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.

A used napkin and tissues were in a receptacle that did not have a lid.

Corrected Corrected by Apr 28, 2025

Category: ratio. 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 file for child #1 lacked emergency contact information that included written consent signed by a parent for emergency medical care prior to admission. The consent was initialed instead of being signed.

Corrected Corrected by Apr 25, 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 file for child #1 lacked signed parental consent for administration of minor first-aid procedures by facility staff prior to admission. The consent was initialed instead of being signed.

Corrected Corrected by Apr 25, 2025

Category: ratio. 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.

3RD CITATION: On 5-23-24, staff person #1, who was supervising a group of 10 school-age children, left the cafeteria with the group and went down the main hallway to the bathroom. One school-age child in the group was observed walking down from the left hallway and then joining the group of children down the main hallway as they arrived at the bathroom. The child was alone in the left hallway, and staff person #1 was not able to see the child and was not aware that the child was not with their group after the group left the cafeteria and walked to the bathroom, resulting in a 0:1 staff to child ratio. PREVIOUSLY CITED ON 2-28-24 and 3-12-24.

Corrected Corrected by Jun 3, 2024

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.

3RD CITATION: On 5-23-24 at approximately 3:15 p.m., staff person #1 answered the outside door to the cafeteria where parents enter the facility to pick up their children. There were 10 total school-age children in the cafeteria and when staff person #1 was talking to a parent at the door, the staff person could not see the children on the other side of the cafeteria for approximately 20-30 seconds. There were no other staff persons present in the room at the time. On 5-23-24, staff person #1, who was supervising a group of 10 school-age children, left the cafeteria with the group and went down the main hallway to the bathroom. One school-age child in the group was observed walking down from the left hallway and then joining the group of children down the main hallway as they arrived at the bathroom. The child was alone in the left hallway, and staff person #1 was not able to see the child and was not aware that the child was not with their group after the group left the cafeteria and walked to the bathroom. PREVIOUSLY CITED ON 2-28-24 and 3-12-24.

Corrected Corrected by Jun 3, 2024

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.

3RD CITATION: On 5-23-24, staff person #1, who was supervising a group of 10 school-age children, left the cafeteria with the group and went down the main hallway to the bathroom. One school-age child in the group was observed walking down from the left hallway and then joining the group of children down the main hallway as they arrived at the bathroom. The child was alone in the left hallway, and staff person #1 was not able to see the child and was not aware that the child was not with their group after the group left the cafeteria and walked to the bathroom. PREVIOUSLY CITED ON 2-28-24 and 3-12-24.

Corrected Corrected by Jun 3, 2024

Category: supervision. Marked corrected in the state record.

3270.25(a) · The facility's current certificate of compliance shall be posted in a conspicuous location used by parents. The operator shall provide the parent of each child enrolled with information on how to access the regulations in this chapter electronically and with instructions for contacting the appropriate regional child care office.

2ND CITATION: The facility's current certificate of compliance was not posted in a conspicuous location used by parents. PREVIOUSLY CITED ON 2-28-24.

Corrected Corrected by Aug 19, 2024

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.

2nd CITATION: PREVIOUSLY CITED ON 2/28/24. At approximately 3:12 PM, 3 young school-aged children were observed walking down the hallway to the bathroom alone without a staff person with them. Staff #1 stood in the cafeteria doorway watching the 3 children go down the hallway to the bathroom alone.

Corrected Corrected by Mar 12, 2024

Category: ratio. Marked corrected in the state record.

3270.51 · *The legal entity must have all staff, including the director, complete in-person training conducted by the ELRC #5 regarding ratio and supervision of children. Proof of attendance will be submitted to the Western Regional office.

2nd CITATION: PREVIOUSLY CITED ON 2/28/24. At approximately 3:12 PM, 3 young school-aged children were observed walking down the hallway to the bathroom alone without a staff person with them. Staff #1 stood in the cafeteria doorway watching the 3 children go down the hallway to the bathroom alone.

Corrected Corrected by May 8, 2024

Category: supervision. Marked corrected in the state record.

3270.52 · When children are grouped in mixed age levels, the age of the youngest child in the group determines the staff:child ratio and maximum group size in accordance with the requirements in § 3270.51 (relating to similar age level).

2nd CITATION PREVIOUSLY CITED ON 2/28/24. At 3:08 PM, 7 Older and Younger school-aged children were observed entering the cafeteria with no staff members present for approximately 1 minute, until Staff #1 entered the cafeteria.

Corrected Corrected by Mar 12, 2024

Category: ratio. Marked corrected in the state record.

3270.113(a) · *The legal entity will conduct mandatory staff meetings at least once per month for the remaining months of the program's operation and then one month when the program re-opens, following the approval of this plan of correction. At each staff meeting, time will be set aside to review and discuss the facility's previous regulatory non-compliance items documented on inspection summaries issued in the last year, as well as the Department of Human Services' regulations relating to ratio and supervision. An agenda will be prepared for each staff meeting and a log identifying the date, time and persons attending each meeting will be maintained. The staff meeting agendas and logs will be made available to OCDEL-DHS representatives upon request.

2nd CITATION. PREVIOUSLY CITED 2/28/24. At 3:08 PM, 7 Older and Younger school-aged children were observed entering the cafeteria with no staff members present for approximately 1 minute, until Staff #1 entered the cafeteria. At approximately 3:12 PM, 3 young school-aged children were observed walking down the hallway to the bathroom alone without a staff person with them. Staff #1 stood in the cafeteria doorway watching the 3 children go down the hallway to the bathroom alone.

Corrected Corrected by Sep 23, 2024

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.

2nd CITATION. PREVIOUSLY CITED 2/28/24. At 3:08 PM, 7 Older and Younger school-aged children were observed entering the cafeteria with no staff members present for approximately 1 minute, until Staff #1 entered the cafeteria. At approximately 3:12 PM, 3 young school-aged children were observed walking down the hallway to the bathroom alone without a staff person with them. Staff #1 stood in the cafeteria doorway watching the 3 children go down the hallway to the bathroom alone.

Corrected Corrected by Mar 12, 2024

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.

2nd CITATION. PREVIOUSLY CITED ON 2/28/24. At approximately 3:12 PM, 3 young school-aged children were observed walking down the hallway to the bathroom alone without a staff person with them. Staff #1 stood in the cafeteria doorway watching the 3 children go down the hallway to the bathroom alone. At 3:08 PM, 7 YSA children were observed entering the cafeteria with no staff members present for approximately 1 minute, until Staff #1 entered the cafeteria.

Corrected Corrected by Mar 12, 2024

Category: supervision. Marked corrected in the state record.

3270.113(a)(1) · *The legal entity shall develop and implement a tangible, identification system for each staff to identify the specific children in their supervisory group. All staff will utilize the identification method appropriately at all times while supervising children. The planned identification system must be submitted to the Regional Office for review and utilized by all staff for a minimum of 3 months after submission of the acceptable plan. Implementation should occur in the current school year and should resume when the program re-opens for the 2024-2025 School Year. Multiple unannounced inspections may be used to assess compliance.

2nd CITATION. PREVIOUSLY CITED ON 2/28/24. At approximately 3:12 PM, 3 young school-aged children were observed walking down the hallway to the bathroom alone without a staff person with them. Staff #1 stood in the cafeteria doorway watching the 3 children go down the hallway to the bathroom alone. At 3:08 PM, 7 YSA children were observed entering the cafeteria with no staff members present for approximately 1 minute, until Staff #1 entered the cafeteria.

Corrected Corrected by Sep 23, 2024

Category: supervision. Marked corrected in the state record.

3270.134(a) · A staff person shall ensure that a child's hands are washed before meals and snacks, after toileting and after being diapered.

The children were observed eating snack without washing their hands prior to eating.

Corrected Corrected by May 10, 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 person #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 person #2, staff person #2 may not work in a child-care position at the facility.

SECOND CITATION previously cited 12/11/23: Staff #2 was observed to be caring for children unsupervised. Staff person #2 has not completed the following pre-service trainings required prior to caring for children unsupervised: Pediatric first-aid/CPR training from a PQAS approved trainer and a PQAS approved curriculum.

Corrected Corrected by Apr 24, 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 file for staff person #1 had fire safety training that exceeded a year between trainings.

Open Not marked corrected in the state record

Category: recordkeeping. Open / not marked corrected.

3270.31(f) · Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10.

Staff person #2 completed the following required pre-service training on 3-8-24 that was over 90 days after their date of hire (see LIS code sheet): Pediatric first-aid/CPR training.

Corrected Corrected by Apr 2, 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. Staff Person #1, Staff Person #2, and Staff Person #3 may not work in a child care position at the facility.

* 2ND CITATION: Previously on 12-11-23, the file for staff person #2 lacked an NSOR verification certificate or verification of application for the NSOR verification certificate at their start date to be a provisional hire and required a current NSOR verification certificate. After 12-11-23, staff person #2 was not able to work in a child care position until the NSOR verification certificate was received. On 2-28-24, staff person #2 was observed in care with children and identified 5 school-age children in their group that they were supervising. Staff person #2 was previously removed from a child care position on 12-11-23 for not having an NSOR verification certificate on file. According to staff statements, staff person #2 continued to work as a staff person in a child care position at the facility after 12-11-23 until being removed from working in a child care position on 2-28-24 until the NSOR verification certificate was received. The file for staff person #1 had an FBI clearance dated 3-14-19 and lacked a current FBI clearance updated within the last 60 months. The file for staff person #3 had a Department of Education FBI clearance dated 8-31-22 and lacked a DHS FBI clearance at their start date and requires a current DHS FBI clearance. The file for staff person #3 had a child abuse clearance and an NSOR verification certificate that were dated after their start date. PREVIOUSLY CITED ON 12-11-23.

Corrected Corrected by May 6, 2024

Category: supervision. Marked corrected in the state record.

3270.25(a) · The facility's current certificate of compliance shall be posted in a conspicuous location used by parents. The operator shall provide the parent of each child enrolled with information on how to access the regulations in this chapter electronically and with instructions for contacting the appropriate regional child care office.

The facility's current certificate of compliance was not posted in a conspicuous location used by parents. The parent of each enrolled child was not provided with the phone number and instructions for contacting the Western regional child care office.

Corrected Corrected by Apr 3, 2024

Marked corrected in the state record.

3270.32(a)/3270.192(4) · The legal entity must develop and provide a method to ensure that all new hires meet the CPSL requirements in order to be employed as a facility person at the facility. This method will be submitted to the Western Regional office upon completion.

* * 2ND CITATION: Previously on 12-11-23, the file for staff person #2 lacked an NSOR verification certificate or verification of application for the NSOR verification certificate at their start date to be a provisional hire and required a current NSOR verification certificate. After 12-11-23, staff person #2 was not able to work in a child care position until the NSOR verification certificate was received. On 2-28-24, staff person #2 was observed in care with children and identified 5 school-age children in their group that they were supervising. Staff person #2 was previously removed from a child care position on 12-11-23 for not having an NSOR verification certificate on file. According to staff statements, staff person #2 continued to work as a staff person in a child care position at the facility after 12-11-23 until being removed from working in a child care position on 2-28-24 until the NSOR verification certificate was received. The file for staff person #1 had an FBI clearance dated 3-14-19 and lacked a current FBI clearance updated within the last 60 months. The file for staff person #3 had a Department of Education FBI clearance dated 8-31-22 and lacked a DHS FBI clearance at their start date and requires a current DHS FBI clearance. The file for staff person #3 had a child abuse clearance and an NSOR verification certificate that were dated after their start date. PREVIOUSLY CITED ON 12-11-23.

Corrected Corrected by May 6, 2024

Category: supervision. 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.

On 2-28-24 at approximately 4:16 p.m. in the cafeteria with a total of 10 children in care with staff person #1 and #2, an older school-age child was observed leaving the cafeteria to go to the bathroom located in the hallway and entered the hallway alone without a staff person present to supervise the child, resulting in a 0:1 staff to child ratio. The older school-age child was in the hallway for approximately 30 seconds before staff person #1 and #2 entered the hallway with the other 9 school-age children to supervise the child.

Corrected Corrected by May 8, 2024

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.

* On 2-28-24 at approximately 4:16 p.m. in the cafeteria with a total of 10 children in care with staff person #1 and #2, an older school-age child was observed leaving the cafeteria to go to the bathroom located in the hallway and entered the hallway alone without a staff person present to supervise the child. The older school-age child was in the hallway for approximately 30 seconds before staff person #1 and #2 entered the hallway with the other 9 school-age children to supervise the child.

Corrected Corrected by Apr 3, 2024

Category: supervision. Marked corrected in the state record.

3270.113(a) · The legal entity must have all staff, including the director, complete in-person training conducted by the ELRC #5 regarding ratio and supervision of children. Proof of attendance will be submitted to the Western Regional office.

* * On 2-28-24 at approximately 4:16 p.m. in the cafeteria with a total of 10 children in care with staff person #1 and #2, an older school-age child was observed leaving the cafeteria to go to the bathroom located in the hallway and entered the hallway alone without a staff person present to supervise the child. The older school-age child was in the hallway for approximately 30 seconds before staff person #1 and #2 entered the hallway with the other 9 school-age children to supervise the child.

Corrected Corrected by May 8, 2024

Category: supervision. Marked corrected in the state record.

3270.113(a) · The facility director will participate in a minimum of two on-site visits with a representative of the ELRC #5 for technical assistance during program hours for program observation and suggestions for improvement regarding environmental/space designs/scheduling concerns that would affect compliance with the regulations regarding supervision/ratio. Proof of participation in two sessions will be submitted to the Western Regional office.

* * * On 2-28-24 at approximately 4:16 p.m. in the cafeteria with a total of 10 children in care with staff person #1 and #2, an older school-age child was observed leaving the cafeteria to go to the bathroom located in the hallway and entered the hallway alone without a staff person present to supervise the child. The older school-age child was in the hallway for approximately 30 seconds before staff person #1 and #2 entered the hallway with the other 9 school-age children to supervise the child.

Corrected Corrected by May 11, 2024

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.

On 2-28-24 at approximately 4:16 p.m. in the cafeteria with a total of 10 children in care with staff person #1 and #2, an older school-age child was observed leaving the cafeteria to go to the bathroom located in the hallway and entered the hallway alone without a staff person present to supervise the child. The older school-age child was in the hallway for approximately 30 seconds before staff person #1 and #2 entered the hallway with the other 9 school-age children to supervise the child.

Corrected Corrected by Apr 3, 2024

Category: supervision. 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 file for child #3 had an agreement that lacked the date on which the fee is to be paid.

Corrected Corrected by Apr 3, 2024

Category: recordkeeping. Marked corrected in the state record.

3270.123(a)(6) · An agreement shall specify the date of the child's admission.

The file for child #2 had an agreement that lacked the child's admission date.

Corrected Corrected by Apr 3, 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 file for child #2 had an emergency contact form that lacked the name of the child's physician. The file for child #3 had an emergency contact form that lacked the address and telephone number of the child's physician.

Corrected Corrected by Apr 3, 2024

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.

The file for child #1 had an emergency contact form that lacked the name of the health insurance and the policy number. The file for child #3 had an emergency contact form that lacked the name of the health insurance.

Corrected Corrected by May 20, 2024

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 #1 lacked a current health assessment updated within the last 24 months. The file for staff person #3 had an initial health assessment that was dated after the staff person provided initial service in a child care setting at the facility.

Corrected Corrected by May 20, 2024

Category: ratio. 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 file for staff person #3 had a tuberculosis screening by the Mantoux method that was dated after initial employment at the facility.

Corrected Corrected by May 20, 2024

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

3270.182(3)/3270.182(5) · A child's record shall contain signed parental consent for emergency medical care for the child. Written consent is required prior to admission. 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 file for child #3 had an emergency contact form that lacked signed parental consent for emergency medical care for the child and signed parental consent for administration of minor first-aid procedures by facility staff.

Corrected Corrected by Apr 3, 2024

Category: ratio. Marked corrected in the state record.

3270.52 · When children are grouped in mixed age levels, the age of the youngest child in the group determines the staff:child ratio and maximum group size in accordance with the requirements in § 3270.51 (relating to similar age level).

On 12-11-23 at approximately 3:13 p.m., staff person #1 was observed supervising a total of 17 school-age children, including 14 young school-age children and 3 older school-age children, resulting in staff person #1 being out of ratio.

Corrected Corrected by Dec 11, 2023

Category: supervision. Marked corrected in the state record.

3270.54(a) · At least two facility persons shall be present in the facility when two or more children are in care. At a minimum, one of the facility persons shall be a staff person.

According to staff statements, there was one staff person present at the facility with multiple children in care without a second staff person/facility person present. This occurred on multiple occasions at least 2-3 times weekly from September to November 2023.

Corrected Corrected by Feb 18, 2024

Category: recordkeeping. 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 #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 person #2, staff person #2 may not work in a child-care position at the facility.

Staff person #2 was observed to be caring for children unsupervised. Staff person #2 has not completed the following pre-service trainings required prior to caring for children unsupervised: Pediatric first-aid/CPR training from a PQAS approved trainer and a PQAS approved curriculum, Health and Safety Training in the topics of 3270.31(f)(1-9).

Corrected Corrected by Feb 18, 2024

Category: supervision. Marked corrected in the state record.

3270.31(e)(4)(i) · Competence is the completion of training by a professional in the field of first-aid and cardiopulmonary resuscitation (CPR). All staff persons shall renew their certification in pediatric first aid and pediatric cardiopulmonary resuscitation (CPR) on or before the expiration of the most current certification.

The file for staff person #1 had current pediatric first-aid and CPR training with a completion date of 7-3-23 that was after the May 2023 expiration of the prior training.

Corrected Corrected by Feb 18, 2024

Category: ratio. 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. Staff Person #2 may not work in a child care position at the facility.

The file for staff person #2 lacked a disclosure statement and lacked an NSOR verification certificate or verification of application for the NSOR verification certificate at their start date to be a provisional hire and requires a current NSOR verification certificate.

Corrected Corrected by Feb 18, 2024

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

3270.33(a)/3270.192(2)(ii) · A staff person or a substitute staff person shall meet one of the applicable staff qualifications for the position in which the person is performing. 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, functioning as a staff person, lacked verification of education/experience to qualify as a staff person.

Corrected Corrected by Feb 18, 2024

Category: recordkeeping. 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 lacked a health assessment prior to providing initial service in a child care setting at the facility and requires a current health assessment.

Corrected Corrected by Feb 18, 2024

Category: ratio. 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 file for staff person #2 lacked a tuberculosis screening by the Mantoux method at initial employment and requires a current tuberculosis screening by the Mantoux method.

Corrected Corrected by Feb 18, 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.

Staff person #1, with a start date prior to 10-4-22, had the Pennsylvania Health and Safety Update 2022 Training dated 2-15-23 that was not completed by 12-30-22 as required. (See LIS CODE SHEET)

Corrected Corrected by Mar 7, 2023

Category: ratio. Marked corrected in the state record.

3270.18(a) · The legal entity shall have comprehensive general liability insurance to cover the persons who are on the premises. A current copy of the insurance policy shall be on file at the facility.

The facility had an insurance policy that lacked documentation of having comprehensive general liability insurance to cover the persons who are on the premises.

Corrected Corrected by Mar 7, 2023

Category: recordkeeping. 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 file for staff person #2 had emergency plan training that exceeded a year between trainings.

Corrected Corrected by Mar 10, 2023

Category: recordkeeping. Marked corrected in the state record.

3270.31(f) · Staff person(s) shall complete professional development in the topics of 3270.31(f)(1-10) within 90 days of hire. Staff person #2 will have until 3-16-23 to complete the required training. Until such time as the required training has been completed, staff person #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 available to supervise staff person #2, staff person #2 may not work in a child-care position at the facility.

Staff person #2 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Approved Health and Safety Training in the topics of 3270.31(f)(1-9).

Corrected Corrected by Mar 16, 2023

Category: supervision. 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 file for child #2 had an emergency contact form that lacked the name of the health insurance and the policy number.

Corrected Corrected by Mar 10, 2023

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 files for child #2 and #3 had an emergency contact form that lacked the address of the individual designated by the parent to whom the child may be released.

Corrected Corrected by Mar 10, 2023

Category: recordkeeping. Marked corrected in the state record.

3270.131(d)(5) · A health report shall include a review of the child's immunized status according to recommendations of the ACIP.

The file for child #1, a school-age child, lacked an immunization record.

Corrected Corrected by Mar 10, 2023

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 file for child #3 had an emergency contact form that lacked signed parental consent for administration of minor first-aid procedures by facility staff.

Corrected Corrected by Mar 20, 2023

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 facility lacked documentation on file of an emergency drill being conducted within the last year.

Corrected Corrected by Mar 27, 2023

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 operator lacked documentation of sending a copy of the updated emergency plan to the local municipality and to the county emergency management agency.

Corrected Corrected by Mar 10, 2023

Category: physical safety. 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 #1, a school-age child, lacked an initial health assessment within 60 days of the child's first day of attendance at the facility and requires a current health assessment.

Corrected Corrected by Mar 10, 2023

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

3270.31(e)(4)(i) · Competence is the completion of training by a professional in the field of first-aid and cardiopulmonary resuscitation (CPR). All staff persons shall renew their certification in pediatric first aid and pediatric cardiopulmonary resuscitation (CPR) on or before the expiration of the most current certification.

The file for staff #1 has a current pediatric first-aid and pediatric CPR certification dated 10/22/21-10/22/23. The certification was not renewed prior to the expiration of the previous certification dated 5/12/19-5/12/21.

Corrected Corrected by Feb 25, 2022

Category: ratio. Marked corrected in the state record.

3270.123(a)(6)/3270.182(2) · An agreement shall specify the date of the child's admission.A child's record shall contain the dates of application, admission and withdrawal of the child.

The files for child # 4 and 5 lacked the date of admission on the agreement form.

Corrected Corrected by Feb 25, 2022

Category: recordkeeping. 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 file for child # 5 lacked the work address of the enrolling parent on the emergency contact form.

Corrected Corrected by Feb 25, 2022

Category: recordkeeping. Marked corrected in the state record.

3270.124(b)(5) · Emergency contact information must include information on the child's special needs, as specified by the child's parent, physician, physician's assistant or CRNP, which is needed in an emergency situation.

The file for child # 2 lacked the information on the child's special needs, on the disabilities information on the emergency contact form.

Corrected Corrected by Feb 25, 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.

The file for child # 3 lacked the child's health insurance coverage and policy number on the emergency contact form.

Corrected Corrected by Feb 25, 2022

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 files for child #2, 3 and 4 lacked the address of the individual designated by the parent to whom the child may be released on the emergency contact form.

Corrected Corrected by Feb 25, 2022

Category: recordkeeping. Marked corrected in the state record.

3270.131(a)(4) · The initial health report for a school-age child must be dated in accordance with the requirements for medical examinations for school attendance in 28 Pa. Code § 23.2 (relating to medical examinations).

The files for child # 1,4 and 5 lacked the initial health report for a school -age.

Corrected Corrected by Feb 25, 2022

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 #1 contained a current health assessment dated 1/15/22. It was not obtained within 24 months of the previous assessment dated 5/15/19.

Corrected Corrected by Feb 25, 2022

Category: ratio. Marked corrected in the state record.