3270.32(a) · The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services).

The two most recent mandated reporter trainings on file for Staff #1 (8/17/20 &8/25/25) and Staff #2 (4/30/20 & 6/7/20) are dated more than 60 months apart.

Corrected Corrected by Feb 5, 2026

Category: recordkeeping. Marked corrected in the state record.

3270.21 · Conditions at the facility may not pose a threat to the health or safety of the children.

Adult scissors were observed accessible on the teacher's desk in the Steelers and Penguins rooms.

Corrected Corrected by Jul 31, 2025

Category: health medication. 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 initial emergency plan training on file for Staff #7 is dated 7/2/25, more than 90 days beyond the facility person's date of hire (SEE IS CODE SHEET).

Corrected Corrected by Jul 31, 2025

Category: recordkeeping. Marked corrected in the state record.

3270.27(e) · The operator shall provide to the parent of each enrolled child a letter explaining the emergency procedures. The operator shall also provide to the parent of each enrolled child a letter explaining any subsequent update to the plan.

The facility's emergency plan parent letter lacked accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions.

Corrected Corrected by Aug 19, 2025

Category: physical safety. 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 two most recent fire safety trainings on file for Staff #1 are dated 6/30/23 and 7/10/24, more than 12 months apart.

Corrected Corrected by Jul 31, 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 #10 contained an NSOR certificate dated 10/3/24, after date of hire, without a NSOR request on file at time of hire required for provisional hiring under the CPSL (SEE IS CODE SHEET).

Corrected Corrected by Jul 31, 2025

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

3270.32(a) · The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services).

The two most recent mandated reporter trainings on file for Staff #1 (4/30/20 & 6/17/25), Staff #2 (4/20/20 & 7/11/25), and Staff #14 (4/27/20 & 6/4/25) are dated more than 60 months apart. Staff #3 and Staff #4 have not completed the mandated reporter training within 90 days of their date of hire (see LIS code sheet). Staff #7 did not complete the mandated reporter training within 90 days of their date of hire (see LIS code sheet). The training was completed on 7/13/25.

Corrected Corrected by Aug 19, 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 two most recent staff evaluations on file for Staff #13 are dated 5/23/24 and 6/30/25, more than 12 months apart.

Corrected Corrected by Aug 19, 2025

Category: recordkeeping. 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.

A protective receptacle cover was missing in an outlet in the Dreamers, Imagineers, and Voyagers rooms.

Corrected Corrected by Jul 31, 2025

Marked corrected in the state record.

3270.66(a) · Cleaning materials and other toxic materials shall be kept in an area or container that is locked or made inaccessible to children.

Hand sanitizer in the Penguins room and antibacterial wipes in the Pirates room, both labeled 'Keep Out of Reach of Children', were observed accessible to children.

Corrected Corrected by Jul 31, 2025

Marked corrected in the state record.

3270.67(a) · Trash shall be removed from the facility at least once per day.

A trash can in the outside play space was observed with garbage from days prior.

Corrected Corrected by Jul 31, 2025

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

3270.67(d) · Trash that has been contaminated by human secretions or excrement shall be contained in closed, plastic-lined receptacles.

In the Penguins and Panthers rooms, garbage cans containing napkins with human secretions lacked lids on the receptacles.

Corrected Corrected by Aug 19, 2025

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.

In the Panthers Room, a piece of baseboard trim was missing on the cabinet in the corner and was not in good repair. Broken tiles with sharp edges located at the bottom of the walls and standing water on the floor and in a bucket were observed in the Boys Bathroom. Broken tiles with sharp edges located at the bottom of the walls and a leaking sink was observed in the Girls Bathroom. In the outside play space, standing water was observed in the toy bins and play tables.

Corrected Corrected by Aug 19, 2025

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

3270.102(a) · Toys, play equipment and other indoor and outdoor equipment used by the children shall be clean, in good repair and free from rough edges, sharp corners, pinch and crush points, splinters and exposed bolts.

A green toy bin in the Voyagers classroom was observed to have a broken handle and not in good repair. Foam blocks with ripped pieces and teeth marks were observed in the Pirates room. Peeling vinyl was observed on the couch in the Dreamers classroom, on the brown couch in the Voyagers classroom, a bean bag in the Panthers classroom, and on the front and back wall mats in the Gym. Rest equipment with torn vinyl and exposed foam was observed in the Dreamers and Imagineers classrooms.

Corrected Corrected by Aug 19, 2025

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

3270.106(f) · At least 2 feet of space is required on three sides of a bed, cot, crib or other rest equipment while the equipment is in use.

Rest equipment in the Dreamers and Imagineers classrooms lacked two feet on three sides of the rest equipment while the equipment was in use.

Corrected Corrected by Jul 31, 2025

Category: physical safety. 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).

The most recent child service report on file for Child #2 is dated 1/7/25, more than 6 months from the child's date of enrollment (SEE IS CODE SHEET). The two most recent child service reports on file for Child #8 are dated 12/1/23 & 2/10/25, more than 6 months apart.

Corrected Corrected by Jul 31, 2025

Category: recordkeeping. Marked corrected in the state record.

3270.123(b)/3270.182(3) · A parent shall receive the original agreement. The facility shall retain a copy of the agreement. A child's record shall contain signed parental consent for emergency medical care for the child. Written consent is required prior to admission.

The file for Child #5, Child #7, Child #9, and Child #10 contained the original financial agreement when the parent is to receive the original agreement.

Corrected Corrected by Aug 19, 2025

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.

The emergency contact form on file for Child #7 and Child #8 lacked a complete address and phone number for the child's physician or source of medical care.

Corrected Corrected by Aug 8, 2025

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 form on file for Child #1, Child #5, Child #6, and Child #7 lacked complete addresses for the enrolling parent's home and work address.

Corrected Corrected by Aug 19, 2025

Category: recordkeeping. Marked corrected in the state record.

3270.124(b)(4)/3270.182(3) · Emergency contact information must include the written consent signed by a parent for emergency medical care. A child's record shall contain signed parental consent for emergency medical care for the child. Written consent is required prior to admission.

The emergency contact form on file for Child #3 and Child #6 lacked the enrolling parent's signature giving the facility written consent to obtain emergency medical care.

Corrected Corrected by Aug 19, 2025

Category: recordkeeping. 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.

The emergency contact form on file for Child #5 lacked the health insurance policy or medical assistance policy number.

Corrected Corrected by Aug 19, 2025

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

3270.124(b)(7) · 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 form on file for Child #1 and Child #7 lacked complete addresses for all release persons.

Corrected Corrected by Aug 19, 2025

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.

The file for Child #2 contained an emergency contact form that was reviewed and updated by the parent dated 9/4/24 & 4/4/25, more than 6 months apart.

Corrected Corrected by Jul 31, 2025

Category: recordkeeping. Marked corrected in the state record.

3270.131(b)(2)/3270.182(1) · The operator shall require the parent to provide an updated health report at least every 12 months for an older toddler or preschool child. A child's record shall contain initial and subsequent health reports.

The two most recent health assessments on file for Child #1 (Preschool Age) are dated 3/14/24 and 4/4/25, more than 12 months apart.

Corrected Corrected by Jul 31, 2025

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

3270.131(d)(5)/3270.131(e)(3) · A health report shall include a review of the child's immunized status according to recommendations of the ACIP. The facility shall implement dismissal policies in accordance with the Department of Health regulation in 28 Pa. Code § 27.77 (relating to immunization requirements for children in child care group settings).

The immunization record for Child #4 (PSA) lacked the following immunizations: 2 doses of Rotavirus and 1 dose of Pneumococcal without a Letter of Exemption in the file. Child #4 must be dismissed from care by close of business on 7/16/25 and may only return to care when the immunization record is updated or when a parent provides a written, signed exemption letter.

Corrected Corrected by Jul 21, 2025

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 health assessment on file for Child #2 dated 9/24/24 does not indicate if the child is free from contagious disease and may participate in child care.

Corrected Corrected by Jul 21, 2025

Category: health medication. 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 files for Staff #3, Staff #4, Staff #5, Staff #8, Staff #9, and Staff #11 lacked two written nonfamily reference letters.

Corrected Corrected by Aug 19, 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 #3 contained an immunization record dated 1/17/25, more than 60 days beyond enrollment (SEE IS CODE SHEET). The file for Child #6, enrolled more than 60 days, lacked an immunization record or letter of exemption from the parent (See LIS Code Sheet). Child #6 must be dismissed from care by close of business on 7/16/25 and may only return to care when the immunization record is provided or when a parent provides a written, signed exemption letter.

Corrected Corrected by Jul 31, 2025

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

3270.151(a)/3270.192(3) · 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. A facility person's record shall include a written report of initial and subsequent health assessments, including the results of initial and subsequent tuberculin skin tests, x-rays or other medical documentation necessary to confirm freedom from communicable tuberculosis.

The most recent health assessment on file for Staff #12 (5/5/23) and Staff #6 (4/26/23) are dated more than 24 months prior. The two most recent health assessments on file for Staff #14 (1/4/23 & 3/3/25) and Staff #11 (7/16/21 & 1/28/24) are dated more than 24 months apart.

Corrected Corrected by Jul 31, 2025

Category: ratio. Marked corrected in the state record.

3270.161(d) · Potentially hazardous food brought from the child's home or provided by the facility shall be refrigerated.

In the Imagineers Room, a child's lunchbox containing potentially hazardous food from home was observed on a table and not refrigerated.

Corrected Corrected by Jul 17, 2025

Category: nutrition. Marked corrected in the state record.

3270.181(c) · 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 file for Child #3 contained a financial agreement form that was reviewed and updated by the parent dated 10/10/24 & 5/5/25, more than 6 months apart.

Corrected Corrected by Jul 31, 2025

Category: recordkeeping. Marked corrected in the state record.

3270.182(5) · A child's record shall contain signed parental consent for administration of minor first-aid procedures by facility staff. Written consent is required prior to admission.

The emergency contact form on file for Child #3 and Child #6 lacked the enrolling parent's signature giving the facility written consent to administer minor first aid.

Corrected Corrected by Aug 19, 2025

Category: ratio. Marked corrected in the state record.

3270.27(a)(6) · Emergency drills shall be conducted annually. Annual emergency drills shall be documented and on file at the facility.

The two most recent emergency drills are dated 2/20/24 and 6/5/25, more than 12 months apart.

Corrected Corrected by Aug 19, 2025

Category: recordkeeping. Marked corrected in the state record.

3270.131(a)/3270.131(e) · 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 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 #6, enrolled more than 60 days, lacked an initial health report (See LIS Code Sheet).

Corrected Corrected by Jul 31, 2025

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

3270.131(a)/3270.182(1) · 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. A child's record shall contain initial and subsequent health reports.

The file for Child #3 contained an initial health assessment dated 1/17/25, more than 60 days beyond enrollment (SEE IS CODE SHEET).

Corrected Corrected by Jul 31, 2025

Category: health medication. 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.

Staff #1 was observed to be caring for children unsupervised. Staff #1 has not completed mandated reporter training within the last 60 months. This is evidenced by the previously documented mandated reporter training on file being dated 6/17/20.

Corrected Corrected by Jun 26, 2025

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 #3 and Staff #4 did not complete the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Pediatric First Aid/CPR training. Staff #3 completed the training on 6/5/25. Staff #4 completed the training on 6/15/25.

Corrected Corrected by Jun 15, 2025

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

3270.32(a)/3270.192(2)(iii) · The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

The two most recent mandated reporter trainings on file for Staff #5 (4/17/20 & 6/13/25), Staff #6 (4/30/20 & 6/5/25), and Staff #7 (4/30/20 & 6/14/25) are dated more than 60 months apart.

Corrected Corrected by Jun 26, 2025

Category: recordkeeping. Marked corrected in the state record.

3270.32(a) · The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Until such time as the required training has been completed, Staff #1 and Staff #2 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 #1 and Staff #2, Staff #1 and Staff #2 may not work in a child-care position at the facility.

Staff #1 and Staff #2 have not completed mandated reporter training within the last 60 months. This is evidenced by the previously documented mandated reporter training on file being dated: Staff 1: 6/17/20 & Staff #2: 4/7/20.

Corrected Corrected by Jun 26, 2025

Category: supervision. Marked corrected in the state record.

3270.95(a)/3270.95(b) · Fire detection devices or systems must be in compliance with standards established under section 1016(c) of the act (62 P.S. §  1016(c)). The Director or designated staff person who is responsible for compliance with this chapter shall ensure the requirements under subsection (a) are met.

The fire alarm 30-day test log includes test dates 12/17/24-1/28/25, 4/2/25-5/12/25 and 5/12/25-6/24/25, more than 30 days apart.

Corrected Corrected by Jun 26, 2025

Category: recordkeeping. Marked corrected in the state record.

3270.51 · When children are grouped in similar age levels, the following maximum child group sizes and ratios of staff persons apply: Infants 1:4 with a maximum group size of 8; Young toddlers 1:5 with a maximum group size of 10; Older toddlers 1:6 with a maximum group size of 12; Preschool children 1:10 with a maximum group size of 20; Young school-age children 1:12 with a maximum group size of 24; Older school-age children 1:15 with a maximum group size of 30. IF USING TIERED LIS: The required staff:child ratios must be maintained at all times. The legal entity must submit documentation in a format approved by DHS proving that the facility is maintaining the required staff:child ratios at all times. The legal entity will confirm continuing compliance by sending copies of the documentation to the -------- Region Office on a weekly basis for a period of three months after DHS approves the documentation format.

Based on the self-reported noncompliance and staff interviews, Child #1 was left along in the Gym for approximately 2 minutes on 12/20/24 between 8:25 AM - 8:30 AM before bus dismissal while Staff #1 and Staff #2 were outside waiting for the buses with the rest of the supervision group.

Corrected Corrected by May 16, 2025

Category: supervision. Marked corrected in the state record.

3270.113(a) · Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Outdoor play space used by the facility is considered part of the facility premises.

Based on the self-reported noncompliance and staff interviews, Child #1 was left along in the Gym for approximately 2 minutes on 12/20/24 between 8:25 AM - 8:30 AM before bus dismissal while Staff #1 and Staff #2 were outside waiting for the buses with the rest of the supervision group.

Corrected Corrected by Feb 17, 2025

Category: supervision. Marked corrected in the state record.

3270.113(a) · *The legal entity must arrange for all facility staff to receive a minimum of two hours of training regarding supervision of children. The legal entity must receive DHS approval of the training content prior to scheduling the training.

Based on the self-reported noncompliance and staff interviews, Child #1 was left along in the Gym for approximately 2 minutes on 12/20/24 between 8:25 AM - 8:30 AM before bus dismissal while Staff #1 and Staff #2 were outside waiting for the buses with the rest of the supervision group.

Corrected Corrected by Mar 17, 2025

Category: supervision. Marked corrected in the state record.

3270.113(a)(1) · Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises.

Based on the self-reported noncompliance and staff interviews, Child #1 was left along in the Gym for approximately 2 minutes on 12/20/24 between 8:25 AM - 8:30 AM before bus dismissal while Staff #1 and Staff #2 were outside waiting for the buses with the rest of the supervision group.

Corrected Corrected by Feb 28, 2025

Category: supervision. Marked corrected in the state record.

3270.20(a)(1) · The operator shall immediately notify a child's parent and shall telephone notice to the appropriate regional office within 24 hours if a child in care at the facility is hospitalized or receives emergency room treatment.

Based on staff statements, on 10/11/24, child #1 was receiving care and bumped their head against a wall in the restroom and resulted in receiving emergency room treatment sometime between 10/11/24 to 10/13/24. The regional office was notified on 10/22/24 but was not within 24 hours of receiving treatment.

Corrected Corrected by Dec 20, 2024

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

3270.113(a) · Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Outdoor play space used by the facility is considered part of the facility premises.

Based on staff statements, on 10/11/24 at approximately 11:45am, child #1 bumped their head against a wall in the boy's restroom which resulted in a mild concussion. Staff person #1 was assisting another child with handwashing and did not observe child #1 bump their head due to staff person #1 was unable to see and properly supervise their group of assigned children on the other side of the restroom.

Corrected Corrected by Dec 23, 2024

Category: supervision. Marked corrected in the state record.

3270.182(7) · A child's record shall contain reports of accidents, injuries and illnesses involving a child in care at the facility. The original report shall be given to the parent on the day of the incident. The second copy of the report shall be retained at the facility in an accident file. The third copy of the report shall be retained at the facility in the child's file.

An incident report on file for child #1 who bumped their head that resulted in a mild concussion on 10/11/24 was completed and dated 10/14/24 and was not given to the parent on the day of the incident.

Corrected Corrected by Dec 23, 2024

Category: health medication. 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 #2 and Staff #17 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 #2 and Staff #17, Staff #2 and Staff #17 may not work in a child-care position at the facility.

Staff #2 and Staff #17 were observed to be caring for children unsupervised. Staff #2 and Staff #17 have not completed the following pre-service training required prior to caring for children unsupervised: Pediatric First Aid/CPR

Corrected Corrected by Aug 2, 2024

Category: supervision. 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 two most recent fire safety trainings on file for Staff #3 (3/31/22 and 7/3/24), Staff #4 (dated 6/22/22 and 7/14/24), Staff #5 (dated 6/24/23 & 7/7/24), are more than 1 year apart.

Corrected Corrected by Jul 25, 2024

Category: recordkeeping. 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.

The file for Staff #8 did not complete the following pre-service training within 90 days of hire (SEE IS CODE SHEET): Pediatric First Aid/CPR. The training was completed on 6/6/24.

Corrected Corrected by Jul 25, 2024

Category: health medication. 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 Facility Person #11 (dated 6/13/23) Facility Person #14 (dated 7/16/24), and Facility Person #15 (dated 6/20/24) contained a Child Abuse clearance beyond their date of hire (SEE IS CODE SHEET). The file for Facility Person #14 lacked documentation of application of an NSOR certificate prior to date of hire required for provisional hiring under the CPSL (See IS CODE SHEET). The NSOR request for Facility Person #14 was dated 7/11/24.

Corrected Corrected by Jul 25, 2024

Category: background checks. 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 two most recent Mandated Reporter trainings on file for Staff #4 are dated 1/25/18 and 7/8/24, more than 60 months apart. The disclosure statement on file for Staff #7 lacked a witness signature. The disclosure statement on file for Facility Person #15 was dated 7/23/24, which is beyond their date of hire (SEE IS CODE SHEET). Facility Person #10, Facility Person #11, Facility Person #12, and Facility Person #13 have not completed the Mandated Reporter training within 90 days of their date of hire (SEE IS CODE SHEET).

Corrected Corrected by Sep 18, 2024

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

3270.66(b) · Cleaning materials and other toxic materials shall be stored in an original labeled container or in a container that specifies the content. Toxics shall be stored away from food, food preparation areas and child care spaces.

A unlabeled spray bottle containing cleaning materials was observed in the Imagineers Room.

Corrected Corrected by Jul 18, 2024

Category: ratio. Marked corrected in the state record.

3270.75(b) · A first-aid kit must be inaccessible to children.

The first aid kit in the Adventurers Room was accessible to children.

Corrected Corrected by Jul 18, 2024

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

3270.102(a) · Toys, play equipment and other indoor and outdoor equipment used by the children shall be clean, in good repair and free from rough edges, sharp corners, pinch and crush points, splinters and exposed bolts.

Magnatiles with broken plastic pieces were observed in the Dreamers classroom.

Corrected Corrected by Jul 18, 2024

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

3270.107 · A facility shall have an operable, clean refrigerator used to store potentially hazardous foods. The refrigerator shall be capable of maintaining food at 45° F or below. An operating thermometer shall be placed in the refrigerator.

Refrigerators in the Imagineers, Steelers, and Panthers classrooms lacked a thermometer.

Corrected Corrected by Jul 19, 2024

Category: nutrition. Marked corrected in the state record.

3270.123(a)(1) · An agreement shall specify the amount of the fee to be charged per day or per week.

The Financial Agreement form on file for Child #3 lacked amount of the fee to be paid by the parent/guardian.

Corrected Corrected by Sep 18, 2024

Category: recordkeeping. Marked corrected in the state record.

3270.123(a)(2) · An agreement shall specify the date on which the fee is to be paid.

The Financial Agreement form on file for Child #3 lacked the date the fee is to be paid by the parent/guardian.

Corrected Corrected by Sep 18, 2024

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).

The two most recent Child Service Reports on file for Child #1 are dated 10/26/23 and 5/31/24, more than 6 months apart.

Corrected Corrected by Jul 26, 2024

Category: recordkeeping. Marked corrected in the state record.

3270.123(a)(4) · An agreement shall specify the child's arrival and departure times.

The Financial Agreement form on file for Child #1 lacked the child's arrival and departure times.

Corrected Corrected by Sep 18, 2024

Category: recordkeeping. Marked corrected in the state record.

3270.123(b)/3270.182(8) · A parent shall receive the original agreement. The facility shall retain a copy of the agreement. A child's record shall contain a copy of the initial agreement and subsequent written agreements between the parent and the operator. The parent receives the original agreement.

The Financial Agreement forms for Child #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10 were the original and not a copy.

Corrected Corrected by Jul 25, 2024

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.

The Emergency Contact form for Child #1 lacked the address of physician or medical care. The Emergency Contact form for Child #5 lacked the phone number of physician or medical care.

Corrected Corrected by Sep 18, 2024

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

3270.124(b)(4)/3270.182(3) · Emergency contact information must include the written consent signed by a parent for emergency medical care. A child's record shall contain signed parental consent for emergency medical care for the child. Written consent is required prior to admission.

The Emergency Contact form for Child #9 lacked written parental consent for the facility to obtain emergency medical care.

Corrected Corrected by Sep 18, 2024

Category: recordkeeping. 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.

The Emergency Contact form for Child #1 and Child #9 lacked the health insurance coverage and policy number.

Corrected Corrected by Sep 18, 2024

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

3270.124(b)(7) · 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 form for Child #2, Child #5, and Child #7 lacked complete addresses for all listed release persons. The Emergency Contact form for Child #9 lacked a telephone number for all listed release persons.

Corrected Corrected by Sep 18, 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.

The file for Child #1 contained parental reviews for the Emergency Contact form dated 3/31/23 and 10/1/23, more than 6 months apart. The most recent 6 month review signature for the Emergency Contact form on file for Child #7 is dated 7/12/24, more than 6 months after the previous 6 month review signature.

Corrected Corrected by Sep 18, 2024

Category: recordkeeping. 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 files for Staff #1 and Staff #16 only includes 1 written nonfamily reference letter. The files for Facility Person #13 and Facility Person #14 lacked 2 written nonfamily reference letters.

Corrected Corrected by Sep 18, 2024

Category: recordkeeping. Marked corrected in the state record.

3270.131(d)(5)/3270.131(e)(3) · A health report shall include a review of the child's immunized status according to recommendations of the ACIP. The facility shall implement dismissal policies in accordance with the Department of Health regulation in 28 Pa. Code § 27.77 (relating to immunization requirements for children in child care group settings).

The file for Child #1 lacked documentation of written immunization record without a letter of exemption from the parent. Child #1 must be dismissed from care by close of business on 7/18/24, and may only return to care when the immunization record is updated or when a parent provides a written, signed exemption letter.

Corrected Corrected by Sep 18, 2024

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

3270.151(a)/3270.192(3) · 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. A facility person's record shall include a written report of initial and subsequent health assessments, including the results of initial and subsequent tuberculin skin tests, x-rays or other medical documentation necessary to confirm freedom from communicable tuberculosis.

The most recent health assessment for Staff #4 (dated 3/21/21) and Facility Person #10 (dated 8/11/21), more than 24 months prior. The two most recent health assessments on file for Staff #6 (dated 10/26/20 and 1/4/23) and Staff #9 (dated 2/18/22 & 7/2/24), are more than 24 months apart. The file for Facility Person #11 lacked a valid staff health assessment.

Corrected Corrected by Sep 18, 2024

Category: ratio. Marked corrected in the state record.

3270.151(c)(2)/3270.192(3) · An adult health assessment must include tuberculosis screening by the Mantoux method at initial employment. Subsequent tuberculosis screening is not required unless directed by a physician, physician's assistant, CRNP, the Department of Health or a local health department. A facility person's record shall include a written report of initial and subsequent health assessments, including the results of initial and subsequent tuberculin skin tests, x-rays or other medical documentation necessary to confirm freedom from communicable tuberculosis.

The file for Facility Person #14 lacked documentation of a Tuberculosis test result being completed within 12 months prior to date of hire (See LIS CODE SHEET). The Tuberculosis test result on file for Staff #14 dated 6/9/23.

Corrected Corrected by Aug 29, 2024

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

3270.181(c) · 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 two most recent 6 month review signatures for the Financial Agreement form on file for Child #1 are dated 8/30/23 and 3/5/24, more than 6 months apart. The most recent review and update by the parent on the Financial Agreement forms for Child #3 (8/23/23) and Child #7 (8/23/23) are dated more than 6 months prior.

Corrected Corrected by Sep 18, 2024

Category: recordkeeping. Marked corrected in the state record.

3270.182(5) · A child's record shall contain signed parental consent for administration of minor first-aid procedures by facility staff. Written consent is required prior to admission.

The Emergency Contact form for Child #4 lacked written parental permission for the facility to administer minor first aid procedures.

Corrected Corrected by Sep 18, 2024

Category: ratio. Marked corrected in the state record.

3270.94(a)(4) · The Director or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that the hypothetical locations of the fire are rotated around the facility for each drill such that the hypothetical location is never the same for consecutive drills.

The facility's fire drill log contained consecutive hypothetical locations of the fire for drills conducted on 10/31/23 and 11/17/23.

Corrected Corrected by Jul 18, 2024

Category: recordkeeping. Marked corrected in the state record.

3270.95(a)/3270.95(b) · Fire detection devices or systems must be in compliance with standards established under section 1016(c) of the act (62 P.S. §  1016(c)). The Director or designated staff person who is responsible for compliance with this chapter shall ensure the requirements under subsection (a) are met.

The two most recent annual fire tests conducted by a fire professional are dated 6/20/23 and 7/5/24, more than 12 months apart.

Corrected Corrected by Jul 25, 2024

Category: recordkeeping. Marked corrected in the state record.

3270.27(f) · The operator shall send a copy of the emergency plan and subsequent plan updates to the local municipality and to the county emergency management agency.

The facility lacked documentation of the Emergency Plan and subsequent plan updates being sent to the local municipality and County Emergency Management Services.

Corrected Corrected by Jul 25, 2024

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

3270.31(e) · A staff person shall obtain an annual minimum of 12 clock hours of child care training.

The file for Staff #4 lacked a minimum of 12 hours of childcare training.

Corrected Corrected by Jul 25, 2024

Category: recordkeeping. 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.

The file for staff #1 contains health and safety update training that was completed late. The training was due 12/2022 and completed 1/2023.

Corrected Corrected by Oct 3, 2023

Category: health medication. 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). Facility Person # 3 may not work in a child care position at the facility until a valid NSOR is on file. 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 #3 lacks an NSOR clearance. Staff #3 was properly provisionally hired however never received the NSOR clearance after requesting it 2 separate times.

Corrected Corrected by Oct 3, 2023

Category: background checks. 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 #2 shows an improper provisional hire. Staff #2 did not have a complete child abuse clearance on file at the time of the provisional hire. The child abuse clearance was due 6/22/23 and obtained 7/21/23. All clearances on file for staff #2 are valid now.

Corrected Corrected by Oct 3, 2023

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

3270.131(a)(3)/3270.182(1) · The initial health report for an older toddler or preschool child shall be dated no more than 1 year prior to the first day of attendance at the facility. A child's record shall contain initial and subsequent health reports.

The file for child #2 contains an initial health assessment that was obtained late. The facility had a medical summary dated 4/2022 on file that appeared to be a health assessment but wasn't. The health assessment was due 11/9/22 and was obtained 2/2023.

Corrected Corrected by Oct 3, 2023

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

3270.131(a)(3)/3270.182(1) · The initial health report for an older toddler or preschool child shall be dated no more than 1 year prior to the first day of attendance at the facility. A child's record shall contain initial and subsequent health reports.

The file for child #1 contains a health assessment that appears to be age appropriate however, it is not dated.

Corrected Corrected by Oct 3, 2023

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

3270.31(f) · Staff persons shall complete professional development within 90 days of hire as listed in subsections ( 3270.31(f)(1 -- 10)within 90 days of hire. Staff person #1 will have until 10/12/22 to complete the required training. Until such time as the required training has been completed, staff person #1 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 #1, staff person #1 may not work in a child-care position at the facility.

Staff person # 1has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): pediatric first aid and cpr.

Corrected Corrected by Oct 7, 2022

Category: supervision. Marked corrected in the state record.

3270.31(f) · Staff person(s) shall complete professional development in the topics of 3270.31(f) within 90 days of hire.

Staff person #2 had not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): general health and safety training.

Corrected Corrected by Sep 27, 2022

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

3270.151(a)/3270.192(3) · 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.A facility person's record shall include a written report of initial and subsequent health assessments, including the results of initial and subsequent tuberculin skin tests, x-rays or other medical documentation necessary to confirm freedom from communicable tuberculosis.

The file for staff #3 contains a health assessment that was renewed late (beyond 24 months).

Corrected Corrected by Sep 22, 2022

Category: ratio. Marked corrected in the state record.

3270.77(a) · Peeled or damaged paint or damaged plaster is not permitted on indoor or outdoor surfaces in the child care facility.

There was peeling paint on the picnic table in the facility's outdoor garden space.

Corrected Corrected by Sep 30, 2021

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

3270.21 · Conditions at the facility may not pose a threat to the health or safety of the children.

There was approximately an inch of brown dirty water observed in a plastic sand/water table in the facility's outdoor grassy area.

Corrected Corrected by Sep 30, 2021

Category: health medication. 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 emergency plan training in the file for staff person #2, #3 and #8 was dated beyond the staff person's initial employment. There was not verification of emergency plan training in the file for staff person #7, who was beyond their initial employment.The file for facility person #9, #10 and #11, all beyond their initial employment did not include evidence of emergency plan training.

Corrected Corrected by Sep 30, 2021

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 last two fire safety trainings in the file for staff person #1, #4, #5 and #6 were dated more than 12 months apart.

Corrected Corrected by Aug 23, 2021

Category: recordkeeping. Marked corrected in the state record.

3270.31(f)/3270.31(f)(10) · Staff persons shall complete professional development in the following topics within 90 days of hire:Pediatric first aid and pediatric cardiopulmonary resuscitation.

The file for staff person #1, hired in 2015 did not include pediatric first-aid/CPR training by 6/17/21. The file for staff person #7 and #8, both employed after 12/31/20 and more than 90 days, did not include pediatric first-aid and CPR training.

Corrected Corrected by Sep 30, 2021

Category: health medication. 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 last two evaluations in the file for staff person #4, #5, #6 and #7 were dated more than 12 months apart.

Corrected Corrected by Aug 23, 2021

Category: recordkeeping. Marked corrected in the state record.

3270.35(b)(2)/3270.192(2)(ii) · A group supervisor shall have a bachelor's degree from an accredited college or university, including 30 credit hours in early childhood education, child development, special education, elementary education or the human services field and 1 year of experience with children.A facility person's record shall include verification of child care experience, education and training prior to service at the facility.

The file for staff person #2, holding the title of Group Supervisor, included a bachelor of arts degree and 30 credits in a human services field, but did not include evidence of 1250 hours of previous child care experience.

Corrected Corrected by Aug 23, 2021

Category: supervision. Marked corrected in the state record.

3270.66(a) · Cleaning materials and other toxic materials shall be kept in an area or container that is locked or made inaccessible to children.

There was a bottle of sunblock in a bookbag on a table in the Penguins room, making it accessible to children in care at the time. The directions included instructions to keep out of the reach of children.

Corrected Corrected by Aug 23, 2021

Marked corrected in the state record.

3270.66(c) · Cleaning materials and other toxic materials shall be used in a way that does not contaminate play surfaces, food, food preparation areas and does not constitute a hazard to the children.

There was a bottle of hand sanitizer sitting on a shelf between a bottle of ketchup and juice boxes and on the same shelf as utensils and cups.

Corrected Corrected by Aug 23, 2021

Category: ratio. Marked corrected in the state record.

3270.66(e) · Arts and crafts materials shall be nontoxic.

Based on conversation with staff, the 2 cans of shaving cream in the cabinet in the Steeler room was used for arts and crafts. The directions included instructions to keep out of the reach of children.

Corrected Corrected by Aug 23, 2021

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.

One of the plastic barrels that lines the bottom of the fence in the facility's outdoor garden space was cracked.

Corrected Corrected by Aug 23, 2021

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

3270.82(h) · A facility person and an able child shall wash his hands after toileting and before eating. A sign on which this requirement is written shall be posted at each toilet, training chair, diapering area and sink in the facility.

There was not a handwashing sign posted at the toilet in the handicap stall in the boys' bathroom. There was not a handwashing sign posted at the toilet in the middle staff in the girls' restroom.

Corrected Corrected by Sep 30, 2021

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 most recent emergency contact information in the file for child #1 did not include any work information for the child's mother.

Corrected Corrected by Sep 30, 2021

Category: recordkeeping. Marked corrected in the state record.

3270.124(b)(4)/3270.182(3) · Emergency contact information must include the written consent signed by a parent for emergency medical care. A child's record shall contain signed parental consent for emergency medical care for the child. Written consent is required prior to admission.

The most recent emergency contact information in the file for child #2 did not include signed parental consent for emergency medical care.

Corrected Corrected by Sep 30, 2021

Category: recordkeeping. Marked corrected in the state record.

3270.124(b)(7) · 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 in the file for child #1 did not include addresses for the individuals designated to whom the child may be released.

Corrected Corrected by Sep 30, 2021

Category: recordkeeping. Marked corrected in the state record.

3270.151(b) · A health assessment shall be conducted and a report shall be written and signed by a physician, physician's assistant or CRNP. The signature must include the individual's professional title.

The health assessment in the file for staff person #7 was signed by a DNP-FNP-C.

Corrected Corrected by Aug 23, 2021

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

3270.151(c)(2) · An adult health assessment must include tuberculosis screening by the Mantoux method at initial employment. Subsequent tuberculosis screening is not required unless directed by a physician, physician's assistant, CRNP, the Department of Health or a local health department.

The TB screening in the file for staff person #7 was dated more than 12 months before they started working with children.

Corrected Corrected by Aug 23, 2021

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

3270.182(5) · A child's record shall contain signed parental consent for administration of minor first-aid procedures by facility staff. Written consent is required prior to admission.

The most recent emergency contact information in the file for child #2 did not include signed parental consent for minor first-aid by staff.

Corrected Corrected by Sep 30, 2021

Category: ratio. Marked corrected in the state record.

3270.27(a)(1) · The facility shall have an emergency plan that provides for accommodations for shelter of children during an emergency including lock-down, shelter in place at the facility and shelter at locations away from the facility premises.

Based on review of the facility's emergency plan and on conversation with the director, the plan did not provide accommodations for shelter of children during a lock-down.

Corrected Corrected by Aug 23, 2021

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