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Home › KY › Winchester › Calvary Christian School
15 Redwing Drive, Winchester KY 40391 · License #L355502 · Center · Licensed
When they operate
Schedule type not published.
Ages served
922 KAR 2:090 · 922 KAR 2:090. Section 8. General.
General: Based on observation, the surveyor found that a cabinet drawer labeled "extra storage" located in Room 204 had a broken lock. When the surveyor opened the drawer, the surveyor observed there to be three (3) adult size scissors that were accessible to children; therefore, the safety of the children was compromised. During interview with the lead staff, the surveyor found that the children in the classroom were three (3) and four (4) years old.
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 observation and interview, the surveyor found that the child-care center was closed on 05/26/26 when the surveyor arrived to conduct the annual visit. The surveyor reviewed the history notes provided in KICCS and found that the closure had not been reported. The surveyor spoke with director via telephone on 05/26/26 and found that the child-care center was closed during the week of 05/25/26 - 05/29/26; however, the closure had not been reported to DRCC prior to the surveyors conversation. The director stated that she was not aware that the closure needed to be reported. Therefore, the child-care center failed to report in writing a change in hours of operation to DRCC.
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 discovered that the personnel files of the following staff (DOH: 10/07/25, 06/02/26, 06/02/26, 06/02/26, 06/02/26, and 06/02/26) did not contain documentation of education in the form of a high school diploma, GED, or Commonwealth Child Care Credential. During an interview with the staff-in-charge, she stated that she did not have proof of the documentation at this time and that the staff were summer camp staff only. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 10 of 33 Inspection Report
Generated from this facility's specific inspection record
Data synced from Kentucky Cabinet for Health and Family Services, Division of Child Care on Jul 11, 2026 · Source records · Report an error
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:090 · 922 KAR 2:090. Section 11. Staff Requirements.
General: Based on review of documentation, the surveyor found the following: 1. The personnel file for one (1) staff member (DOH: 06/15/20) contained a negative tuberculin result that was no longer current; therefore, the child-care center failed to show proof that the employee was free of active tuberculosis or provide a copy of a negative tuberculin result. 2. The personnel file for one (1) staff member (DOH: 06/02/26) did not contain documentation that the employee was free of active tuberculosis or a copy of a negative tuberculin result.
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, the surveyor discovered that no date was entered in KY-TRIS indicating that the following staff (DOH: 11/10/15 and 06/15/20) had received the training on first aid and cardiopulmonary resuscitation (CPR). During a review of the staff personnel files, the surveyor did not find documentation indicating that staff had completed the training on first aid and cardiopulmonary resuscitation (CPR); therefore, the child-care center failed to ensure that every staff member has received training on first aid and cardiopulmonary resuscitation (CPR) as required.
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 in Room 204 that there was a ceiling tile that was propped up and appeared to be broken; therefore, the ceiling was not kept in good repair. During interview with staff-in-charge, she stated that a work order had already been put in place to fix the ceiling tile.
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 the following: Room 103: 1. There were food and debris under the diaper changing pad located on the diaper changing table; therefore, the diaper changing surface was not clean. Room 105: 1.There was debris under the diaper changing pad located on the diaper changing table; therefore, the diaper changing surface was not clean.
Open Not marked corrected in the state record
Category: physical safety. Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 7. First Aid and Medicine.
General: Based on observation, the surveyor found a bucket that was placed near the classroom door in Room 204 that contained five (5) bottles of sunscreen. The bucket did not have lid nor was the bucket placed out of reach of children; therefore, the sunscreen was accessible and within reach of children. During interview with the classroom lead staff, the surveyor was informed that the children in the classroom were between the ages three (3) and four (4) years of age. Outdoor Play Area 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, interview and review of documentation, 1) On 03/05/26, a staff member physically disciplined a child by spanking the child and directing the child to stop crying. During the course of the investigation, the staff member admitted to spanking two separate children. Additionally, another staff member witnessed the incident involving the child being spanked. Interviews conducted with staff confirmed that the staff member acknowledged spanking two separate children. Documentation provided by the facility indicated that the staff member was scheduled to be placed on administrative leave; however, the staff member chose to resign prior to the leave being implemented. Therefore, the health, safety, and comfort of the children was compromised. Programming Not In Compliance
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 2. Child Care Services.
General: Based on observation, interview and review of documentation, 1) On 03/05/26, a staff member physically disciplined a child by spanking the child and directing the child to stop crying. During the course of the investigation, the staff member admitted to spanking two separate children. Additionally, another staff member witnessed the incident involving the child being spanked. Interviews conducted with staff confirmed that the staff member acknowledged spanking two separate children. Documentation provided by the facility indicated that the staff member was scheduled to be placed on administrative leave; however, the staff member chose to resign prior to the leave being implemented. Therefore, the children were subjected to physical discpline.
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 surveyor discovered the following: Classroom 107: 1. Children's backpacks were touching. This creates a potential risk of cross-contamination. Nursery: 1. Diaper bags and cooler bags were touching. This creates a potential risk of cross-contamination. Classroom 109: 1. Children's backpacks were touching. This creates a potential risk of cross-contamination.
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 4. Premises Requirements.
General: Based on observation, the surveyor discovered the following: Classroom 103: 1. There were what appeared to be dead bugs on the light fixture's plastic covering. Classroom 105: 1. There were what appeared to be dead bugs on two (2) of the light fixture's plastic coverings. Classroom 204: 1. There was a layer of dust on one (1) ceiling tile that was located by the air vent.
Open Not marked corrected in the state record
Category: physical safety. Open / not marked corrected.
922 KAR 2:090 · 922 KAR 2:090. Section 8. General.
General: Based on observation, the surveyor found the following: Older Boys' Restroom: 1. There was a scrub brush placed beside the toilet in the handicap stall. Older Girls' Restroom: 1. There was a dirty dustpan and broom placed beside the paper towel dispenser. Little Girls' Restroom: 1. There was a plunger placed beside the toilet in the handicap stall.
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 review of documentation, the surveyor found documentation from the Fire Marsal that stated the child-care center had failed their inspection on 03/28/24 due to a damaged door in Room 105. During an interview with stafff-in-charge, she stated that the child-care center had fixed the door and proceeded to show the surveyor where the door had been fixed. Staff-in-charge stated that the Fire Marshal had not returned to the child-care center since March 2024 and had not issued a new Fire Marshal Report for the facility. Director Requirements In Compliance 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: physical safety. Open / not marked corrected.
922 KAR 2:090 · 922 KAR 2:090. Section 11. Staff Requirements.
General: Based on review of documentation, the surveyor found the following: 1. A staff’s (DOH: 12/01/15) file did not contain documentation of a current TB skin test or a statement from a health professional stating that the individual was free from active tuberculosis. The surveyor did find documentation in the file where the staff person had gone to a health professional to request a TB skin test; however, the form did not contain a date that the test was administrated or when the TB test was read by a medical provider. 2. A staff’s (DOH: 08/09/22) file did not contain documentation of a current TB skin test or a statement from a health professional stating that the individual was free from active tuberculosis. The staff’s file did contain a TB skin test that was no longer current as of 08/08/22.
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 surveyor found the following: 1. Based on review of ECE-TRIS, one (1) staff person (DOH: 11/01/15) did not complete the one and one-half (1 ½) hours of cabinet-approved pediatric abusive head trauma (PAHT) training within the last five (5) years. The record did verify the staff person completed PAHT on 11/14/18. 2. Based on review of ECE-TRIS, one (1) staff person (DOH: 05/28/24) completed six (6) hours of the required fifteen (15) hours of cabinet-approved early care and education training for the review period 07/01/23 - 06/30/24. The ECE-TRIS record verified that the staff person had a first year start date of 01/04/22. 3. Based on review of ECE-TRIS, one (1) staff person (DOH: 08/05/24) completed zero (0) hours of the required fifteen (15) hours of cabinet-approved early care and education training for the review period 08/30/23 - 08/30/24. The ECE-TRIS record verified that the staff person had a first year start date of 08/30/23. Programming In Compliance Premises Not In Compliance
Open Not marked corrected in the state record
Category: recordkeeping. Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 3. General Requirements.
General: Based on observation, the surveyor found a spray bottle of Supersorb Lemon Granular Absorbment placed on top of the paper towel dispenser located in the Older Girls' Restroom. The spray bottle had a label located on the bottle that stated, "Keep Out of Reach of Children." Hygienic Practices Not In Compliance
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 12. Toilet, Diapering, and Toiletry Requirements.
General: Based on observation, the surveyor found five (5) trash cans that did not contain lids located in the Little Girls' Restroom. The trash cans contained dirty/soiled pull-ups; therefore, the soiled diapers/pull-ups were not kept in a covered container. 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 In Compliance Kitchen Requirements Not In Compliance
Open Not marked corrected in the state record
Category: physical safety. Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 8. Kitchen Requirements.
General: Based on observation, the surveyor found that the refrigerator located in Room 113 did not contain a thermometer; therefore, the surveyor was unable to determine if the refrigerator temperature was at forty (40) degrees Fahrenheit or below. 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, the surveyor found the following: 1. Two (2) children’s (DOE: 05/01/23 and 05/20/23) files did not contain the contact telephone numbers for the preferred family physician. 2. One (1) child's (DOE: 05/20/23) file did not contain the name of the preferred family physician. 3. Seventeen (17) children’s (DOE: 02/19/20, 08/13/20, 02/23/21, 08/02/21, 08/18/21, 11/01/21, 01/02/22, 01/13/22, 02/01/22, 02/09/22, 02/23/22, 02/21/23, 05/01/23, 05/20/23, 01/04/24, 02/20/20 and 07/31/24) files did not contain the contact telephone number for the preferred hospital. Written Documentation In Compliance Posted Documentation In Compliance Animals In Compliance
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:280 · 922 KAR 2:280. Section 11. Status of Employment.
General: Based on review of documentation, this regulation was not met. The center must maintain employment status of the employees listed in KARES. There were several staff listed in KARES that no longer work at the center. 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, two (2) staff hired on 8/16/18 and 12/20/18 respectively did not have 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, three (3) staff hired on 10/26/22, 8/15/22, and 3/6/23 did not have documentation of education on file at the facility. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 4 Inspection Report
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:090 · 922 KAR 2:090. Section 11. Staff Requirements.
General: Based on review of documentation, this regulation was not met. 1) One (1) staff hired on 8/14/17 did not have updated documentation on file at the facility of a negative TB test or a statement from a health care professional stating that the staff is free from active tuberculosis. The TB results on file for this staff were no longer current as of 4/6/23. 2) One (1) staff hired on 8/16/18 did not have updated documentation on file at the facility of a negative TB test or a statement from a health care professional stating that the staff is free from active tuberculosis. The TB results on file for this staff were no longer current as of 4/7/23. 3) One (1) staff hired on 8/13/20 did not have updated documentation on file at the facility of a negative TB test or a statement from a health care professional stating that the staff is free from active tuberculosis. The TB results on file for this staff were no longer current as of 8/10/22. 4) One (1) staff hired on 9/8/20 did not have updated documentation on file at the facility of a negative TB test or a statement from a health care professional stating that the staff is free from active tuberculosis. The TB results on file for this staff were no longer current as of 9/11/22. 5) One (1) staff hired on 7/25/22 did not have updated documentation on file at the facility of a negative TB test or a statement from a health care professional stating that the staff is free from active tuberculosis. The TB results on file for this staff were no longer current as of 1/8/23.
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, three (3) staff members did not have the required fifteen (15) hours on annual training. Hire dates for these staff are 8/16/18, 8/16/18, and 12/28/21. Programming In Compliance Premises Not In Compliance
Open Not marked corrected in the state record
Category: recordkeeping. Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 3. General Requirements.
General: Based on observation, the following was found: 1) A drawer lock was not in working order within room 116. The following items were stored in the drawer and therefore accessible to the children in care: adult scissors, germ-x, batteries, lotion, and a small screwdriver. 2) Additionally, a cabinet lock within classroom 205 was not in working order; the cabinet contained staff purses. 3) A staff member’s backpack was also discovered stored under a desk in classroom 205, as well as draped on a back of a chair in classroom 107.
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 drywall on the wall behind the trashcan in classroom 203 was exposed. 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 12. Toilet, Diapering, and Toiletry Requirements.
General: Based on observation, there was not a vent in the bathroom of classroom 116. 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, there was a small tear in the vinyl protective covering of the diaper changing pads in room 116 and room 114, which renders the pads unable to be properly sanitized. First Aid/Medication 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 7. First Aid and Medicine.
General: Based on observation and interview, the surveyor inquired whether any of the children in room 107 have medication. The staff person in this classroom explained that a child in the classroom has a nebulizer inhaler to use in case of an emergency, and that it is stored in their backpack. The backpack was hung on a hook and was accessible to the children in care. The emergency medication was not kept out of reach. Outdoor Play Area In Compliance Equipment Not In Compliance
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, a crib sheet in classroom 104 was loosely fitted to the mattress. Transportation In Compliance Kitchen Requirements In Compliance Food Service In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 4 Inspection Report Meal Planning/Center Provides Meals In Compliance Meal Planning/Center Does Not Provide Meals In Compliance Children's Records In Compliance Written Documentation Not In Compliance
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) staff hired on 12/20/18 did not have evidence of a recent professional development plan 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 and review of documentation, the lesson plan posted in classroom 114 was not current. The posted plan was dated 4/17/2023-4/21/2023. 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, a staff member (hire date: 8/12/2021) did not have evidence of a high school diploma, GED, or Commonwealth Child Care Credential on file at the facility.
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 staff members (hire dates: 8/12/2021, 3/8/2012, 11/1/2015, 8/3/2008, and 1/10/2014) did not have current TB documentation or statement from a health professional on file. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 7. First Aid and Medicine.
General: Based on observation and review of documentation, a staff member (hire date: 11/15/2015) did not have evidence of completing CPR/First Aid training on file at the facility. A review of ECE-TRIS records supports the information found during 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 11. Staff Requirements.
General: Based on review of documentation, the following was found: 1. A staff member (hire date: 11/15/2015) completed PAHT training on 5/6/2016; however, did not renew the training due 5/6/2021. 2. Eight staff members (hire dates: 8/13/2020, 6/15/2020, 11/15/2015, 8/13/2020, 8/15/2020, 8/28/2020, 8/4/2018, and 8/16/2018) did not have evidence of completing 15 hours of annual early care and education training. 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, this regulatory requirement was not met. During a tour of Room #116 (two-year-old classroom), the surveyor opened an unlocked storage room door and observed approximately 25 to 30 bottles of cleaners, disinfectant sprays, and disinfecting wipes. The storage closet is located across from the children's classroom bathroom; therefore, the items were accessible to them. Hygienic Practices In Compliance First Aid/Medication In Compliance Outdoor Play Area Not In Compliance
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 4. Premises Requirements.
General: Based on observation, this regulatory requirement was not met. During a tour of the two-year-old outdoor grassy play area, the surveyor observed approximately 20 to 30 wood bees flying around in the area where the children were playing. In addition, the surveyor observed two ladders positioned against the side of the building and a push lawn mower under a set of stairs. These items were accessible to the children playing in the area. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3 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, this regulatory requirement was not met. A brown area rug in Room #109 (three-year-old classroom) contained frayed edges on three sides. Transportation Not Applicable Kitchen Requirements In Compliance Food Service In Compliance Meal Planning/Center Provides Meals In Compliance Meal Planning/Center Does Not Provide Meals In Compliance Children's Records In Compliance Written Documentation In Compliance Posted Documentation In Compliance Animals In Compliance
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:090 · 922 KAR 2:090. Section 8. General.
General: Based on review of documentation, at approximately 12:00pm on 06/01/2021, a five-year-old child and several other children were seen on video footage running in the gym when the five-year-old child was pushed down by another child, causing her to hit her head on the gym floor. The child received a large bump to her head. The staff person in the gym gave the child ice to put on her forehead and had her sit down. At 12:09pm the staff person texted the staff person in charge letting her know that a child had received a head injury, and he also stated that he emailed an incident report to a few staff. It is to be noted that no phone call was made to the parents. The child went back to her classroom at 12:30pm. The child's main teacher stated that she did notice the large bump to the child's forehead. The child's main teacher stated that she did watch the child throughout the day and said that the child appeared to be fine and played with the other children. The child was picked up from the facility at 4:35pm and the parent noticed the large bump to the child's head; the child was taken to the emergency room. The child did not get diagnosed with a concussion but was the parent was told to monitor the child for the next forty-eight (48) hours and to not let her engage in any running, jumping or other activities. It is to be noted that the child had a concussion approximately 6 months ago at another location. 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, a five-year-old child received a large bump to the forehead at approximately 12:00pm on 06/01/2021 after falling and hitting her head on the gym floor. An incident report was emailed to the parent but the parent did not see the email until later on that evening. The parents did not know about the fall until the child was picked up at 4:35pm. The child was taken to the emergency room where a neuro exam was performed and a referral was made to see a neurologist. Prior to this accident, the child had previously had a concussion approximately 6 months at another location. According to staff, it is the facility's policy to call the parent/guardian if a child receives a head injury. 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
Open / not marked corrected.
922 KAR 2:090 · 922 KAR 2:090. Section 11. Staff Requirements.
General: Based on review of documentation, a staff member completed PAHT training on 02/06/2013; however, the staff person did not renew the training due by 02/06/2018. The ECE-TRIS system was reviewed. It needs to be noted that this staff person had a hire date of 06/02/2021; however, this staff person has been in charge of the summer camp for the last two summers.
Open Not marked corrected in the state record
Category: recordkeeping. Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 2. Child Care Services.
General: Based on observation, the following was observed: 1) Seven three-year-old children and one staff person were observed in the hallway in front of the boys' and girls' bathroom. The surveyor observed the staff person send the children to their respective bathroom while she stood in an open space in front of the bathrooms. Although the staff person was observed walking into each bathroom periodically to check on the children, she could not see all of the children at the same time. Supervision for this age group requires the children be within scope of vision and range of voice. 2) Children in Room 114 were observed napping. The windows on both of the doors to the classroom were covered and the lights were turned off. The surveyor could not see staff or children unless the door leading into hallway was left open or the lights were turned on. Staff in the room could not visually supervise the children while they napped. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 8 Inspection Report Staffing Requirements Not 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 and interview, at approximately 9:45 a.m. during an initial walk-through of the facility, 11 children ages six-months to four-years-old were observed in Room 104 (Infants) with two staff members. Both the group-size and the staff-to-child ratio were over by one child. An interview with one of the staff members found the four-year-old child was her daughter and is not enrolled at the facility. The staff person stated her daughter had been in the room since 6:30 a.m. and her babysitter should be at the facility by 10:30 a.m. The child was still present at approximately 10:12 a.m. but was gone when the surveyor checked again at 10:35 a.m. At 10:35 a.m.; however, there were 10 infants and one staff person in the room. One staff person had taken the four-year-old child to the front because her babysitter had arrived. The staff person had been gone for a few minutes. At this time, the staff-to-child ratio was over by five children. Then, at approximately 2:37 p.m., the surveyors and the staff person in charge entered the room to measure square footage. There were seven infants and one staff person in the room. The staff person stated the other staff person gets off at 2:30 p.m. and had already left for the day. The staff person in charge stated that another staff person comes in at 3:00 p.m. The staff-to-child ratio at this time was over by two children. The staff-to-child ratio was not met intermittently throughout the day. 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 and interview, the following was found: 1) A staff person in the infant room placed an infant in a bouncy seat in front of her while she sat in a chair and fed another infant. The infant in the bouncy seat started to cry. The staff person placed her bare foot on the side of the seat near the infant's hand and proceeded to bounce the seat using her foot. This is an unsanitary practice. 2) In the room labeled Discover Zone, there was an artificial Christmas tree with ornaments in one corner of the room. Wire hooks were used to hang the ornaments on the tree. The staff person in charge indicated this room is used as an indoor gross motor space for the children in the toddler rooms. The hooks present a choking hazard for children of this age. The tree was accessible to the children. 3) In Room 111, the cord from a CD player located on a low shelf hung loose as it was plugged into the electrical outlet in the wall. A light table was also observed in this same area. The cord to the table laid loose on the floor as it was plugged into the same electrical outlet in the wall causing a tripping hazard. 4) In Room 114, the cord to a wall mounted CD player was observed plugged into an outlet on the lower portion of the wall. It should be noted that it was naptime and the room was very dark. The staff turned on the lights and a child was observed on a mat beside the outlet. The cord was loose and accessible to the child. 5) In room 115, the cord from lights strung across the ceiling was plugged into an outlet located in the dramatic play area. The cord was not secure and accessible to the children. 6) Throughout the facility, children's backpacks, diaper bags and coats were stored on hooks on the wall or in cubbies. These items were observed touching the child's belongings on either side. This method of storing children's backpacks, diaper bags and coats is unsanitary. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 8 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, out of 45 staff files reviewed, 35 staff were eligible for a professional development plan. None of these staff had a current professional development plan in their file at the facility.
Open Not marked corrected in the state record
Category: supervision. Open / not marked corrected.
922 KAR 2:090 · 922 KAR 2:090. Section 10. Director Requirements and Responsibilities.
General: Based on observation, interview and review of documentation, a staff person in Room 201 was observed supervising seven three-year-old children alone. A review of this staff person's personnel file found she had been hired on 8/21/2019 and the results of a criminal background check was not included. The staff person in charge indicated the staff person turned 18 in March of 2021. The staff person in charge stated further that a criminal records check had been submitted and the results returned. 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 9. Records.
General: Based on interview and review of documentation, three staff had turned eighteen-years-old and did not have the results of a criminal records check or proof of submission located in their file. The staff person in charge indicated that applications for the results of a criminal records check for each of the staff persons has been submitted and the results received. It should be noted that all three staff had the results of a Child Abuse and Neglect check 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, five staff did not have a copy of a high school diploma, GED or other qualifying documentation on file. The dates of hire for these staff are: 1) 6/15/2020 2) 6/10/2019 3) 10/19/2020 4) 9/8/2020 5) 9/14/2020 An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 8 Inspection Report
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:090 · 922 KAR 2:090. Section 11. Staff Requirements.
General: Based on review of documentation, the following was found: 1) A staff member hired on 3/16/2020, did not complete the required PAHT training. This staff member has been employed for more than one year. The ECE-TRIS system was reviewed. 2) A staff member hired 12/20/20, did not complete the required Orientation I and II courses. This staff member has been employed for more than three months. The ECE-TRIS system was reviewed. 3) A staff member hired 3/16/20 did not take the Orientation I and II courses within three months of employment. The courses were taken 8/4/20. The ECE-TRIS system was reviewed. 4) A staff member hired 8/13/20 did not take the Orientation I and II courses within three months of employment. The courses were taken 12/4/20. The ECE-TRIS system was reviewed. Programming Not In Compliance
Open Not marked corrected in the state record
Category: recordkeeping. Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 2. Child Care Services.
General: Based on observation, interview and review of documentation, the following was observed during a tour of Room 104 (Infants) : 1) A planned program of activities (lesson plan) was not posted. 2) Infants were observed strapped in bouncy seats, in swings, on the floor and in exersaucers. At times, the infants were moved from one piece of equipment to another piece of equipment with no activity provided. The children placed on the floor had access to some small toys and books. Some of the children were also observed crying while strapped in the various pieces of equipment. Staff indicated they do not have a planned program of activities but provide puppet shows and other activities; however, during the course of the survey, staff was not observed conducting any activities with the children. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 4 of 8 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 during a tour of the facility, the following was found: 1) In Room 105 (toddlers) an adult's purse had been placed on the counter near the edge. The strap to the purse hung over the edge and was within reach of a child. A child was also observed standing by the counter. 2) In Room 118 the child safety latch was no longer working on a cabinet under the counter labeled Cleaning Supplies. Inside the cabinet was a spray bottle labeled Bleach Water, containers of disinfectant wipes and cans of disinfectant spray. The labels on these containers have a warning to keep out of the reach of children. In addition, a drawer located above the cabinet contained a pair of adult scissors. The child safety latch was not working properly making the scissors accessible to the children. The children in this room were ages two-to three-years-old.
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 facility, there were areas within the classrooms that had chipping and peeling paint on the walls. Hygienic Practices Not In Compliance
Open Not marked corrected in the state record
Category: physical safety. Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 3. General Requirements.
General: Based on observation and interview during a tour of Room 205, the staff person was observed kneeling behind a desk as she helped a child who had wet clothes due to an accident. The staff person did not wash her hands with soap and running water after handling clothing wet with urine.
Open Not marked corrected in the state record
Category: recordkeeping. Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 10. Toilet, Diapering, and Toiletry Requirements.
General: Based on observation, the following was found: 1) In Room 103 a clipboard with papers attached had been placed on the surface of the diaper changing mat. In addition, a stack of construction paper had been placed between the wall and the edge of the mat. The construction paper was observed touching the surface of the mat. 2) In room 118, a child's bag used to store items for nap time had been placed on top of the diaper-changing mat. This method of storing items and materials is unsanitary. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 5 of 8 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 11. Toys and Furnishings.
General: Based on interview, toys mouthed by children not toilet trained are sprayed with bleach water and disinfectant spray and wiped off with disinfectant wipes. This process does not meet the requirement for the sanitation of toys mouthed by children not toilet trained. First Aid/Medication In Compliance Outdoor Play Area Not In Compliance
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 4. Premises Requirements.
General: Based on observation, large pieces of rubber padding under the swings had been secured in the ground with large bolts and washers that were exposed, creating a safety hazard if a child should fall.
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 mulch located under a hexagon climber and tall climber with a slide and swings was scattered and sparse leaving the dirt beneath exposed. Equipment Not In Compliance
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, there were several nap mats that were torn around the edges exposing the foam inside. This does not allow the mat to be adequately sanitized.
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 following was found: 1) Cribs located in Room 104 (Infants) and Room 105 (Toddlers) had smudges and an accumulation of dirt and grime on the plexi-glass ends. 2) A long white shelf located in Room 116 had numerous areas where the paint had chipped and peeled away from the surface. Transportation In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 6 of 8 Inspection Report Food Service/Food Program 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 Meal Requirements.
General: Based on observation and interview, it was found that the parents provide lunch for their children. At the time of the inspection, it was found that not all lunches brought contained the required components. Some staff indicated milk is provided for the children if their parents do not send it with their lunch. Others stated that the children are only served milk if their parent purchases a milk card. Staff also stated that other components missing from the children's lunches are supplemented by the facility. At the time of the survey, several classrooms were observed eating lunch. Many of the lunches were missing required components. Milk was only provided if a child had a milk card. Examples of some of the lunches observed are as follows: 1) Cookies, fruit snacks, a Lunchable that contained cheese, crackers and bologna. 2) Doritos, macaroni and cheese, mandarin oranges, Teddy Grahams and a Kool-Aid Jammer. 3) Cheetos, an Uncrustable brand peanut butter sandwich, and a squeezable yogurt. 3) Mini muffins, 1/2 of a ham sandwich, raisins, Doritos and squeezable yogurt. These missing components including milk were not supplemented. 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 Meal Requirements.
General: Based on observation and interview, a snack menu was not posted. The staff person in charge indicated they have a cart that contains various snack items that are served to the children. This cart was observed by the surveyor at the time of the survey. Children's Records In Compliance Written Documentation Not In Compliance
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 3. General Requirements.
General: Based on interview and review of documentation, there was no documentation to verify that a monthly fire drill had been conducted for July 2020, December 2020 and March 2021. In addition, there was no documentation to verify that quarterly earthquake drills are being conducted. The staff person in charge confirmed that quarterly earthquake drills had not been conducted. Posted Documentation Not In Compliance
Open Not marked corrected in the state record
Category: physical safety. Open / not marked corrected.
922 KAR 2:090 · 922 KAR 2:090. Section 10. Director Requirements and Responsibilities.
General: Based on observation and interview, it was found that a schedule of daily activities including the dates and times of activities to be conducted with the children was not posted in Room 104 (Infants) and in Room 201. Animals In Compliance Emergency Regulation Not Applicable An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 7 of 8
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 a review of documentation the following was found: Staff members hired 3/16/2020, 6/15/2020 and 6/29/2020, had results for the child abuse and neglect check on file (CAN); however, there were no results of a criminal records check or documentation to verify a criminal records check had been submitted for each staff member. Due to COVID19 the fingerprint based National Background check is not available. A name-based criminal records check is now required along with the results of a child abuse and neglect check (CAN). This requirement is part of the emergency regulations as a response to COVID19. It was not determined that these staff have been working alone with children. 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 2:280 · 922 KAR 2:280 - Section 4. Procedures and Payments.
General: Based on record review, it was found that two staff members hired 6/3/19, had the results of a CAN check on file due to being under the age of 18 years old at the time of hire. Since both staff members turned 18 in January of 2020, a National Background Check through the KARES system should have been facilitated at that time; however, it was not. Now due to the COVID-19 pandemic, a named-based criminal records check should be conducted on the two adult staff members until the fingerprint based Nation background Check is available. It was not determined that these staff have been working alone with children. 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 observation in the 1-2 room, there were soft cloth books available to the children, which are prohibited at this time by the emergency regulations. 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 9. Records.
General: Based on a review of staff files, the following was found: 1. One staff person did not have a documented date of employment. 2. The results of the background checks for all staff whose checks were conducted within the KARES system were not in each staff member’s file. Documentation presented in staff’s files verified the staff member had gone for fingerprinting, but the results were not included.
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, interview and review of documentation, the following was found: 1. Staff members hired 6/4/18, 11/18/19 and 6/29/2020, did not have a copy of a high school diploma, GED or other qualifying documentation on file. 2. Two staff members hired 6/3/19, did not have a copy of a high school diploma, GED or other qualifying documentation on file. 3. One staff person hired 8/21/19, is still in high school but did not have documentation on file to verify the staff person is enrolled in secondary education. An interview the staff person in charge found that staff who recently graduated should have already received their diplomas. 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
Open / not marked corrected.
922 KAR 2:090 · 922 KAR 2:090. Section 11. Staff Requirements.
General: Based on observation and review of staff files, the following was found: 1. A staff person hired 2/28/17, did not have a copy of a negative T.B. test or a statement from a health professional on file to verify the individual is free from the symptoms of T.B. A copy of a negative T.B. test or a statement from a health professional is required to be completed prior to employment. 2. A staff person whose date of hire could not be determined had a T.B. test on file that was read on 10/1/15. This test result is beyond the requirement to provide test results every 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 review of staff files and ECE-TRIS records, the following was found: 1. A staff person hired 1/10/14, had evidence of cabinet-approved pediatric abusive head trauma training on 1/9/15. This training is required to be completed every five years from the last date it was taken. There was no documentation to verify the training had been taken again. 2. A staff person hired 8/16/18, had evidence of cabinet-approved pediatric abusive head trauma training on 5/14/12. This training is required to be completed every five years from the last date it was taken. There was no documentation to verify this staff person has taken the training again. 3. A staff person hired 1/3/19, had evidence of cabinet-approved pediatric abusive head trauma on 8/13/13. This training is required to be completed every five years from the last date it was taken. There was no documentation to verify the staff person has taken this training again. 4. Two staff members hired 6/3/19, did not have evidence of having completed 6 hours of cabinet-approved orientation training within the first 90 days of employment. Programming Not In Compliance
Open Not marked corrected in the state record
Category: recordkeeping. Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 2. Child Care Services.
General: Based on observation and review of documentation, there was not a current lesson plan available for the school-age room. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 of 4 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, there was an unlocked open closet door in the 3's-4's room. The closet contained bug spray that was accessible to the children. In addition, there was a bottle of bleach solution on the counter accessible to the children. 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 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, it was found that one child's file did not contain a current immunization certificate. Written Documentation In Compliance Posted Documentation In Compliance Animals In Compliance
Open Not marked corrected in the state record
Category: health medication. Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 2. Child Care Services.
General: Based on interviews, the surveyor found the maximum group size for children aged three-years-old was not maintained. On 1/28/2020, thirty-nine children aged three-years-old were present in the gymnasium. The facility exceeded the group size for this age group by fifteen children. Based on interviews with staff, four classrooms of three-year-old children are intermingled during gym time each day from 10:25 a.m. until 10:50 a.m., exceeding the maximum group size. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 2 Inspection Report General Administration In Compliance Director Requirements 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 10. Director Requirements and Responsibilities.
General: Based on interviews, the surveyor found the child-care center failed to ensure the health, safety, and comfort of a child in care. On 1/28/2020, thirty-nine children aged three-years-old were present in the gymnasium when a child tripped over a ball and fell forward onto the gym floor. Staff reported that the child appeared dazed for approximately one minute and complained that the top of his head hurt. The child received medical attention at the local hospital where it was determined that he had a concussion. The facility exceeded the group size for this age group by fifteen children. Based on interviews with staff, four classrooms of three-year-old children are intermingled during gym time each day from 10:25 a.m. until 10:50 a.m., exceeding the maximum group size. Employee Records In Compliance
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 observation and review of documentation, a staff member hired on 8/16/18 did not have written evidence of completing the fingerprints for the national background check. The KARES report did not list a date that the fingerprints were taken. Both the KARES report and the staff file were reviewed. The staff member was not observed working alone with the children 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 3 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 9. Records.
General: Based on observation and review of documentation, three (3) staff members did not have written evidence of completing CAN checks. These staff were under eighteen (18) years-old; therefore, they would need to have a CAN check completed. The staff were hired on 8/04/18, 8/16/18, and 01/10/19. None of these staff were observed working alone with the children.
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, three (3) staff did not have proof of education on file. These staff were hired on 8/04/18, 9/26/18, and 1/10/19.
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, two (2) staff did not complete their TB skin tests prior to employment. A staff hired on 9/26/18 completed her TB skin test on 10/26/18 and a staff hired on 8/18/18 completed her TB skin test on 1/25/19. Two (2) other staff had TB documentation on file that was no longer current. A staff hired on 11/28/18 had a TB skin test on file that was dated 12/05/16 and a staff hired on 2/28/17 had a TB skin test on file that was dated 1/12/17.
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, two (2) staff members did not complete the fifteen (15) hours of cabinet-approved early care and education training within their completed training year. A staff hired on 8/01/16 completed 9.50 hours of training and a staff hired on 8/15/16 did not have any training hours on file. Four (4) other staff did not have written evidence of completing orientation training within their first three (3) months of employment. These staff were hired on 8/16/18, 8/20/18, 12/13/18, and 1/11/19. ECE-TRIS and the staff files were both 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, the outlet was not attached properly to the wall and the blinds were broken in Room 104. 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 3 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 6. Sleeping and Napping Requirements.
General: Based on observation, there was a blue mat with black duct tape covering it in Room 115.
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 round floor rug in Room 105 was covered with dark dirt spots. Transportation In Compliance Food Service/Food Program In Compliance Food Service In Compliance Children's Records In Compliance Written Documentation In Compliance Posted Documentation In Compliance Animals In Compliance
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. Two (2) staff eligible for an annual performance review did not have current documentation of a review on file in the facility. The documentation on file was dated 9/2016. One (1) additional staff person (hire date: 2/28/17) eligible for an annual performance review did not have documentation of a review on file in 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 9. Records.
General: Based on Review of Documentation, this regulatory requirement was not met. A review of staff files during the investigation found two (2) staff that did not have the date of employment listed in their file. The staff person in charge reviewed internal documentation and then identified 2/28/17 and 9/8/17 as the hire dates. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 3 Inspection Report
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:090 · 922 KAR 2:090. Section 11. Staff Requirements.
General: Based on Review of Documentation and interview, this regulatory requirement was not met. Two (2) staff (hire dates: 8/18/16 and 8/26/16) did not have educational documentation on file. The staff person in charge acknowleged the finding and stated, "These two (2) girls were high school students when they were hired. They graduated May 2017". The only educational documentation in their file was a copy of their twelth (12th) grade class schedule.
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 (2) staff files (hire dates: 8/15/15 and 1/11/16) contained results of negative T.B. tests that are no longer current. The tests were dated 9/29/15 and 10/21/15 which exceeds the two (2) year time frame.
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: 1. Two (2) staff files (hire dates: 8/30/08 and 8/13/15) contained a pediatric abusive head trauma training class certificate that was dated 2/7/13 and 7/9/12; therefore, the training is no longer valid. 2. Three (3) staff files (hire dates: 1/10/14, 11/15/15 and 8/18/16) did not contain the required fifteen (15) hours of training. Programming In Compliance Premises Not In Compliance
Open Not marked corrected in the state record
Category: recordkeeping. Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 3. General Requirements.
General: Based on Observation, in Room 108, a canister of cleaning/disinfecting wipes was found sitting on a countertop that was easily 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, the floors in Room 111 had dirt and food particles layered in the corners of the room. In Room 118 a large water stain was observed on the ceiling tile closest to the windows on the rear wall. Hygienic Practices In Compliance First Aid/Medication In Compliance An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 2 of 3 Inspection Report Outdoor Play Area 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 4. Premises Requirements.
General: Based on Observation, it was found the playground area was sparsely covered with mulch in several places over the entire playground for the older children's play area and the younger play area. The mulch was thin and the ground could be seen throughout both play areas. Mulch was nonexistent in high traffic areas such as slides and swings. Equipment In Compliance Transportation Not Applicable Food Service/Food Program In Compliance Food Service 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 Review of Documentation, a child with an enrollment date of 04/04/2016, did not have a preferred hospital listed. The file read "closest" when reviewed. 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, this regulatory requirement was not met. Two (2) staff did not have evidence of a current staff professional development plan on file in the facility. The documentation on file was dated 9/2016 and 10/2016. One (1) additional staff person (hire date: 2/28/17) did not have a staff professional development plan on file in the facility. Posted Documentation In Compliance Animals In Compliance
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 Observation, it was found that the facility developed a second outdoor play area for the two-year-old children. This play area was not inspected or approved by the Division of Regulated Child Care prior to being used by the children. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 1 of 7 Inspection Report Director Requirements Not In Compliance
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, it was found that: 1) plungers were accessible to the children in the bathrooms located in the hallway by Rooms 205 and 206; 2) the sinks used for handwashing after diaper changes in the classrooms for two-year-olds were also being used to fill up sippy cups with water. During interviews with the staff it was found that the sinks were not sanitized prior to filling the sippy cups; 3) the staff in Room 118 unpacked and set out the lunches for the children at 10:22 a.m. and then went outside to join her class. The children did not eat lunch until 10:45 a.m. In Room 116, the staff unpacked and set out the lunches for the children at 10:10 a.m. She then went outside to join her class. The children did not eat lunch until 10:50 a.m. During these times, the food sat uncovered in the open air. The food included items such as fruits, vegetables, sandwiches, yogurt, lunch meat and cheese. Employee Records Not In Compliance
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:090 · 922 KAR 2:090. Section 6. License Issuance.
General: Based on Review of Documentation, it was found through a review of thirty-five (35) staff files that a staff person with a hire date of 01/17/2017 did not have the results of or evidence of submission for a child abuse and neglect check on file. This staff person was not working alone. It was found that a child abuse and neglect check for a staff hired on 08/18/2016 was not received until 09/06/2016. A child abuse and neglect check for a staff hired on 08/26/2016 was not received until 10/05/2016. A child abuse and neglect check for a staff hired on 08/25/2016 was not received until 09/20/2016 and a child abuse and neglect check for a staff hired on 06/11/2016 was not received until 09/06/2016. There was no evidence of submission dates for these central registry checks. These instances are not in accordance with 922 KAR 1:470 which states that a request for a central registry check must be submitted within five (5) working days after the date of employment of an individual. It was also found that a staff person with a hire date of 08/18/2016 had not evidence of a completed criminal records check or evidence that one had been applied for. This instance is not in accordance with KRS 17.165 which requires that application for the criminal record of a probationary employee be made no later than the date probationary employment begins.
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, it was found through a review of thirty-five (35) staff files that five (5) staff files did not have documentation of proof of education. The dates of hire for the staff were 12/01/2015, 08/18/2016, 08/25/2016, 08/26/2016 and 01/09/2017.
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, it was found through a review of thirty-five (35) staff files that six (6) staff had TB skin test completed past their date of hire. A staff person hired on 08/01/2016 did not receive a completed TB skin test until 09/06/2016. A staff person hired on 08/18/2016 did not receive a completed TB skin test until 09/08/2016. A staff person hired on 08/26/2016 did not receive a completed TB skin test until 10/28/2016. A staff person hired on 08/25/2016 did not receive a completed TB skin test until 09/08/2016. A staff person hired on 06/01/2016 did not receive a completed TB skin test until 06/09/2016 and a staff person hired on 11/28/2016 did not receive a completed TB skin test until 12/05/2016. 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 2:110 · 922 KAR 2:110. Section 5. Staff Requirements.
General: Based on Review of Documentation, it was found through a review of thirty-five (35) staff files that three (3) staff files did not have evidence of the fifteen (15) hours of cabinet-approved early care and education training during each subsequent year of employment. A review of ECE-TRIS confirmed this. It was also found that three (3) staff files did not contain evidence of the six (6) hours of cabinet-approved orientation training. A review of ECE-TRIS also confirmed this. 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, it was found that an unlocked drawer in Room 109 contained a screwdriver. The cabinet below this drawer was also unlocked. It was found to contain several boxes of gallon size plastic bags. During the survey a child's nap mat was observed to be positioned next to this cabinet. In room 105, an unlocked drawer located under the changing area contained a roll of plastic bags. An unlocked cabinet under the sink in this room was found to contain multiple boxes of plastic bags and a container of Assured anti-bacterial wipes. This container bore the label "Keep Out of Reach of Children."
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, it was found that an unlocked drawer in Room 109 contained a screwdriver. The cabinet below this drawer was also unlocked. It was found to contain several boxes of gallon size plastic bags. In room 105, an unlocked drawer located under the changing area contained a roll of plastic bags. An unlocked cabinet under the sink in this room was found to contain multiple boxes of plastic bags. These items were not being used as part of a scheduled activity or being used to store personal belongings.
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, it was found that there were two (2) ceiling tiles in Room 108 that were stained from water damage. There were also five (5) stained ceiling tiles in Room 107, four (4) stained ceiling tiles in Room 206 and one (1) stained ceiling tile in Room 118.
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, it was found that a toilet in the boys' bathroom located in the hallway by Rooms 205 and 206 was unflushed and contained urine and feces. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 3 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, it was found that the children in Room 205 did not have their hands washed before being seated to have snack. First Aid/Medication In Compliance Outdoor Play Area Not In Compliance
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 4. Premises Requirements.
General: Based on Observation, it was found that the ground cover used on the large Two-Year-Old playground and the playground used by the older children was large, non-uniform pieces of wood mulch. Several of the pieces were three (3) to four (4) inches long and pointed at the ends and along the sides. The pieces of wood mulch were hard, not shredded. The playground equipment on these areas included climbers, slides, a dome-shaped jungle gym, swings and large wooden forts.
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, it was found that a wooden playset which included a slide, climbing fort and swings was located on grass on the Two Year Old playground located to the left of the exit door to the playground area. On the larger Two Year Old playground it was found that two (2) climber/slide combination units were located on a sparse layer of wood chips and dirt. On the large playground for children ages three-years-old and older it was found that two (2) sets of swings were located on sparse mulch and dirt. Equipment Not In Compliance
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 4. Premises Requirements.
General: Based on Observation, it was found that there was a large sandbox located on the playground used by the older children. This sandbox did not have a cover. During interview, it was found that the sandbox was not covered when not in use at the end of the day or when school was not in session. Transportation Not Applicable An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 4 of 7 Inspection Report 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 Meal Requirements.
General: Based on Observation, it was found that the staff in Room 118 unpacked and set out the lunches for the children at 10:22 a.m. and then went outside to join her class. The food remained uncovered until the children came in to eat lunch at 10:45 a.m. In Room 116, the staff unpacked and set out the lunches for the children at 10:10 a.m. She then went outside to join her class. At 10:35 a.m. the class came back inside, washed their hands and sat down on the floor for circle time. The food remained uncovered until the children sat down to eat lunch at 10:50 a.m.
Open Not marked corrected in the state record
Category: nutrition. Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 9. Food and Meal Requirements.
General: Based on Observation, it was found that the posted menu was for the month of March.
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, it was found that the children's parents are responsible for sending in their snack. Several of the children's snacks in Room 205 did not meet the required nutritional components. These snacks included goldfish crackers and water, an apple and water, Chex mix and Capri-sun and chocolate muffins and Capri-sun.
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, it was found that the children were not served millk with their lunch. The teachers stated that milk was not provided during lunch time unless the parents ordered it. An Equal Opportunity Employer M/F/D @chfsky | CHFS.KY.GOV Page 5 of 7 Inspection Report 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, it was found through a review of eleven (11) children's records that three (3) children's files did not contain an immunization certificate. The dates of enrollment for the children were 06/27/2014, 05/26/2015 and 06/30/2015.
Open Not marked corrected in the state record
Category: health medication. Open / not marked corrected.
922 KAR 2:110 · 922 KAR 2:110. Section 3. Records.
General: Based on Review of Documentation, it was found through a review of eleven (11) children's files that seven (7) children's files did not have documentation of the preferred hospital to be used. It was also found that two (2) children's files did not contain the physician's contact information. The dates of enrollment for the children were 05/26/2015 and 06/30/2015. Written Documentation 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 Review of Documentation, it was found that the fire drill documentation did not include evidence of fire drills being completed during the months of October and December of 2016.
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, it was found that the tornado and earthquake drill documentation did not include evidence of drills being conducted during the fourth quarter of 2016. 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 2:110 · 922 KAR 2:110. Section 2. General.
General: Based on Observation, it was found that the statement of deficiencies issued and the plan of correction submitted for the relicensure survey conducted in 2016 were not posted in the facility.
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, it was found that the schedules of daily activies posted in Room 109, Room 113, Room 111 and Room 103 were dated for the week of April 17th. The posted schedules of daily activiites in Room 107, Room 205 and Room 118 were not dated.
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, it was found that the handwashing procedure was not posted in Room 114 which is a two-year-old classroom. Animals In Compliance
Open Not marked corrected in the state record
Category: physical safety. Open / not marked corrected.
922 KAR 2:110 · 922 KAR 2:110. Section 4. Director Requirements and Responsibilities.
General: Based on Review of Documentation, four (4) out of thirty-five (35) staff eligible for an annual evaluation not have evidence of an evaluation on file in the facility. The Director acknowledged the deficiency during the exit interview.
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, 1. Staff persons hired 11/1/15, 1/11/16, 12/1/15, 11/1/15 and 8/17/15 did not have the results of or evidence of the application for a criminal background check as required by KRS 199.896(19) on file in the facility. 2. Staff persons hired 11/1/15, 12/1/15, 11/15/15, 11/1/15 and 8/17/15 did not have the results of or evidence of the application for a CA/N check on file in the facility. The Director stated that these staff persons are not left alone with 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 and interview, it was determined that a staff persons hired 11/1/15, 8/15/15, 6/15/15 and 11/1/15 did not have evidence of proof of education on file in the facility. The Director stated that he was not aware that these staff persons did not have this documentation on file in the facility.
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 persons hired 11/1/15, 12/1/15, 11/15/15, 11/1/15 and 8/17/15 did not have documentation of negative T.B. results on file in the facility that had been obtained within the past two (2) years. The Director acknowledge the deficiency during the exit interview.
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, 1. Seven (7) out of twenty-five (25) staff that had been employed for more than one (1) year did not have evidence of 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. Staff persons hired 11/1/15, 8/13/15, 11/15/15 and 6/15/15 did not have 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. 3. A staff person hired 8/14/14 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.
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 Review of Documentation, room 109 did not have a posted lesson plan and room 114 had a lesson plan posted that was outdated. The plan was dated 3/14/16. The director acknowledged the deficiency.
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, room 206 contained 3 stained ceiling tiles. The director acknowledged the deficiency.
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 measured in the hand washing sink in Room 108 (3 year-old room) was 130 degrees Fahrenheit. The maximum water temperature at a sink is 120 degrees Fahrenheit. The director acknowledged the deficiency.
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, room 107, a three (3) year-old room, contained 2 bottles of Ibuprofen and a bottle of Children's Tylenol in an unlocked cabinet. The cabinet was not located within reach of a child. The bottles were not labeled with any names. The director indicated that he thought that the medication may have belonged to a staff member. Outdoor Play Area
Open Not marked corrected in the state record
Category: health medication. Open / not marked corrected.
922 KAR 2:110 · 922 KAR 2:110. Section 3. Records.
General: Based on Review of Documentation, four (4) children's files did not contain immunization certificates. Two (2) other children's files contained immunization certificates that were no longer current. These two (2) immunizations were dated 9/30/11 and 6/30/15. All of the children had been enrolled in excess of thirty (30) days. The director acknowledged the deficiency. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 23 of 26 Web site: http://chfs.ky.gov/ Inspection Report
Open Not marked corrected in the state record
Category: health medication. Open / not marked corrected.
922 KAR 2:110 · 922 KAR 2:110. Section 3. Records.
General: Based on Review of Documentation, six (6) children's files did not contain a preferred hospital and one (1) other file listed "any" for the preferred hospital. In addition, two (2) children's files did not contain a physician's name or phone number. The director acknowledged the deficiency.
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, staff member hired on 08/14/14 has previously lived in Tennessee. Staff member hired on 08/12/14 had Virginia and Alabama listed as previous residences. An out of state record check has not been completed on either 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 Review of Documentation, staff member hired on 08/15/13 has lived in Tennessee. An out of stated background check has not been completed on that staff person.
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 member hired on 09/29/14 did not have education documentation on file.
Open Not marked corrected in the state record
Open / not marked corrected.
922 KAR 2:110 · 922 KAR 2:110. Section 5. Staff Requirements.
General: Based on Review of Documentation, staff member hired on 10/21/14 did not have current documentation from a health care professional that the staff member was free of active tuberculosis. Staff members hired on 09/29/14 and 06/06/14 had a negative TB skin test on file that was dated after they were hired.
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 members hired on 08/10/11, 05/16/11, 08/08/13, 08/09/13 and 03/11/14 did not have the fifteen (15) hours of cabinet approved training on file. Staff members hired on 09/29/14 and two (2) staff members hired on 08/14/14 had Orientation I and II on file that had been completed after the first three (3) months of employment.
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 observed five (5) ceiling tiles that had brown water stains located in classroom 206.
Open Not marked corrected in the state record
Category: physical safety. Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 10. Toilet, Diapering, and Toiletry Requirements.
General: Based on Observation, the surveyor observed a diaper changing station located along the wall in the children's dramatic play area in classroom 118. The diapering area was not immediately adjacent to the hand-washing sink. The staff person stated the diapering area had always been there and it was there to give the children some privacy when diapers are changed.
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 did not contain valid immunization certificates at the time of the inspection. One (1) child's file (enrollment date: 1/23/12 had an immunization certificate that was no longer valid as of 9/15/2013. The other child's file (enrollment date: 8/10/14) contained an immunization document that did not have a date; therefore, it could not be determined if the child's immunizations were up to date. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 23 of 26 Web site: http://chfs.ky.gov/ Inspection Report
Open Not marked corrected in the state record
Category: health medication. Open / not marked corrected.
922 KAR 2:110 · 922 KAR 2:110. Section 3. Records.
General: Based on Review of Documentation, all ten (10) children's files reviewed did not contain the parents' preferred hospital information. One (1) child's file (enrollment date: 8/10/14) did not have a physician's name or contact information.
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 state licensing regulations on file were dated 2010.
Open Not marked corrected in the state record
Category: ratio. Open / not marked corrected.
922 KAR 2:090 · 922 KAR 2:090. Section 6. License Issuance.
General: Based on Review of Documentation, it was found that two (2) staff files out of twenty-seven (27) staff files reviewed did not have evidence of a child abuse and neglect check or a criminal records check. These staff were not alone and their dates of employment were 08/17/2013 and 01/06/2014.
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, it was found that three (3) staff files out of twenty-seven (27) staff files reviewed did not have evidence of proof of education. The staffs' dates of hire were 08/08/2013, 03/11/2014 and 01/6/2014.
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, it was found that three (3) staff files out of twenty-seven (27) staff files reviewed did not have evidence of a TB skin test or a statement from a health professional indicating they are free of TB. The staffs' dates of hire were for 08/08/2013, 08/09/2013 and 03/11/2014.
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, it was found that one (1) staff file out of twenty-seven (27) staff files reviewed did not have evidence of orientation training completed within the first ninety days of employment. The staffs' date of hire was 08/08/2013. It was also found that three (3) staff files out of twenty-seven (27) staff files reviewed did not have evidence of the required 15 hours of annual training training. The staffs' hire dates were 08/15/2012, 08/10/2011 and 09/12/2011. 345 - Driver Requirements Not Applicable 922 KAR 2:120. Section 12. Transportation. (18) A driver of a vehicle transporting a child for a center shall: (a) Be at least twenty-one (21) years old; (b) Complete: 1. The background checks as described in 922 KAR 2:110; and 2. An annual check of the: a. Kentucky driver history records in accordance with KRS 186.018; or b. Driver history records through the state transportation agency that issued the driver’s license; (c) Hold a current driver’s license which has not been suspended or revoked during the last five (5) years; and (d) Not caused an accident which resulted in the death of a person. Programming
Open Not marked corrected in the state record
Category: recordkeeping. Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 4. Premises Requirements.
General: Based on Observation, there were water stains on the ceiling tiles in Room #104, #116, #109 and #114.
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, there was blue duct tape covering edges of several mats that were torn in Room 109 and Room 206.
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, there were several torn books in Room 109.
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 Review of Documentation, there was not documentation of a current food service permit at the facility.
Open Not marked corrected in the state record
Category: nutrition. Open / not marked corrected.
922 KAR 2:110 · 922 KAR 2:110. Section 3. Records.
General: Based on Review of Documentation, child enrolled on 11/12/13 did not have a current immunization record on file.
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 surveyor found that the facility did not submit their emergency preparedness plan according to KRS 199.8982 for 2013. The last one submitted was 03/19/12.
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, a earthquake/tornado drill was conducted in August 2013 and not again until February 2014.
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 Interview, the following was found: 1. Staff stated during interview that on 6/4/13 during the children's nap time, a seventeen (17) year old staff person was left alone with ten (10) children in Preschool Room #111 when the adult staff person left the room to gather supplies. While the adult staff person was out of the room the seventeen (17) year old staff person walked through a closet and into another classroom (Room #113) and talked with the two (2) staff working in that classroom for an undetermined amount of time. Therefore, the children in Room #111 were left unsupervised. 2. Staff interview revealed that on 6/4/13 during the children's nap time a staff person (hire date: 8/10/11) placed a four (4) year old child in a closet/storage area with his nap mat and instructed him to go to sleep. The staff person stated that the child was being disruptive to other students that were trying to take a nap; therefore, she moved him into the closet area. Staff stated during interview that the closet was dark due to the closet and classroom lights not being on. The only light was from a desk lamp positioned in Room #111. The exact amount of opening in the closet door could not be determined; however, staff interview revealed that the door was not open enough to allow staff to maintain visual supervision with the child. Staffing Requirements
Open Not marked corrected in the state record
Category: supervision. Open / not marked corrected.
922 KAR 2:110 · 922 KAR 2:110. Section 5. Staff Requirements.
General: Based on Interview, the facility failed to meet this regulatory requirement. Staff stated during interview that on 6/4/13 during the children's nap time, a seventeen (17) year old staff person was left alone with ten (10) children in Preschool Room #111 when the adult staff person left the room to gather supplies. Staff stated during interview that the seventeen (17) year old staff person has been left alone with children several times during similiar situations.
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 three (3) staff who did not have annual evaluations on file. The hire dated for these staff were 9/12/11, 8/8/11, and 8/1/11.
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, the following issues were found with staff background checks, A staff person hired on 5/24/12 had a CAN check that was not submitted until 3/3/13. A staff person hired on 8/15/12 had a CRC submitted in 11/1/12. A staff person hired on 9/4/12 had a CAN check on file that had been completed by a previous employer.
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 two (2) staff who did not have evidence of meeting the education requirment on file at the center. The hire dates for these staff are 8/15/12 and 8/21/12.
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 two (2) staff who did not have documentation of being TB free prior to employment. A staff person hired 5/24/12 had documenation dated 11/1/12. A staff person hired 8/28/12 had documentation dated 2/28/13.
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922 KAR 2:110 · 922 KAR 2:110. Section 5. Staff Requirements.
General: Based on Review of Documentation, a staff person hired 9/12/11 had only six (6) hours of annual training. 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 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; and (d) Not caused an accident which resulted in the death of a person. Programming
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Category: recordkeeping. Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 3. General Requirements.
General: Based on Observation, 1. There were two (2) bottles of correction fluid and a pair of adult scissors in a drawer under the counter in Room 103. These items were accessible to the children in care. 2. There was a roll of plastic trash bags being stored on top of a shelving unit in Room 109. The unit was approximately three (3) feet tall making the bags accessible to the children in care. 3. In Room 114 a lower drawer contained plastic gallon bags and plastic garbage bags. The bags were accessible to the children in care. 4. There were two (2) pair of adult scissors observed a a lower drawer of the teacher's desk in Room 116.
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922 KAR 2:120 · 922 KAR 2:120. Section 4. Premises Requirements.
General: Based on Observation, the black gardening liner was coming up through the mulch in several areas on the lower playground. This poses a tripping tripping hazard.
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Category: physical safety. Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 4. Premises Requirements.
General: Based on Observation, there was a plastic climber/slide unit that was approximately four (4) feet tall that was positioned approximately two (2) feet from fence on the lower playground.
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922 KAR 2:120 · 922 KAR 2:120. Section 9. Food and Meal Requirements.
General: Based on Observation, there was no menu posted in a conspicuous place in the facility. The only menu observed was posted in kitchen. 1055 - Breakfast Requirements Not Applicable 922 KAR 2:120. Section 9. Food and Meal Requirements. (17) Breakfast shall include: (a) Milk; (b) Bread; and (c)1. Fruit; 2. Vegetable; or 3. 100 percent juice. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 22 of 25 Web site: http://chfs.ky.gov/ Inspection Report
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922 KAR 2:120 · 922 KAR 2:120. Section 9. Food and Meal Requirements.
General: Based on Observation, 1. It was determined that the afternoon snack consists of a snack mix and water in Room 205. 2. The children bring their morning snack from home. Several of the snacks brought from home in Room 205 did not contain the appropriate components (Cheetos w/ water, doughnuts w/ water).
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922 KAR 2:110 · 922 KAR 2:110. Section 3. Records.
General: Based on Review of Documentation, there was one (1) staff person with hire date 6/30/11 who did not have a current annual professional development plan.
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922 KAR 2:110 · 922 KAR 2:110. Section 2 General.
General: Based on Observation, there was no information from the Kentucky Consumer Product Safety Program as specified in KRS 199.897 posted in the facility.
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922 KAR 2:120 · 922 KAR 2:120. Section 10. Toilet, Diapering, and Toiletry Requirements.
General: Based on Observation, there were no diapering procedures posted in Room 114 in the changing area. Animals
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Category: physical safety. Open / not marked corrected.
922 KAR 2:120 · 922 KAR 2:120. Section 13. Animals.
General: Based on Observation, it was determined that the facility had not obtained written parental consent for the turtles in Room 103
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922 KAR 2:110 · 922 KAR 2:110 - Section 5 (1)
General: Based on Review of Documentation, there were two (2) staff hired 8/1/11 and 6/11 who had the results of a T.B. skin test documented after their date of hire. The regulation requires that a T.B. skin test or a statement from a health professional be obtained prior to employment. There were two (2) additional staff persons hired 9/17/07 and 9/12/11 who did not have current results of a T.B. skin test or a statement from a health professional on file. 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 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 An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 8 of 42 Web site: http://chfs.ky.gov/ Inspection Report 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 Not In Compliance Findings: General: Based on Review of Documentation, there were three (3) staff hired 8/10/11, 6/11 and 9/12/11 who did not have evidence of having completed six (6) hours of orientation training. There were two (2) staff with a hire date of 6/11 who completed six (6) hours of orientation training 10/19/11 and 1/17/12. These dates are after the required ninety (90) day period to have the orientation training completed. 3) 15 hours annually Not In Compliance Findings: General: Based on Review of Documentation, there were ten (10) staff who had not completed fifteen (15) hours of required training for the 2010-2011 training year. 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. 2) 9 hours-first year In Compliance 317 - Driver requirements Not Applicable 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 Not Applicable 2) Background checks Not Applicable 3) Drivers license Not Applicable 4) No convictions for vehicle operation Not Applicable 5) No accident causing death Not Applicable 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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922 KAR 2:110 · 922 KAR 2:110 - Section 5 Staff Requirements.
General: Based on Review of Documentation, there were three (3) staff who did not have a high school diploma, GED or other qualifying documentation on file. There were two (2) additional staff persons who are high school students who did not have documentation on file to verify they are enrolled in high school.
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922 KAR 2:120 · 922 KAR 2:120 - Section 3
Classroom 7 - Fours III: Based on Interview, it was determined that the children have access to the internet while using the facility's computers. Staff stated that the computers are not equipped with a monitoring device that would limit access by a child to items inappropriate for a child to view or hear. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 11 of 42 Web site: http://chfs.ky.gov/ Inspection Report 195 - Rest Period 922 KAR 2:120 - Section 3 (11) Except for an infant, toddler, or a child who attends nontraditional hours of care, a child shall have rest periods not to exceed two (2) hours. A child who does not sleep shall be permitted to play quietly after a reasonable rest period specific to the needs of the child. 1) 2 hour limit In Compliance 2) Alternate activity In Compliance
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922 KAR 2:120 · 922 KAR 2:120 - Section 6
Classroom 8 - Threes II: Based on Observation, there were several torn mats used for napping. Some had been repaired with duct tape, however, the tape was peeling back on some of the mats. The exposed sticky side of the tape cannot be properly sanitized between uses. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 28 of 42 Web site: http://chfs.ky.gov/ Inspection Report 294 - Toys/Equipment/Furniture 922 KAR 2:120 - Section 11 (1) All toys, equipment, and furniture contacted by a child shall be: (a) Kept clean and in good repair and (b) Free of peeling, flaking, or chalking paint. 1) Clean In Compliance 2) Good repair In Compliance 3) Free from peeling, flaking, chalking paint In Compliance 295 - Indoor/outdoor Equipment 922 KAR 2:120 - Section 11 (2) Indoor and outdoor equipment shall: (a) Be clean, safe, and in good repair; (b) Meet the physical, developmental needs, and interests of children of different age groups; (c) Be free from sharp points or corners, splinters, protruding nails or bolts, loose or rusty parts, hazardous small parts, lead-based paint, poisonous material, and flaking or chalking paint; and (d) Be designed to guard against entrapment or situations that may cause strangulation. 1) Clean In Compliance 2) Safe In Compliance 3) Good repair In Compliance 4) Meets needs In Compliance 5) Free from harmful conditions In Compliance 6) Guard against entrapment/strangulation In Compliance 296 - Toys 922 KAR 2:120 - Section 11 (3) Toys shall be: (a) Used according to the manufacturer's safety specifications; (b) Durable; and (c) Without sharp points or edges. 1) Used according to manufacturers specifications In Compliance 2) Durable In Compliance 3) No sharp points/edges In Compliance
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922 KAR 2:110 · 922 KAR 2:110 - Section 3
General: Based on Review of Documentation, there were three (3) children who did not have a current immunization certificate on file. The children have been enrolled more than thirty (30) days. 99 - Documentation for Off Premise Trip Not Applicable 922 KAR 2:110 - Section 3 The following records shall be maintained at the child-care center for five (5) years: (4) Permission forms for each trip off the premises signed by the parent; An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 38 of 42 Web site: http://chfs.ky.gov/ Inspection Report Written Documentation 93 - Policies and Procedures 922 KAR 2:110 - Section 2 (5) Program policies and procedures shall: (a) Be in writing; and (b) Include: 1. Staff policies; 2. Job descriptions; 3. An organization chart; 4. Chain of command; and 5. Other procedures necessary to ensure implementation of: a. KRS 199.898, Rights for children in child-care programs and their parents, custodians, or guardians - posting and distribution requirements; b. 922 KAR 2:090, Child-care center licensure; c. 922 KAR 2:120, Child-care center health and safety standards; and d. This administrative regulation. 1) Writing In Compliance 2) Staff Policies In Compliance 3) Job Description In Compliance 4) Organization Chart In Compliance 5) Chain of Command In Compliance 6) Other Procedures-a) Rights for Children b)922 KAR 2:090 c) 922 KAR 2:110 d)922 KAR 2:120 In Compliance 100 - Daily Attendance Records 922 KAR 2:110 - Section 3 (5) Daily attendance records documenting the arrival and departure time of each child; 1) Arrival In Compliance 2) Departure In Compliance
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Category: health medication. Open / not marked corrected.
922 KAR 2:110 · 922 KAR 2:110 - Section 4 (1)
General: Based on Interview, with staff, the surveyor found that on several occasions preschool children in different classrooms were placed in the hallway alone for disturbing other children in the classroom. One (1) of the three (3) preschoolers was placed in the hallway on his mat and blanket during nap time. An Equal Opportunity Employer M/F/D Cabinet For Health and Family Services Page 1 of 2 Web site: http://chfs.ky.gov/ Inspection Report Programming 180 - Waiting Period 922 KAR 2:120 - Section 2 (8) A child shall not be required to stand or sit for a prolonged period of time: (a) During an activity; (b) While waiting for an activity to start; or (c) As punishment. 3) Punishment Not In Compliance Findings: Preschool Classroom: Based on Interview, with staff person, a behavior chart dipicting a green, yellow and red light card is used for each child. A child starts out on green. If the child moves to yellow for a behavior issue it is a five (5) minute time out and if a child moves to red they are placed in a chair for a fifteen (15) minute time out. This staff person works with the three (3) year old class. 182 - Discipline 922 KAR 2:120 - Section 2 (10) A child shall not be subjected to: (a) Corporal physical discipline pursuant to KRS 199.896(18); (b) Loud, profane, threatening, frightening, or abusive language; or (c) Discipline that is associated with: 1. Rest; 2. Toileting; or 3. Food. 2) Loud, profane, threatening, frightening or abusive language In Compliance Equipment - Classroom
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922 KAR 2:120 · 922 KAR 2:120 - Section 6
Preschool Classroom: Based on Observation, of the preschool classrooms, found a couple of mats to be torn exposing the foam padding inside.
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