Everbrook Academy

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.

On 3.3.26, a child in care at the facility received emergency room treatment, but the regional office was not notified until 3.12.26, which was beyond the required 24 hours.

Corrected by Mar 18, 2026

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3270.20(b) · The operator shall mail or deliver a written report to the appropriate regional office within 72 hours after hospitalization of a child in care, emergency room treatment of a child in care, death of a child in care, a facility fire requiring the services of a fire department.

On 3.3.26, a child in care at the facility received emergency room treatment, but a written report was not submitted to the regional office until 3.13.26, which was beyond the required 72 hours.

Corrected by Mar 18, 2026

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3270.31(e)(4)(i)/3270.192(2)(iii) · 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. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

The file for Staff #10 contained documentation of Pediatric First-Aid/CPR which expired on 10.3.25, and it was not renewed until 11.17.25. The file for Staff #11 contained documentation of Pediatric First-Aid/CPR which expired on 10.3.25, and it was not renewed until 11.17.25. The file for Staff #12 contained documentation of Pediatric First-Aid/CPR which expired on 10.3.25, and it was not renewed until 11.17.25. The file for Staff #13 contained documentation of Pediatric First-Aid/CPR which expired on 10.3.25, and it was not renewed until 11.17.25. The file for Staff #18 contained documentation of Pediatric First-Aid/CPR which expired on 3.9.26, and it was not renewed. The file for Staff #21 contained documentation of Pediatric First-Aid/CPR which expired on 12.20.25, and it was not renewed until 2.3.26. The file for Staff #25 contained documentation of Pediatric First-Aid/CPR which expired on 6.21.25, and it was not renewed until 2.3.26. The file for Staff #27 contained documentation of Pediatric First-Aid/CPR which expired on 10.3.25, and it was not renewed until 2.3.26.

Corrected by Apr 27, 2026

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3270.31(e)(4)(ii)/3270.192(2)(iii) · Staff persons shall participate, at least annually, in fire safety 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. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

The file for Staff #11 contained documentation of Fire Safety Training on 11.20.25, but none in 2024. The file for Staff #15 contained documentation of Fire Safety Training on 6.13.24 and 7.22.25, which exceeded the annual requirement. The file for Staff #16 (see IS Code Sheet) contained documentation of Fire Safety Training on 7.24.26, which exceeded 1 year of hire. The file for Staff #17 contained documentation of Fire Safety Training on 12.6.24, but none in 2025. The file for Staff #21 contained documentation of Fire Safety Training on 1.2.25 and 2.3.26, which exceeded the annual requirement. The file for Staff #22 contained documentation of Fire Safety Training on 11.19.24 and 2.27.26, which exceeded the annual requirement. The file for Staff #24 contained documentation of Fire Safety Training on 12.9.24, but none in 2025. The file for Staff #25 contained documentation of Fire Safety Training on 11.26.24 and 2.3.26, which exceeded the annual requirement.

Corrected by Apr 10, 2026

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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 #8 and Staff #21 may not work in a child care position at the facility.

The file for Staff #3 (see IS Code Sheet) contained a Disclosure Statement dated 3.2.26, which exceeded the first day caring for children. The file for Staff #5 (see IS Code Sheet) contained a Disclosure Statement dated 6.12.24, which exceeded the first day caring for children. The file for Staff #7 (see IS Code Sheet) contained a Disclosure Statement dated 3.2.26, which exceeded the first day caring for children. The file for Staff #8 (see IS Code Sheet) did not contain a Disclosure Statement. The file for Staff #21 (see IS Code Sheet) contained a Disclosure Statement dated 12.7.23, but did not contain a witness signature or date, making it invalid.

Corrected by Apr 3, 2026

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

The file for Staff #3 (see IS Code Sheet) contained a Child Abuse Clearance dated 1.14.26, an FBI Clearance dated 1.16.26, and an NSOR Certificated dated 1.28.26, which exceeded the first day caring for children. The file for Staff #15 (see IS Code Sheet) contained a Child Abuse Clearance dated 6.21.24, which exceeded the first day caring for children. The file for Staff #15 contained documentation of Mandated Reporter training on 9.10.20, and none thereafter, which exceeded the 60-month renewal requirement.

Corrected by Apr 10, 2026

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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 file for Staff #21 did not contain documentation of written evaluations in 2024 or 2025. The file for Staff #23 did not contain documentation of a written evaluation in 2025. The file for Staff #25 did not contain documentation of a written evaluation in 2024.

Corrected by Apr 15, 2026

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3270.75(c) · A first-aid kit must contain the following: soap, an assortment of adhesive bandages, sterile gauze pads, tweezers, tape, scissors and disposable, nonporous gloves.

In Room 114, the first-aid kit did not contain tape. In Room 127, the first-aid kit did not contain nonporous gloves. In Room 140, the first-aid kit did not contain scissors, tweezers, or soap. In Room 141, the first-aid kit did not contain tweezers.

Corrected by Mar 18, 2026

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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.

In Room 120, a handwashing sign was not located at the toilet in the second restroom. In Room 122, a handwashing sign was not located at the toilet in the second restroom. In The Brook, a handwashing sign was not located in the restroom on the right, at the toilet.

Corrected by Mar 18, 2026

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

The Agreement in the files for Child #1, Child #2, Child #3, Child #4, Child #5, Child #6, Child #7, Child #8, Child #9, and Child #10 did not specify the child's arrival and departure times.

Corrected by Apr 21, 2026

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3270.123(a)(5) · An agreement shall specify the persons designated by a parent to whom the child may be released.

The Agreement, in the files for Child #1, Child #2, Child #3, Child #4, Child #5, Child #6, Child #7, Child #8, Child #9, and Child #10, did not specify the release person(s).

Corrected by Apr 21, 2026

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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, in the file for Child #2, did not include the work phone number of the enrolling parent. The Emergency Contact form, in the file for Child #5, did not include the work address or work phone number of the enrolling parent.

Corrected by Apr 21, 2026

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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, in the files for Child #7 and Child #8, did not include signed, parental consent for emergency medical care.

Corrected by Apr 21, 2026

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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 Emergency Contact form, in the file for Child #2, did not include information on the child's special needs.

Corrected by Apr 21, 2026

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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, in the file for Child #8, did not include the health insurance policy number.

Corrected by Apr 21, 2026

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

The Emergency Contact form and the Financial Agreement, in the files for Child #1, Child #2, Child #3, Child #4, Child #5, Child #7, Child #8, Child #9, and Child #10, did not include documentation that the parent reviewed/updated the information at least once in a 6-month period.

Corrected by Apr 21, 2026

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3270.131(b)(1)/3270.182(1) · The operator shall require the parent to provide an updated health report at least every 6 months for an infant or young toddler. A child's record shall contain initial and subsequent health reports.

The Health Assessment, in the file for Child #6, an infant, was not updated within the required 6 months.

Corrected by Apr 24, 2026

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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 Health Assessments, in the files for Child #1, Child #2, Child #3, Child #4, Child #5, Child #7, Child #9, and Child #10, were not updated within the required 12 months.

Corrected by Apr 24, 2026

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3270.133(5) · Medication shall be stored in accordance with the manufacturer's or health professional's instructions on the original label.

In Room 134, an Epi-Pen with an expiration date of 1/2026, was still stored at the facility for a preschool child.

Corrected by Mar 18, 2026

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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 #7 (see IS Code Sheet) did not contain documentation of a health assessment conducted within 12 months prior to providing initial service in a child care setting. The file for Staff #8 (see IS Code Sheet) did not contain documentation of a health assessment conducted within 12 months prior to providing initial service in a child care setting. The two (2) most recent Health Assessments in the file for Staff #13 exceeded the 24-month renewal requirement. The two (2) most recent Health Assessments in the file for Staff #22 exceeded the 24-month renewal requirement. The two (2) most recent Health Assessments in the file for Staff #25 exceeded the 24-month renewal requirement. The file for Staff #26 (see IS Code Sheet) did not contain documentation of a health assessment conducted within 12 months prior to providing initial service in a child care setting.

Corrected by Apr 24, 2026

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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 Staff #7 (see IS Code Sheet) did not contain a tuberculosis test dated within 12 months of initial employment. The file for Staff #8 (see IS Code Sheet) did not contain a tuberculosis test dated within 12 months of initial employment. The file for Staff #25 (see IS Code Sheet) did not contain a tuberculosis test dated within 12 months of initial employment. The file for Staff #26 (see IS Code Sheet) did not contain a tuberculosis test dated within 12 months of initial employment.

Corrected by Apr 24, 2026

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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.

Then Emergency Contact form, in the files for Child #6, Child #7, and Child #8, did not contain signed, parental consent for administration of minor first-aid procedures by facility staff.

Corrected by Apr 15, 2026

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3270.192(2)(iv) · A facility person's record shall include acceptable verification of experience, education or training is a transcript or a diploma or a letter signed by a representative of the experiential, educational or training entity.

The file for Staff #7 did not contain evaluated proof of the foreign education, and therefore, the educational equivalency could not be determined.

Corrected by May 22, 2026

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

The file for Staff #1 contained one (1) nonfamily reference, which did not meet the requirement of two (2). The file for Staff #2 contained one (1) nonfamily reference, which did not meet the requirement of two (2). The file for Staff #4 did not contain any nonfamily references, which did not meet the requirement of two (2).

Corrected by Mar 31, 2026

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3270.31(f)(7)/3270.192(2)(iii) · Staff persons shall complete professional development in the topic of emergency preparedness and response planning for emergencies resulting from a natural disaster or a man-caused event (such as violence at a child care facility) within the meaning of those terms under 602(a)(1) of the Robert T. Stafford Disaster Relief and Emergency Assistance Act (42 U.S.C.A. § 5195a(a)(1)) within 90 days of hire. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

The file for Staff #5 (see IS Code Sheet) contained documentation of Emergency Plan Training on 11.18.25, which exceeded the 90-day requirement. The file for Staff #6 (see IS Code Sheet) contained documentation of Emergency Plan Training on 11.18.25, which exceeded the 90-day requirement. The file for Staff #9 (see IS Code Sheet) contained documentation of Emergency Plan Training on 11.18.25, which exceeded the 90-day requirement. The file for Staff #11 contained documentation of Emergency Plan Training on 11.14.24, but none in 2025. The file for Staff #12 contained documentation of Emergency Plan Training on 11.14.24, but none in 2025. The file for Staff #14 contained documentation of Emergency Plan Training on 9.18.24 and 2.3.26, which exceeded the annual requirement. The file for Staff #15 contained documentation of Emergency Plan Training on 6.6.24, but none in 2025. The file for Staff #16 contained documentation of Emergency Plan Training on 6.10.24, but none in 2025. The file for Staff #18 contained documentation of Emergency Plan Training on 7.8.24, but none in 2025. The file for Staff #19 contained documentation of Emergency Plan Training on 8.26.24, but none in 2025. The file for Staff #20 contained documentation of Emergency Plan Training on 9.16.24 and 11.17.25, which exceeded the annual requirement. The file for Staff #23 contained documentation of Emergency Plan Training on 11.14.24, but none in 2025.

Corrected by Apr 10, 2026

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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.

Child #1, a young toddler, was not supervised when Child #1 eloped from The Brook on 2.18.26, for over one (1) minute.

Corrected by Mar 20, 2026

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3270.113(a)(1) · 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. This portion of the plan shall have an immediate correction date. 2. The legal entity must arrange for all staff to complete Better Kid Care Training: Supervision: What's Required?. Training may count toward annual training requirement. Training certificates will be sent to the certification representative upon completion. The operator shall provide a date for when this training will be completed. 3. Following the completion of the Better Kid Care training and the installation of the alarms on the doors of The Brook, the provider will notify the certification representative of the completion. The certification representative will then conduct two (2) unannounced visits to ensure implementation of the plans. The provider shall provide a date for when the installation of the door alarms will be completed.

Child #1, a young toddler, was not supervised when Child #1 eloped from The Brook on 2.18.26, for over one (1) minute. Staff #1 was not physically present and did not know the whereabouts of Child #1.

Corrected by Apr 3, 2026

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3270.51 · 1. 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. 2. The legal entity must arrange for all staff to complete Better Kid Care Training: Big Emotions and Self-Regulation for Adults & Children. Training may count toward annual training requirement. 3. The legal entity must arrange for the Director(s) to participate in a minimum of three (3) in-person, technical assistance sessions with the ELRC #5 Quality Coach to address delegation of work, leadership, and the development of a policy for overwhelmed staff who need a short break.

On 9.30.25, Staff #1 was left alone with sixteen (16) preschool children, making the staff:child ratio 1:16.

Corrected by Feb 6, 2026

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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.

In Room 107, Infants #3, three (3) cribs which contained sleeping infants, were spaced as follows: 1 crib had 2' of space on one (1) side, with 1' of space on the other two (2) sides; 2 cribs had 2' of space on two (2) sides, with 1' space on the third side.

Corrected by Oct 30, 2025

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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 #2 (see IS Code Sheet), did not contain any documentation of Pediatric First-Aid/CPR training, which is required within 90 days of hire.

Corrected by Oct 29, 2025

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3270.32(a) · The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Staff #1 may not work in a child care position at the facility.

The file for Staff #1 (see IS Code Sheet) did not contain an NSOR Certificate.

Corrected by Oct 29, 2025

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

During family style breakfast Staff Person #1 placed a bowl of hard-boiled eggs cut into halves in front of Child #1 who is allergic to eggs. Child #1 took an egg from the bowl and took a bite; Staff #2 saw Child #1 ingest the egg and encouraged Child #1 to spit it out. Child #1 then had an allergic reaction to ingesting the egg, epi-pen was administered by the parents and Child #1 was transported to the hospital for further evaluation.

Corrected by Sep 5, 2025

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

Observed adult scissors and a stapler, which were accessible to children, on a table in the PreK Room.

Corrected by Apr 29, 2025

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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 most recent emergency plan trainings in the file for Staff Person #10 exceeded 12 months between trainings.

Corrected by Apr 29, 2025

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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 most recent Pediatric First Aid/CPR Certification in the files for Staff Person #2 and #8 were conducted after the previous certifications had expired.

Corrected by Apr 29, 2025

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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. Facility Person #1, 3 and 7 may not work in a child care position at the facility.

The files for Staff Person #1, #3 and #7 do not contain out of state child abuse clearances for the states in which staff persons resided within the past five years. Staff Person #1: New York. Staff Person #3: West Virginia. Staff Person #7: Ohio. The required clearances for the following staff persons were conducted after the staff person's first day working in child care. Staff Person #4: Child Abuse. Staff Person #5: State Police, Child Abuse and FBI. Staff Person #9: State Police. Staff Person #10: State Police, Child Abuse, FBI, NSOR. Staff Person #11, 12 and 13: FBI, NSOR. (See LIS Code Sheet).

Corrected by May 7, 2025

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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 first written evaluation in the file for Staff Person #1 was conducted more than 12 months after the staff person's first day working in child care. (See LIS Code Sheet).

Corrected by Apr 29, 2025

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3270.36(b)(5)/3270.192(2)(ii) · An assistant group supervisor shall have a high school diploma or a general educational development certificate and 2 years 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 files for Staff Person #4, #6 and #9 who work as Assistant Group Supervisors, lacked verification of two years child care experience.

Corrected by May 5, 2025

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3270.66(a)/3270.66(d) · Cleaning materials and other toxic materials shall be kept in an area or container that is locked or made inaccessible to children. Toxic plants are not permitted in a child care space.

Observed a golden pothos, which was accessible to children, in Room 140.

Corrected by Apr 29, 2025

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3270.75(c) · A first-aid kit must contain the following: soap, an assortment of adhesive bandages, sterile gauze pads, tweezers, tape, scissors and disposable, nonporous gloves.

The first aid kits in the facility lacked tape.

Corrected by Apr 29, 2025

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3270.82(e) · Toilets and sinks shall be at proper heights for children using them or shall be easily approached by means of platforms or steps.

Room 109, in which young toddlers who could stand on their own were in care, lacked a platform or steps for children to easily reach the sink to wash their hands.

Corrected by May 5, 2025

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3270.106(a) · Individual, clean, age-appropriate rest equipment shall be provided for preschool, toddler and infant children as agreed between the child's parent and the operator. The rest equipment shall be labeled for the use of a specific child and used only by the specified child.

The cots in Rooms 109, 120, 122, 134, 140 and 141 were not labeled.

Corrected by May 5, 2025

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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.

Observed less than 2 feet of space on 3 sides of two cribs in Room 107 and one crib in Room 108, where infants were napping.

Corrected by Apr 29, 2025

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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 reports in the file for Child #5 exceeded six months between reports. The first child service report in the file for Child #6 was conducted more than six months after the child's first day in care.

Corrected by Apr 29, 2025

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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 fee agreements in the files for Child #1, 2 and 3 were the original documents.

Corrected by Apr 29, 2025

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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 forms in the files for Child #7 and #8 did not include the addresses of the release persons.

Corrected by May 6, 2025

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

The emergency contact binder in Room 110 did not include an emergency contact form for Child #1, who was receiving care in that room.

Corrected by Apr 29, 2025

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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 file for Child #1, an older toddler, did not include an updated health report conducted within the past 12 months.

Corrected by Apr 29, 2025

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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). Child #1 and #4 must be dismissed from care by close of business 4/23/25 and may only return to care when the immunization record is updated or when a parent provides a written, signed exemption letter.

The most recent immunization record in the file for Child #1, an older toddler lacks the following immunizations according to the recommendations of the ACIP: 3rd Hep B, 4th DTAP, 4th Pneumococcal. The file for Child #4, who has been enrolled for more than 60 days, lacks an immunization record.

Corrected by Apr 29, 2025

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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 initial health assessment in the file for Staff Person #4 was conducted after the staff person's first day working in child care. (See LIS Code Sheet).

Corrected by May 5, 2025

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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 most recent parental updates for the emergency plans and fee agreements in the files for Child #1, 2, 3, 4, 5, 6 and 8 exceeded 6 months between updates.

Corrected by Apr 29, 2025

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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 in the file for Child #4 did not include signed parental consent for administration of minor first-aid procedures by facility staff.

Corrected by May 5, 2025

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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.

One of the reference letters in the file for Staff Person #5 was dated after the staff person's first day working in child care. (See LIS Code Sheet).

Corrected by Apr 29, 2025

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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 #4, who has been enrolled for more than 60 days, did not include an initial health report.

Corrected by May 5, 2025

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

The file for Staff #6 contained documentation of the 1-Hour Health & Safety Update training on 1.19.24, which was due by 12.30.22. The file for Staff #9 contained documentation of the 1-Hour Health & Safety Update training on 1.24.24, which was due by 12.30.22. The file for Staff #16 contained documentation of the 1-Hour Health & Safety Update training on 12.28.23, which was due by 12.30.22. The file for Staff #17 contained documentation of the 1-Hour Health & Safety Update training on 10.27.23, which was due by 12.30.22.

Corrected by Jan 2, 2025

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3270.27(c)/3270.192(2)(iii) · 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. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

The Emergency Plan training in the file for Staff #5, was dated 8.1.23, and none thereafter, which exceeded the 12-month renewal requirement. The Emergency Plan training in the file for Staff #6, was dated 8/23, and none thereafter, which exceeded the 12-month renewal requirement. The Emergency Plan training in the file for Staff #7, was dated 8/23, and none thereafter, which exceeded the 12-month renewal requirement. The Emergency Plan training in the file for Staff #8, was dated 8/23, and none thereafter, which exceeded the 12-month renewal requirement. The Emergency Plan training in the file for Staff #9, was dated 8/23, and none thereafter, which exceeded the 12-month renewal requirement. The Emergency Plan training in the file for Staff #10, was dated 8/23, and none thereafter, which exceeded the 12-month renewal requirement. The Emergency Plan training in the file for Staff #11, was dated 8/23, and none thereafter, which exceeded the 12-month renewal requirement. The Emergency Plan training in the file for Staff #12, was dated 8/23, and none thereafter, which exceeded the 12-month renewal requirement. The Emergency Plan training in the file for Staff #13, was dated 8/23, and none thereafter, which exceeded the 12-month renewal requirement. The Emergency Plan training in the file for Staff #14, was dated 8/23, and none thereafter, which exceeded the 12-month renewal requirement. The Emergency Plan training in the file for Staff #15, was dated 4/23, and none thereafter, which exceeded the 12-month renewal requirement. The Emergency Plan training in the file for Staff #16, was dated 8/23, and none thereafter, which exceeded the 12-month renewal requirement. The Emergency Plan training in the file for Staff #18, was dated 8.1.23, and none thereafter, which exceeded the 12-month renewal requirement. The Emergency Plan training in the file for Staff #19, was dated 8.1.23, and none thereafter, which exceeded the 12-month renewal requirement. The Emergency Plan training in the file for Staff #20, was dated 8.14.23, and none thereafter, which exceeded the 12-month renewal requirement. The Emergency Plan training in the file for Staff #21, was dated 8/23, and none thereafter, which exceeded the 12-month renewal requirement. The Emergency Plan training in the file for Staff #22, was dated 8/23, and none thereafter, which exceeded the 12-month renewal requirement.

Corrected by Jan 2, 2025

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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.

No documentation was provided that a letter was provided to the parent of each enrolled child which explained the emergency procedures.

Corrected by Jan 2, 2025

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3270.31(e)(4)(i)/3270.192(2)(iii) · 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. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

The file for Staff #5 contained Pediatric First-Aid/CPR training which expired on 7.25.24, and it was not renewed until 10.3.24. The file for Staff #6 contained Pediatric First-Aid/CPR training which expired on 4.18.24, and it was not renewed until 5.28.24.

Corrected by Jan 2, 2025

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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 (see IS Code Sheet) did not contain documentation of the 10-hour Health & Safety training, which is beyond 90 days of hire.

Corrected by Jan 2, 2025

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3270.133(5) · Medication shall be stored in accordance with the manufacturer's or health professional's instructions on the original label.

In Room 115, two bottles of medication were expired: Epi-Pen expired on 6/24, and Children's Cetrizine expired on 7/24.

Corrected by Jan 2, 2025

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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 #3 may not work in a child care position at the facility.

The file for Staff #3 did not contain a date on the Disclosure Statement. It could not be determined if the Disclosure Statement was obtained at the time of hire due to the missing date.

Corrected by Jan 2, 2025

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

The file for Staff #1 (see IS Code Sheet) contained a Child Abuse Clearance dated 8.13.24, which was after the start date with children. The file for Staff #1 contained FBI Clearances dated 9.17.19 and 9.30.24, which exceeded the 60-month renewal requirement. The file Staff #4 contained documentation of Mandated Reporter training on 9.17.19 and 10.5.24, which exceeded the 60-month renewal requirement. The file for Staff #2 (see IS Code Sheet) contained a Child Abuse Clearance dated 4.9.24, which was after the start date with children. The file for Staff #6 contained documentation of Mandated Reporter training on 10.25.18 and 6.3.24, which exceeded the 60-month renewal requirement. The file for Staff #9 contained documentation of Mandated Reporter training on 2.28.18 and 2.2.24, which exceeded the 60-month renewal requirement. The file for Staff #14 (see IS Code Sheet), contained an FBI Clearance dated 3.17.23, with an Application dated 3.10.23, which was beyond the first date working with children.

Corrected by Jan 2, 2025

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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 file for Staff #17 (see IS Code Sheet), contained documentation of a written evaluation on 7.1.24, which exceeded the 12-month requirement.

Corrected by Jan 2, 2025

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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, in the files for Child #1, Child #3, Child #7, and Child #9, did not include the enrolling parent's work phone number.

Corrected by Jan 2, 2025

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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, in the file for Child #9, did not include the release person's address.

Corrected by Jan 2, 2025

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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.

As confirmed by the operator and lack of documentation, the Emergency Contact forms and Financial Agreements were not reviewed/updated by a parent, within a 6-month period, for Child #2, Child #3, Child #4, Child #5, Child #6, Child #7, and Child #8.

Corrected by Jan 2, 2025

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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 most current Health Assessment in the file for Staff #2 was verified to contain a forged signature, as verified by the medical professional whose name appears on the form. Therefore, the Health Assessment is deemed forged and is therefore unacceptable.

Corrected by Jan 2, 2025

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3270.151(a) · ** All staff, including the director, will obtain the training "Ethics: A Guide for Professional Behavior" from Better Kid Care. Training hours can be credited towards annual training requirements.

** The most current Health Assessment in the file for Staff #2 was verified to contain a forged signature, as verified by the medical professional whose name appears on the form. Therefore, the Health Assessment is deemed forged and is therefore unacceptable.

Corrected by Jan 2, 2025

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3270.151(a) · *** The director/LE will create and maintain a written policy addressing the accuracy and authenticity of all documents maintained in the facility, staff and children's files and outline consequences for individuals who create, present and/ or submit deceptive and/ or fraudulent documentation. The policy will be submitted to the Western Region office for review. The facility/staff handbook will then be updated to include this policy. All staff will confirm receipt and understanding of the policy in writing, to include any staff hired after acceptance of the POC. Review of this policy and topics addressed in the "Ethics" training will be discussed at staff meetings for three months after acceptance of the POC. Documentation of the receipt of policy by staff and staff meeting agendas will be available to Certification for review upon request.

*** The most current Health Assessment in the file for Staff #2 was verified to contain a forged signature, as verified by the medical professional whose name appears on the form. Therefore, the Health Assessment is deemed forged and is therefore unacceptable.

Corrected by Jan 2, 2025

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3270.192(3) · 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 Health Assessment for Staff #2 was deemed invalid and therefore, the file lacked a current health assessment.

Corrected by Jan 2, 2025

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3270.31(f)(7)/3270.192(2)(iii) · Staff persons shall complete professional development in emergency preparedness and response planning for emergencies resulting from a natural disaster or a man-caused event (such as violence at a child care facility) within the meaning of those terms under section 602(a)(1) of the Robert T. Stafford Disaster Relief and Emergency Assistance Act (42 U.S.C.A. § 5195a(a)(1)) within 90 days of hire. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

The Emergency Plan training, in the file for Staff #4 (see IS Code Sheet), was dated 8.1.24, which exceeded 90 days of hire.

Corrected by Jan 2, 2025

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

The file for Staff #20 (see IS Code Sheet), contained documentation of Pediatric First-Aid/CPR training on 12.20.23, which exceeded 90 days of hire.

Corrected by Jan 2, 2025

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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.

No documentation was available that the Emergency Plan was sent to the local municipality and county emergency management agency.

Corrected by Jan 3, 2025

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3270.171(a) · An operator shall notify local traffic safety authorities annually in writing of the location of the facility and the program's use of pedestrian and vehicular routes around the child care facility.

No documentation was available that the operator notified the local traffic safety authorities in writing of the location of the facility and the program's use of pedestrian and vehicular routes around the child care facility.

Corrected by Jan 7, 2025

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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.

Previously cited on 2/7/24 SIN-00239502. Based on conversations with staff, on 3/12/24 at approximately 10:30 AM, Staff Person #1 was supervising Child #1 in the office. Child # 1 was sick and, in the office, to be picked up by parent. Staff Person #1 walked out of the office into the lobby and left Child #1 alone in the office alone and unsupervised.

Corrected by Mar 13, 2024

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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.

*Previously cited on 2/7/24 SIN-00239502. Based on conversations with staff, on 3/12/24 at approximately 10:30 AM, Staff Person #1 was supervising Child #1 in the office. Child # 1 was sick and, in the office, to be picked up by parent. Staff Person #1 walked out of the office into the lobby and left Child #1 alone in the office alone and unsupervised.

Corrected by Mar 13, 2024

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3270.113(a) · **Children must be supervised at all times. The legal entity must arrange for all childcare staff to complete two separate trainings. "Supervision: What's Required " and Supervision: Teamwork" both are available on Better Kid Care. Verification of completion of the supervision training will be submitted to DHS within 1 month of the approval of this plan of correction. The training may count towards the staff annual minimum of 12 clock hours of childcare training.

**Previously cited on 2/7/24 SIN-00239502. Based on conversations with staff, on 3/12/24 at approximately 10:30 AM, Staff Person #1 was supervising Child #1 in the office. Child # 1 was sick and, in the office, to be picked up by parent. Staff Person #1 walked out of the office into the lobby and left Child #1 alone in the office alone and unsupervised.

Corrected by Jun 3, 2024

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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.

Previously cited on 2/7/24 SIN-00239502. Based on conversations with staff, on 3/12/24 at approximately 10:30 AM, Staff Person #1 was supervising Child #1 in the office. Child # 1 was sick and, in the office, to be picked up by parent. Staff Person #1 walked out of the office into the lobby and left Child #1 alone in the office alone and unsupervised.

Corrected by Mar 13, 2024

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3270.113(b) · A facility person may not use any form of physical punishment, including spanking a child.

On 2/1/24 at approximately 10:30 AM camera footage shows Staff #1 using their forearm to push Child #1 to the ground.

Corrected by Feb 5, 2024

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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.

According to Staff statements made to Cert Rep during an investigation on 2/7/24 it was disclosed that previously on 1/26/24 at approximately 4:00 PM a child was left alone in a classroom. Staff statements indicated that Staff #1 and Staff #2 were leaving the Gross Motor space and headed back to the classrooms to get the children's coats on to go outside. Upon getting the children's coats, Staff #1 left her classroom going next door to Staff #2's classroom and left Child #1 behind. Child #1 was left alone and unsupervised in the classroom where they could not be seen, heard, directed, or assessed. Staff#1 noticed the child was missing when the parent showed up to pick the child up from the facility. Therefore, ratio was 0:1.

Corrected by Feb 8, 2024

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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.

According to Staff statements made to Cert Rep during an investigation on 2/7/24 it was disclosed that previously on 1/26/24 at approximately 4:00 PM a child was left alone in a classroom. Staff statements indicated that Staff #1 and Staff #2 were leaving the Gross Motor space and headed back to the classrooms to get the children's coats on to go outside. Upon getting the children's coats, Staff #1 left her classroom going next door to Staff #2's classroom and left Child #1 behind. Child #1 was left alone and unsupervised in the classroom where they could not be seen, heard, directed, or assessed. Staff#1 noticed the child was missing when the parent showed up to pick the child up from the facility.

Corrected by Feb 8, 2024

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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.

According to Staff statements made to Cert Rep during an investigation on 2/7/24 it was disclosed that previously on 1/26/24 at approximately 4:00 PM a child was left alone in a classroom. Staff statements indicated that Staff #1 and Staff #2 were leaving the Gross Motor space and headed back to the classrooms to get the children's coats on to go outside. Upon getting the children's coats, Staff #1 left her classroom going next door to Staff #2's classroom and left Child #1 behind. Child #1 was left alone and unsupervised in the classroom where they could not be seen, heard, directed, or assessed. Staff#1 noticed the child was missing when the parent showed up to pick the child up from the facility. Staff#1 was not physically present or know the whereabouts of all of the children in their assigned group.

Corrected by Feb 8, 2024

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

The file for Staff #1 (see IS Code Sheet) contained an FBI Clearance and application dated 3.17.23, which exceeded the initial start date. The file for Staff #2 (see IS Code Sheet) contained an FBI Clearance and application dated 7.7.23, which exceeded the initial start date. The file for Staff #3 (see IS Code Sheet) contained an FBI Clearance dated 9.18.23, and an application dated 9.13.23, which exceeded the initial start date. The file for Staff #6 (see IS Code Sheet) contained an FBI Clearance and application dated 8.18.23, which exceeded the initial start date. The file for Staff #7 (see IS Code Sheet) contained an FBI Clearance dated 5.16.23, and no application was available, which exceeded the initial start date. The file for Staff #7 (see IS Code Sheet) contained documentation of Mandated Reporter training on 8.18.23, which exceeded the 90-day requirement. The file for Staff #8 (see IS Code Sheet) contained an FBI Clearance dated 9.18.23, and an application dated 9.13.23, which exceeded the initial start date. The file for Staff #15 (see IS Code Sheet) contained an NSOR Certificate dated 10.7.21, and an application dated 9.30.21, which exceeded the initial start date. The file for Staff #20 contained documentation of Mandated Reporter training on 2.28.18, and none thereafter, which exceeded the 60-month renewal requirement. The file for Staff #23 (see IS Code Sheet) contained an FBI Clearance and application dated 8.26.21, which exceeded the initial start date. The file for Staff #23 (see IS Code Sheet) contained documentation of Mandated Reporter training on 4.15.22, which exceeded the 90-day requirement.

Corrected by Nov 21, 2023

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

The files for Staff #11, Staff #12, Staff #13, Staff #14, Staff #15, Staff #16, Staff #17, Staff #18, Staff #19, Staff #20 and Staff #23 did not contain documentation of the Health and Safety, 1-hour Update training, which was required by December 30, 2022.

Corrected by Nov 21, 2023

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3270.27(c)/3270.192(2)(iii) · 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. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

The file for Staff #9 contained documentation of Emergency Plan training on 4.27.21 and 8.1.23, which exceeded the annual requirement. The file for Staff #13 contained documentation of Emergency Plan training on 9.12.22, and none thereafter, which exceeded the annual requirement. The file for Staff #15 contained documentation of Emergency Plan training on 8.8.21 and 8/2023, which exceeded the annual requirement. The file for Staff #16 contained documentation of Emergency Plan training on 8/2021 and 8/2023, which exceeded the annual requirement. The file for Staff #17 contained documentation of Emergency Plan training on 8.23.21 and 8/2023, which exceeded the annual requirement. The file for Staff #18 contained documentation of Emergency Plan training on 8.9.21 and 8/2023, which exceeded the annual requirement. The file for Staff #19 contained documentation of Emergency Plan training on 8.9.21, and none thereafter, which exceeded the annual requirement. The file for Staff #20 contained documentation of Emergency Plan training on 8/2021 and 8/2023, which exceeded the annual requirement. The file for Staff #21 contained documentation of Emergency Plan training on 5.10.21, and none thereafter, which exceeded the annual requirement. The file for Staff #22 contained documentation of Emergency Plan training on 7.6.21, and none thereafter, which exceeded the annual requirement.

Corrected by Nov 21, 2023

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3270.31(e)(4)(i)/3270.192(2)(iii) · 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. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

The file for Staff #9 contained documentation of Pediatric First-Aid/CPR training on 8.25.21 and 10.3.23, which exceeded the expiration date of the 2021 training. The file for Staff #11 contained documentation of Pediatric First-Aid/CPR training on 11.24.20, and none thereafter, which exceeded the expiration date of the 2020 training. The file for Staff #12 contained documentation of Pediatric First-Aid/CPR training on 8.25.21 and 10.3.23, which exceeded the expiration date of the 2021 training. The file for Staff #13 contained documentation of Pediatric First-Aid/CPR training on 8.22.21, and none thereafter, which exceeded the expiration date of the 2021 training. The file for Staff #14 contained documentation of Pediatric First-Aid/CPR training on 4.24.21, and none thereafter, which exceeded the expiration date of the 2021 training. The file for Staff #15 contained documentation of Pediatric First-Aid/CPR training on 8.25.21, and none thereafter, which exceeded the expiration date of the 2021 training. The file for Staff #16 contained documentation of Pediatric First-Aid/CPR training on 8.25.21, and none thereafter, which exceeded the expiration date of the 2021 training. The file for Staff #17 contained documentation of Pediatric First-Aid/CPR training on 6.4.20 and 10.3.23, which exceeded the expiration date of the 2020 training. The file for Staff #18 contained documentation of Pediatric First-Aid/CPR training on 8.25.21 and 10.3.23, which exceeded the expiration date of the 2021 training. The file for Staff #19 contained documentation of Pediatric First-Aid/CPR training on 8.25.21, and none thereafter, which exceeded the expiration date of the 2021 training. The file for Staff #21 contained documentation of Pediatric First-Aid/CPR training on 6.5.21, and none thereafter, which exceeded the expiration date of the 2021 training. The file for Staff #22 contained documentation of Pediatric First-Aid/CPR training on 2.19.20, and none thereafter, which exceeded the expiration date of the 2020 training. The file for Staff #23 contained documentation of Pediatric First-Aid/CPR training on 8.25.21 and 10.3.23, which exceeded the expiration date of the 2021 training.

Corrected by Nov 21, 2023

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3270.31(e)(4)(ii)/3270.192(2)(iii) · 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. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

The file for Staff #9 contained documentation of Fire Safety training on 4.30.21 and 12/2022, which exceeded the annual requirement. The file for Staff #10 contained documentation of Fire Safety training on 8.25.21 and 12/2022, which exceeded the annual requirement. The file for Staff #11 contained documentation of Fire Safety training on 1.11.22 and 12/2023, which exceeded the annual requirement. The file for Staff #12 contained documentation of Fire Safety training on 8.25.21 and 12/2022, which exceeded the annual requirement. The file for Staff #13 did not contain documentation of Fire Safety training, which was required by 9.15.22. The file for Staff #15 contained documentation of Fire Safety training on 8/2021 and 12/2022, which exceeded the annual requirement. The file for Staff #16 contained documentation of Fire Safety training on 8/2021 and 12/2022, which exceeded the annual requirement. The file for Staff #17 contained documentation of Fire Safety training on 8.25.21 and 12/2022, which exceeded the annual requirement. The file for Staff #18 contained documentation of Fire Safety training on 8.25.21 and 12/2022, which exceeded the annual requirement. The file for Staff #19 contained documentation of Fire Safety training on 8.25.21 and 12/2022, which exceeded the annual requirement. The file for Staff #20 contained documentation of Fire Safety training on 8/2021 and 12/2022, which exceeded the annual requirement. The file for Staff #21 contained documentation of Fire Safety training on 6.17.21 and 12/2022, which exceeded the annual requirement. The file for Staff #22 contained documentation of Fire Safety training on 6.1.21 and 12/2022, which exceeded the annual requirement. The file for Staff #23 contained documentation of Fire Safety training on 8.25.21 and 12/2022, which exceeded the annual requirement.

Corrected by Nov 21, 2023

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3270.31(f) · Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10. Staff #7 shall complete professional development in the topics of 3270.31(f)(1-10) within 90 days of hire. Staff #7 will have until 12.5.23 to complete the required training. Until such time as the required training has been completed, Staff #7 must be supervised, when interacting with children, by an AGS who has completed the required training related to this citation. If there are no staff available to supervise Staff #7, Staff #7 may not work in a child care position at the facility.

The file for Staff #4 (see IS Code Sheet) contained documentation of Health and Safety training, 10 hours, on 10.27.23, which was not within 90 days of hire. Staff #7 (see IS Code Sheet) has not completed the following required pre-service training within 90 days of the date of hire: Health & Safety - Revised, 10 hours.

Corrected by Nov 22, 2023

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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 file for Staff #13 (see IS Code Sheet) did not contain documentation of a written evaluation by 9/2023. The file for Staff #18 (see IS Code Sheet) did not contain documentation of a written evaluation in 2022. The file for Staff #19 (see IS Code Sheet) did not contain documentation of a written evaluation by 9/2023. The file for Staff #22 (see IS Code Sheet) did not contain documentation of a written evaluation by 8/2023. The file for Staff #23 (see IS Code Sheet) did not contain documentation of a written evaluation in 2022.

Corrected by Nov 21, 2023

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3270.75(c) · A first-aid kit must contain the following: soap, an assortment of adhesive bandages, sterile gauze pads, tweezers, tape, scissors and disposable, nonporous gloves.

The First-Aid Kit, in Room 122, did not contain adhesive bandages.

Corrected by Nov 21, 2023

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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.

No handwashing sign was located at one (1) toilet in Room 127 or at the right toilet in Room 134.

Corrected by Nov 21, 2023

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3270.111(b) · The written plan of daily activities shall be posted in the group space.

The daily schedule was not posted in Room 110, Room 115, or Room 122.

Corrected by Nov 22, 2023

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

The Agreement, in the file for Child #5, did not specify the fee amount.

Corrected by Nov 6, 2023

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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 Agreement, in the files for Child #4, Child #5, and Child #6, did not contain the date of admission.

Corrected by Nov 22, 2023

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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, in the files for Child #1, Child #5, Child #6, and Child #7, did not contain the release person's address.

Corrected by Nov 22, 2023

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3270.124(e) · A written plan identifying the means of transporting a child to emergency care and staffing provisions in the event of an emergency shall be displayed conspicuously in every child care space and shall accompany a staff person who leaves on an excursion with children.

The Emergency Transportation Plan was not posted in Room 110.

Corrected by Nov 22, 2023

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3270.131(b)(1)/3270.182(1) · The operator shall require the parent to provide an updated health report at least every 6 months for an infant or young toddler. A child's record shall contain initial and subsequent health reports.

The Health Assessment, in the file for Child #3, who is a young toddler, was dated more than 6 months ago.

Corrected by Nov 22, 2023

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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).Child #2, Child #3, Child #4, Child #5, and Child #6 must be dismissed from care by close of business on 10.20.23, and may only return to care when the immunization record is updated or when a parent provides a written, signed exemption letter.

The Immunization Record, in the file for Child #2, Child #3, Child #4, Child #5, and Child #6, did not contain documentation of the influenza vaccination according to the ACIP recommendations.

Corrected by Nov 22, 2023

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3270.133(5) · Medication shall be stored in accordance with the manufacturer's or health professional's instructions on the original label.

The Epinephrine Injection Pen, for Child #8, in Room 140, contained an expiration date of 11/2022.

Corrected by Nov 29, 2023

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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 Health Assessments, in the file for Staff #5 and Staff #6 (see IS Code Sheets), were not conducted prior to providing initial service. The two (2) most recent Health Assessments, in the file for Staff #9, Staff #12, Staff #14, Staff #15, Staff #16, Staff #17, Staff #18, Staff #19, Staff #20, Staff #21, Staff #22, and Staff #23, exceeded the 24-month renewal requirement.

Corrected by Nov 29, 2023

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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, in the file for Child #1, did not contain the enrolling parent's work address. The Emergency Contact form, in the file for Child #2, did not contain the enrolling parent's work address or work phone number.

Corrected by Oct 11, 2022

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3270.31(e)(4)(i)/3270.192(2)(iii) · 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. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

The file for Staff #4 did not have a current Pediatric First-Aid/CPR certification, as the previous one had expired on 9.3.22.

Corrected by Oct 27, 2022

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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 #3 (see IS Code Sheet) contained a Child Abuse Clearance dated 4.13.22, and and NSOR Certificate dated 4.18.22, with no proof of application. The file for Staff #5 (see IS Code Sheet) contained an NSOR Certificate dated 10.7.21, with no proof of application. The file for Staff #6 (see IS Code Sheet) contained an NSOR Certificate dated 10.22.21, with no proof of application.

Corrected by Oct 11, 2022

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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.

The "4-Square," rubberized surface, on the ground in Play Area #2, which is used by children of all ages, was cracked and breaking apart in all four areas, creating a tripping/falling/choking hazard for children in care.

Corrected by Oct 12, 2022

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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.

No handwashing signs were posted at 1 toilet in room 127 or at 2 toilets in room 134.

Corrected by Oct 11, 2022

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

The Fee Agreement, in the file for Child #1, did not contain the fee amount.

Corrected by Oct 11, 2022

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3270.124(e) · A written plan identifying the means of transporting a child to emergency care and staffing provisions in the event of an emergency shall be displayed conspicuously in every child care space and shall accompany a staff person who leaves on an excursion with children.

An Emergency Transportation Plan was not posted in room 115.

Corrected by Oct 11, 2022

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

The Immunization Record, in the files for Child #1 and Child #3, did not contain documentation of the influenza vaccine according to the ACIP recommendations.

Corrected by Oct 26, 2022

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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 Staff #2 did not contain any documentation of the Mantoux screening.

Corrected by Nov 1, 2022

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3270.31(f)(10) · Staff persons shall complete professional development in pediatric first aid and pediatric cardiopulmonary resuscitation within 90 days of hire. Staff #1 will have until October 31, 2022, to complete the required training. Until such time as the required training has been completed, Staff #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 #1, Staff #1 may not work in a child care position at the facility.

The file for Staff #1 has not completed Pediatric First-Aid/CPR training, which is a required pre-service training within 90 days of date of hire (see IS Code Sheet).

Corrected by Oct 28, 2022

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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 #9 did not contain the NSOR certificate until 10.14.21, and she began working at the facility on 10.7.21. No provisional waiver was obtained for the facility. The file for Staff #10, with a hire date of 8.25.21, did not contain out-of-state clearances and may NOT work at the facility until the out-of-state clearances are obtained, reviewed, and approved.

Corrected by Nov 8, 2021

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

The emergency bag, containing a first-aid kit, was on the floor in The Brook, and accessible to children in care.

Corrected by Nov 8, 2021

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3270.75(c) · A first-aid kit must contain the following: soap, an assortment of adhesive bandages, sterile gauze pads, tweezers, tape, scissors and disposable, nonporous gloves.

There were no rubber gloves in a first-aid kit in Room 127.

Corrected by Nov 5, 2021

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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.

Dead bugs were located behind the wooden cart near the restroom and on the restroom floor in Room 134, which is not currently being used by children. Gnats, a live spider, and webs were located on the window sill and floor under the window in Room 134, which is not currently being used by children. Dead bugs were located in the storage closet, on the blue tarp under the sand table, and behind the wooden stand near the baseboard, located near the restroom in Room 140, which is not currently being used by children.

Corrected by Nov 5, 2021

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3270.103 · Toys and objects with a diameter of less than 1 inch, objects with removable parts that have a diameter of less than 1 inch, plastic bags and styrofoam objects may not be accessible to children who are still placing objects in their mouths.

Uncooked, hard macaroni noodles were present in the Discovery Table in Room 120, which were less than 1", were accessible to older toddlers in care and posed a choking hazard. Wooden, foam, and pom-pom craft items, less than 1", were present in Room 127 in the wooden stand with plastic containers near the entrance door, and they were accessible to older toddlers in care.

Corrected by Nov 5, 2021

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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.

No thermometer was present in the refrigerator in Room 108, which had no children in care. A white, sticky substance was present on approximately 75% of the bottom shelf of the refrigerator in room 110.

Corrected by Nov 5, 2021

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3270.115(c) · A water play table or a container used for water play that contains unfiltered water shall be emptied daily.

Standing water from the previous days' activity was still present in the Sensory Table in Room 141. Based on statements, the Sensory Table had not been emptied the previous day due to "picture day" activities.

Corrected by Nov 5, 2021

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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 Emergency Contact forms in the files for Child #1, Child #2, Child #3, Child #4, Child #5, Child #6, and Child #7 did not contain documentation of the services provided to the family and the child.

Corrected by Nov 29, 2021

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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 Agreements for Child #1, Child #2, Child #3, Child #4, Child #5, Child #6, and Child #7 did not contain the admission date.

Corrected by Nov 29, 2021

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

The files for Child #2, Child #3, Child #5, and Child #7 did not contain the enrolling parent's work address or work phone number.

Corrected by Nov 8, 2021

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3270.131(d)(5)/3270.131(e)(1) · A health report shall include a review of the child's immunized status according to recommendations of the ACIP.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 health record, for Child #3, did not contain documentation of an influenza vaccine since 11.14.16, nor was there an exemption letter.

Corrected by Nov 5, 2021

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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 files for Staff #1, Staff #2, Staff #3, Staff #4, Staff #5, Staff #6, and Staff #7 did not contain a TB test dated within 12 months of initial employment.

Corrected by Dec 15, 2021

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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 #7 and Staff #8 did not contain two (2) nonfamily references.

Corrected by Nov 22, 2021

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

Mushrooms, in grassy area of play area #4, were accessible to children. A basketball hoop, in The Brook, was not weighted down, and could easily fall onto children in care.

Corrected by Jul 19, 2021

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

Two protective receptacle covers were missing in The Brook, a room which is expected to be used by children 5 years of age and younger.

Corrected by Jul 13, 2021

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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.

Sharp edges, on bulletin boards in rooms 115 and 122, were accessible to children. Sharp fence post ties, in all four outdoor spaces, were accessible to children.

Corrected by Jul 19, 2021

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3270.82(e) · Toilets and sinks shall be at proper heights for children using them or shall be easily approached by means of platforms or steps.

Toilets / sinks were not at the proper height for the children who will be in care in rooms 140, 141, 134, and The Brook. A platform / step was not available.

Corrected by Jul 22, 2021

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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.

A handwashing sign was not posted for each toilet and sink in rooms 140 and 141.

Corrected by Jul 13, 2021

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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.

There were rough and sharp metal nubs on the green megaphones, accessible to children, in play area #1. Set screws were missing from the infant/toddler playhouse in play area #1, creating a pinch point due to loose metal and movement on the column. Sharp burrs were located on the green bell on the climbing equipment in play area #2. Sharp burrs were located on the rails and posts of the climbing equipment in play area #2. Sharp burrs were located on the climbing equipment in play area #3.

Corrected by Jul 19, 2021

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3270.103 · Toys and objects with a diameter of less than 1 inch, objects with removable parts that have a diameter of less than 1 inch, plastic bags and styrofoam objects may not be accessible to children who are still placing objects in their mouths.

The fruit stand, in room 122, had a plastic covering on the white board, which was accessible to children, and pose a choking hazard. Some of the strands of the ground cover turf, which were less than 1', were unattached, accessible to children, and pose a choking hazard, in play areas #1 and #2.

Corrected by Jul 14, 2021

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3270.124(e) · A written plan identifying the means of transporting a child to emergency care and staffing provisions in the event of an emergency shall be displayed conspicuously in every child care space and shall accompany a staff person who leaves on an excursion with children.

An emergency transportation plan was not displayed in room 141.

Corrected by Jul 13, 2021

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3270.134(d) · Liquid or powdered soap shall be used for handwashing.

Soap dispensers were installed in a location which would not allow access by the children in rooms 115, 120, 122, and 127.

Corrected by Jul 19, 2021

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3270.135(a)(3) · If disposable diapers are provided by a parent or by a facility, a soiled diaper shall be discarded by immediately placing the diaper into a plastic-lined, hands-free covered can.

A hands-free covered can was not operational initially, in the diaper changing area in room 127, until the covering was removed.

Corrected by Jul 13, 2021

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