3270.27(c) · The operator shall assure that each facility person receives training regarding the emergency plan at the time of initial employment, on an annual basis and at the time of each plan update. The operator shall document the date of each training and the names of all facility persons who received the training and kept on file at the facility.

The file for staff person #1 did not include documentation of training regarding the emergency plan at the time of initial hire (see LIS code sheet).

Corrected Corrected by Aug 7, 2025

Category: recordkeeping. Marked corrected in the state record.

3270.32(a)/3270.192(4) · The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL.

The file for staff person #2, #3 and #4 included NSOR clearances which were not updated within 60 months of the previous clearance. The current NSOR clearance for staff person #2 was dated 02/19/2025 with the previous clearance dated 02/15/2020. Staff person #2 was not removed from a child care position until the clearances were returned. The current NSOR clearance for staff person #3 was dated 02/21/2025 with the previous clearance dated 02/10/2020. Staff person #3 was not removed from a child care position until the clearances were returned. The current NSOR clearance for staff person #4 was dated 02/21/2025 with the previous clearance dated 02/10/2020. Documentation of staff person #4 being removed from a child care position until the clearances were returned was not on file. The file for staff person #5 included an NSOR, Child Abuse and FBI clearance which were not updated within 60 months of the previous clearance. The current NSOR clearance was dated 02/11/2025 with the previous clearance dated 02/10/2020. The current child abuse clearance was dated 01/28/2025 with the previous clearance dated 01/13/2020. The current FBI clearance was dated 03/26/2025 with the previous clearance dated 02/16/2020. Documentation of the staff person #5 being removed from a child care position until the clearances were returned was not on file.

Corrected Corrected by Aug 27, 2025

Category: background checks. Marked corrected in the state record.

3270.192(5) · A facility person's record shall include two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person.

The file for staff person #1 did not include two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person.

Corrected Corrected by Aug 27, 2025

Category: recordkeeping. Marked corrected in the state record.

3270.94(a)(1) · The Director or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that fire drills are conducted at least once every 60 days.

The director or designated staff person did not ensure a fire drill was conducted at least once every 60 days; the fire drill conducted between 12/04/2024 and 02/21/2025 exceeded 60 days.

Corrected Corrected by Aug 28, 2025

Category: recordkeeping. Marked corrected in the state record.

3270.95(b) · The Director or designated staff person who is responsible for compliance with this chapter shall ensure the requirements under subsection (a) are met.

The director or designated staff person did not ensure a manual test of the fire detection system was conducted at least once every 30 days; the tests conducted between 12/04/2024, 01/07/2025 and 02/21/2025 exceeded 30 days.

Corrected Corrected by Aug 28, 2025

Category: recordkeeping. Marked corrected in the state record.

3270.31(e)(4)(ii) · Staff persons shall participate, at least annually, in firesafety training conducted by a fire protection professional. Staff persons and volunteers shall receive training in maintenance of smoke detectors, the duties of facility persons during a fire drill and during a fire and the use of the facility's fire extinguishers, not including discharge of the fire suppressant agent.

The annual firesafety training for staff person #1 was not completed within 12 months of the previous training, the current training was completed on 11/18/2024 the previous training was completed on 10/04/2023.

Corrected Corrected by Jan 7, 2025

Category: recordkeeping. Marked corrected in the state record.

3270.34(a)(6) · A director is responsible for written evaluation of staff persons on a regular basis, a minimum of one evaluation every 12 months.

The most recent written evaluation for staff person #1 was completed on 09/12/2023 with no subsequent evaluation within the subsequent 12 months.

Corrected Corrected by Jan 7, 2025

Category: recordkeeping. Marked corrected in the state record.

3270.104(a) · Furniture must be durable, safe, easily cleaned and appropriate for the child's size, age and special needs.

Observed a small blue couch in the older toddler classroom which with tear exposing the foam cushion inside. Observed a nut missing from the bolt in the water play table located in the preschool classroom, causing the legs to wobble.

Corrected Corrected by Jan 7, 2025

Category: physical safety. Marked corrected in the state record.

3270.124(f)/3270.181(c) · The parent shall update in writing emergency contact information once in a 6-month period or as soon as there is a change in the information. A parent is required to review and update the emergency contact information and the financial agreement at least once in a 6-month period or as soon as there is a change in the information.

The emergency contact form for child #1 was last reviewed on 04/10/2024, with no subsequent review within 6 months. The financial agreement for child #2 was last reviewed on 02/23/2024, with no subsequent review within 6 months. *Corrected at the time of the inspection.

Corrected Corrected by Jan 7, 2025

Category: recordkeeping. Marked corrected in the state record.

3270.131(e)(1) · The facility shall require the parent to provide updated written verification from a physician, physician's assistant, CRNP, the Department of Health or a local health department of ongoing vaccines administered to an infant, toddler or preschool child in accordance with the schedule recommended by the ACIP.

The file for child #1 (see LIS code sheet) included a record of the child's immunization status which lacked a varicella immunization.

Corrected Corrected by Jan 7, 2025

Category: health medication. Marked corrected in the state record.

3270.161(c) · Food that has been previously served to a person or returned from a table shall be discarded.

Observed leftover food that had been previously served was not discarded, the food was placed in the child's lunchbox and the lunchbox was placed in the child's cubby to return to the parent.

Corrected Corrected by Jan 7, 2025

Category: nutrition. Marked corrected in the state record.

3270.14/3270.21 · A facility shall be operated in conformity with applicable Federal and State laws and regulations.State agencies whose regulations may relate to the operation of a facility include the Department of Environmental Resources, the Department of Labor and Industry, the Department of Health, the Department of Education and the Department of Transportation. Conditions at the facility may not pose a threat to the health or safety of the children.

The emergency plan does not include a Continuity of Operations plan.

Corrected Corrected by Jan 11, 2024

Category: ratio. Marked corrected in the state record.

3270.27(c) · The operator shall assure that each facility person receives training regarding the emergency plan at the time of initial employment, on an annual basis and at the time of each plan update. The operator shall document the date of each training and the names of all facility persons who received the training and kept on file at the facility.

The operator did not ensure staff person #1 and #2 received training regarding the emergency plan annually. The current emergency plan training for staff person #1 was completed on 12/07/2023 with the previous training completed on 01/10/2022. The current emergency plan training for staff person #2 was completed on 12/05/2023 with the previous training completed on 11/17/2022.

Corrected Corrected by Jan 5, 2024

Category: recordkeeping. Marked corrected in the state record.

3270.34(a)(6) · A director is responsible for written evaluation of staff persons on a regular basis, a minimum of one evaluation every 12 months.

The director did not complete a written evaluation for staff person #1 within a minimum of every 12 months; the current evaluation was completed on 09/12/2023 with the previous evaluation completed on 08/31/2021.

Corrected Corrected by Jan 5, 2024

Category: recordkeeping. Marked corrected in the state record.

3270.76 · Floors, walls, ceilings and other surfaces, including the facility's outdoor play space surfaces shall be kept clean, in good repair and free from visible hazards.

Observed a broken latch on a drawer located in the toddler 1 classroom which contained power cords. Observed a broken latch on a drawer located in the PreK classroom which contained batteries.

Corrected Corrected by Jan 8, 2024

Category: physical safety. Marked corrected in the state record.

3270.124(b)(3)/3270.124(b)(7) · Emergency contact information must include the home and work addresses and telephone numbers of the enrolling parent. Emergency contact information must include the name, address and telephone number of the individual designated by the parent to whom the child may be released.

The emergency contact information for child #3 did not include the complete work address for the enrolling parent or the complete address for the individuals designated by the parent to whom the child may be released.

Corrected Corrected by Jan 12, 2024

Category: recordkeeping. Marked corrected in the state record.

3270.124(c) · When children are in the facility, emergency contact information shall be present in a child care space for children receiving care in the space.

Emergency contact information for child #6 and #8 were not present in the Kindergarten/School-Age classroom while receiving care in the space. Emergency contact information for child #9 and #10 were not present in the PreK classroom while receiving care in the space.

Corrected Corrected by Jan 5, 2024

Category: recordkeeping. Marked corrected in the state record.

3270.124(f)/3270.181(c) · The parent shall update in writing emergency contact information once in a 6-month period or as soon as there is a change in the information. A parent is required to review and update the emergency contact information and the financial agreement at least once in a 6-month period or as soon as there is a change in the information.

A review of the emergency contact and financial agreement for child #2, #3, #4 and #7 was not completed within 6-months of the previous review. The emergency contact information for child #2 was reviewed on 08/15/2023 and previously reviewed on 12/02/2022. The financial agreement for child #2 was reviewed on 10/12/2023 and previously reviewed on 12/02/2022. The emergency contact information for child #3 was reviewed on 06/2023 and previously reviewed on 09/21/2022. The financial agreement for child #3 was reviewed on 10/20/2023 and previously reviewed on 12/22/2022. The emergency contact information for child #5 was reviewed on 10/13/2023 & 07/21/2023 and previously reviewed on 12/12/2022. The financial agreement for child #2 was reviewed on 10/13/2023 and previously reviewed on 03/24/2022. The emergency contact information for child #7 was reviewed on 09/14/2023 and previously reviewed on 12/02/2022. The financial agreement for child #7 was reviewed on 06/12/2023 and previously reviewed on 10/12/2022.

Corrected Corrected by Jan 5, 2024

Category: recordkeeping. Marked corrected in the state record.

3270.131(b)(1) · The operator shall require the parent to provide an updated health report at least every 6 months for an infant or young toddler.

The file for child #2 included an updated health report which was not completed at least every 6 months for an infant or young toddler (see LIS code sheet). The current health report on file was dated 12/08/2023 with the previous completed on 04/03/2023.

Corrected Corrected by Jan 5, 2024

Category: health medication. Marked corrected in the state record.

3270.131(e) · The facility may not accept or retain an infant 2 months of age or older, a toddler or a preschool child at the facility for more than 60 days following the first day of attendance at the facility unless the parent provides written verification from a physician, physician's assistant, CRNP, the Department of Health or a local health department of the dates (month, day and year) the child was administered immunizations in accordance with the recommendations of the ACIP.

The file for child #4 (see LIS code sheet) included a record of the child's immunization status which lacked an influenza immunization.

Corrected Corrected by Jan 5, 2024

Category: health medication. Marked corrected in the state record.

3270.94(a)(1) · The Director or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that fire drills are conducted at least once every 60 days.

The Director or designated staff person did not ensure a fire drill was completed at least once every 60 days, fire drills exceeded 60 days on the following dates: 05/23/2023 - 08/18/2023.

Corrected Corrected by Jan 12, 2024

Category: recordkeeping. Marked corrected in the state record.

3270.95(b) · The Director or designated staff person who is responsible for compliance with this chapter shall ensure the requirements under subsection (a) are met.

The Director or designated staff person did not ensure a manual test of the fire detection system was completed at least once every 30 days; a test of the fire detection system exceeded 30 days on the following dates: 01/11/2023 - 02/16/2023 - 03/28/2023 - 04/28/2023; 05/03/2023 - 06/05/2023 - 09/18/2023.

Corrected Corrected by Jan 12, 2024

Category: recordkeeping. Marked corrected in the state record.

3270.131(a) · The operator shall require the parent of an enrolled child, including a child, a foster child and a relative of an operator or a facility person, to provide an initial health report no later than 60 days following the first day of attendance at the facility.

The file for child #1 did not include an initial health report with immunization record within 60 days of enrollment (see LIS code sheet). The file for child #4 did not include an initial health report within 60 days of enrollment (see LIS code sheet); the file included an immunization record dated 08/11/2023.

Corrected Corrected by Jan 5, 2024

Category: health medication. Marked corrected in the state record.

3270.104(a) · Furniture must be durable, safe, easily cleaned and appropriate for the child's size, age and special needs.

Observed a child size vinyl couch in the Toddler 2 classroom which was torn, exposing the foam padding inside.

Corrected Corrected by Jan 3, 2023

Marked corrected in the state record.

3270.76 · Floors, walls, ceilings and other surfaces, including the facility's outdoor play space surfaces shall be kept clean, in good repair and free from visible hazards.

Observed a ceiling tile in the corner of the Toddler 1 classroom which was water damaged and sagging. Observed a metal air vent cover in the preschool bathroom which was rusty.

Corrected Corrected by Jan 3, 2023

Category: physical safety. Marked corrected in the state record.

3270.14/3270.21 · A facility shall be operated in conformity with applicable Federal and State laws and regulations. State agencies whose regulations may relate to the operation of a facility include the Department of Environmental Resources, the Department of Labor and Industry, the Department of Health, the Department of Education and the Department of Transportation. Conditions at the facility may not pose a threat to the health or safety of the children. Until such time as the required pre-service trainings are completed, staff person #3 & #5 must be supervised, when interacting with children, by an AGS who has completed the required training related to this citation. If there are no staff person(s) available to supervise staff person #3 and #5-, staff person #3 and #5 may not work in a child-care position at the facility.

Staff person #3 was observed to be caring for children in the Toddler 1 classroom unsupervised. Staff person #3 has not completed the following pre-service training required prior to caring for children unsupervised: Get Started with Center-Based Care: Building Blocks for Quality. Staff person #5 was observed to be caring for children in the infant classroom unsupervised. Staff person #5 has not completed the following pre-service training required prior to caring for children unsupervised: Get Started with Center-Based Care: Building Blocks for Quality.

Corrected Corrected by Jan 3, 2023

Category: supervision. Marked corrected in the state record.

3270.31(f) · Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10. Staff person #3, #4, #5, #6 and #7 will have until 02/07/2023 to complete the required training. Until such time as the required training has been completed, staff person #3, #4, #5, #6 and #7 must be supervised, when interacting with children, by an AGS who has completed the required training related to this citation. If there are no staff available to supervise staff person #3, #4, #5, #6 and #7, staff person #3, #4, #5, #6 and #7 may not work in a child-care position at the facility.

Staff person #1 did not complete the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Pediatric First Aid and CPR. Their training was completed on 11/01/2022. Staff person #3, #4, #5 and #6 have not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Get Started with Center-Based Care: Building Blocks for Quality. Staff person #3, #4, #5 and #6 completed the 6-hour Health and Safety Basics prior to 09/30/2016 and did not complete the updated training. Staff person #7 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Get Started with Center-Based Care: Building Blocks for Quality.

Corrected Corrected by Jan 3, 2023

Category: supervision. Marked corrected in the state record.

3270.65 · Protective receptacle covers shall be placed in electrical outlets accessible to children 5 years of age or younger.

Observed an electrical outlet in the preschool bathroom without a protective receptacle cover.

Corrected Corrected by Dec 29, 2022

Marked corrected in the state record.

3270.124(b)(2) · Emergency contact information must include the name, address and telephone number of the child's physician or source of medical care.

The emergency contact information for child #2 did not include the name, address and telephone number of the child's physician or source of medical care.

Corrected Corrected by Jan 24, 2023

Category: health medication. Marked corrected in the state record.

3270.124(b)(3) · Emergency contact information must include the home and work addresses and telephone numbers of the enrolling parent.

The emergency contact information for child #1 did not include the work address and telephone number of the enrolling parent. The emergency contact information for child #4 did not include the work address of the enrolling parent.

Corrected Corrected by Jan 19, 2023

Category: recordkeeping. Marked corrected in the state record.

3270.131(c) · A health report must be written and signed by a physician, physician's assistant or a CRNP. The signature must include the individual's professional title.

The file for child #1 included an After Visit Summary report which did not include the signature of the physician, physician's assistant or a CRNP that completed the report.

Corrected Corrected by Jan 4, 2023

Category: health medication. Marked corrected in the state record.

3270.131(d)(7) · A health report shall include a statement that the child is able to participate in child care and appears to be free from contagious or communicable disease.

The file for child #1 included an "After visit summary" that did not include a statement that the child is able to participate in child care and appears to be free from contagious or communicable disease. The file for child #3 included a child health report where the statement that the child is able to participate in child care and appears to be free from contagious or communicable disease was left blank on the form. The file for child #4 included an old version of the child health report from which did not include a statement that the child is able to participate in child care and appears to be free from contagious or communicable disease.

Corrected Corrected by Feb 10, 2023

Category: health medication. Marked corrected in the state record.

3270.131(e)(1) · The facility shall require the parent to provide updated written verification from a physician, physician's assistant, CRNP, the Department of Health or a local health department of ongoing vaccines administered to an infant, toddler or preschool child in accordance with the schedule recommended by the ACIP.

The file for child #1 (see LIS code sheet) included a record of the child's immunization status which lacked a 4th dose of PCV13, a 2nd dose of Hep A and an influenza immunization. The file for child #3 (see LIS code sheet) included a record of the child's immunization status which lacked an influenza immunization.

Corrected Corrected by Feb 10, 2023

Category: health medication. Marked corrected in the state record.

3270.151(a) · A facility person providing direct care who comes into contact with the children or who works with food preparation shall have a health assessment conducted within 12 months prior to providing initial service in a child care setting and every 24 months thereafter. A health assessment is valid for 24 months following the date of signature, if the person does not contract a communicable disease or develop a medical problem.

The file for staff person #2 included a health assessment which was not conducted within 12 months prior to providing initial service in a child care setting (see LIS code sheet). The current health assessment on file was dated 06/16/2022; no prior health assessments were on file. The file for staff person #5 included a health assessment which was not updated at least once every 24 months. The current health assessment on file was dated 10/19/2021; the previous health assessment was dated 06/22/2019.

Corrected Corrected by Jan 27, 2023

Category: ratio. Marked corrected in the state record.

3270.94(a)(1) · The Director or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that fire drills are conducted at least once every 60 days.

The director or designated staff person did not ensure a fire drill was conducted at least once every 60 days. Fire drills which exceeded 60 days were documented on the following dates: 05/05/2022 - 07-07-2022, 07/07/2022 - 09/22/2022 and 09/22/2022 - 11/22/2022.

Corrected Corrected by Jan 3, 2023

Category: recordkeeping. Marked corrected in the state record.

3270.95(b) · The Director or designated staff person who is responsible for compliance with this chapter shall ensure the requirements under subsection (a) are met.

The director or designated staff person did not ensure a manual test of the fire detection system was completed at least once every 30 days. Tests exceeding 30 days were documented on the following dates: 05/05/2022 - 06/13/2022, 08/02/2022 - 09/22/2022, 10/18/2022 - 11/22/2022, and 11/22/2022 - 12/28/2022.

Corrected Corrected by Jan 27, 2023

Category: recordkeeping. Marked corrected in the state record.

3270.34(a)(6) · A director is responsible for written evaluation of staff persons on a regular basis, a minimum of one evaluation every 12 months.

On 02/10/2022, the director did not ensure a written evaluation of staff persons were completed at least once every 12 months. The most recent evaluation for staff person #1 was completed on 01/12/2022 with the previous evaluation completed on 12/30/2020. The most recent evaluation for staff person #2 was completed on 01/14/2022 with the previous evaluation completed on 08/15/2020. The most recent evaluation for staff person #2 was completed on 01/14/2022 with the previous evaluation completed on 08/17/2020.

Corrected Corrected by Feb 18, 2022

Category: recordkeeping. Marked corrected in the state record.

3270.123(a)(3) · The services to be provided to the family and the child, including the Department's approved form to provide information to the family about the child's growth and development in the context of the services being provided. The operator shall complete and update the form and provide a copy to the family in accordance with the updates regarding emergency contact information in § 3270.124(f) (relating to emergency contact information).

On 02/10/2022, observed the agreement forms for children #1, #2, #3, #4, #5 and #6 did not include the services to be provided to the family and the child. The agreement form created by the facility does not include this information on the agreement form.

Corrected Corrected by Feb 21, 2022

Category: recordkeeping. Marked corrected in the state record.

3270.124(b)(2) · Emergency contact information must include the name, address and telephone number of the child's physician or source of medical care.

On 02/10/2022, the emergency contact information for child #1 and #3 did not include the complete address of the child's physician or source of medical care.

Corrected Corrected by Feb 23, 2022

Category: health medication. Marked corrected in the state record.

3270.124(b)(6) · Emergency contact information must include health insurance coverage and policy number for a child under a family policy or Medical Assistance benefits, if applicable.

On 02/10/2022, the emergency contact information for child #1 did not include the health insurance policy number. The emergency contact information for child #2 and #5 did not include the information for health insurance coverage or the policy number.

Corrected Corrected by Feb 23, 2022

Category: health medication. Marked corrected in the state record.

3270.131(b)(2) · The operator shall require the parent to provide an updated health report at least every 12 months for an older toddler or preschool child.

On 02/10/2022, observed the health report for child #3, a 5-year-old, was not updated at least once every 12 months for a preschool child; the current health report on file for child #3 was completed on 12/06/2021 and the previous was dated 10/23/2020.

Corrected Corrected by Feb 21, 2022

Category: health medication. Marked corrected in the state record.

3270.131(d)(7) · A health report shall include a statement that the child is able to participate in child care and appears to be free from contagious or communicable disease.

On 02/10/2022, the health report for child #1, #3, and #6 did not include a statement that the child is able to participate in child care and appears to be free from contagious or communicable disease; the health report was an older form which did not include this information on the form.

Corrected Corrected by Feb 23, 2022

Category: health medication. Marked corrected in the state record.

3270.27(a)(5) · The facility shall have an emergency plan that provides for accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions.

On 01/21/2022, observed the emergency plan did not include accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions.

Corrected Corrected by Feb 18, 2022

Category: physical safety. Marked corrected in the state record.

3270.94(a)(1) · The Director or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that fire drills are conducted at least once every 60 days.

On 01/21/2022, observed a lapse of greater than 60 days on the fire drill log between fire drills conducted on 10/29/20210 - 01/10/2022.

Corrected Corrected by Feb 18, 2022

Category: recordkeeping. Marked corrected in the state record.

3270.95(b) · The Director or designated staff person who is responsible for compliance with this chapter shall ensure the requirements under subsection (a) are met.

On 01/21/2022, observed a test of the fire detection system was not being documented at least once every 30 days.

Corrected Corrected by Feb 21, 2022

Category: recordkeeping. Marked corrected in the state record.