Open Not marked corrected in the state record

Open / not marked corrected.

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

General: Based on review of documentation, the surveyor found that the individual times that the earthquake and tornado drills had been practiced were not recorded. Posted Documentation

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 following issues were found: 1) An employee (DOH 03/01/13) record presented for review contained evidence that six (6) hours of cabinet-approved orientation dated 08/09/13 was not completed within the first three (3) months of hire as required by regulations. 2) An employee (DOH 03/01/13) record presented for review contained evidence that six (6) hours of cabinet-approved orientation dated 08/09/13 was not completed within the first three (3) months of hire as required by regulations. 345 - Driver Requirements Not Applicable 922 KAR 2:120. Section 12. Transportation. (18) A driver of a vehicle transporting a child for a center shall: (a) Be at least twenty-one (21) years old; (b) Complete: 1. The background checks as described in 922 KAR 2:110; and 2. An annual check of the: a. Kentucky driver history records in accordance with KRS 186.018; or b. Driver history records through the state transportation agency that issued the driver’s license; (c) Hold a current driver’s license which has not been suspended or revoked during the last five (5) years; and (d) Not caused an accident which resulted in the death of a person. Programming

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

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

General: Based on interview, the surveyor found the following: 1. On 8/19/13 a staff person bit a toddler on the upper right arm leaving a red mark and teeth indentions on the child's arm. 2. A staff person disciplines the children, whose ages range from ten to twenty-nine (10-29) months by “spanking” them on their “butts and legs”.

Open Not marked corrected in the state record

Open / not marked corrected.

922 KAR 2:120 · 922 KAR 2:120 - Section 3

Early Head Start 1: Based on observation, an infant was observed sleeping on his stomach on a flower mat inside the octagon padded play area. There was a crib available but the staff person said that they let him play in the octagon play area and if he falls asleep then they do not disturb him.

Open Not marked corrected in the state record

Open / not marked corrected.