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

Observed rust on the grate cover in the Preschool/School-Age Outdoor Play Space.

Corrected Corrected by Sep 10, 2025

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

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

Staff #1 lacked documentation of completing mandated reporter training every 60 months. Staff #1 had documentation of completing mandated reporter training on 3/24/25 with previous training completed on 3/23/20.

Corrected Corrected by Aug 8, 2025

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.

The file of Staff #2 lacked documentation of completing the Pennsylvania Health and Safety Update 2022 by December 30, 2022 (SEE LIS Code Sheet). The file of Staff #2 contained documentation of completing the health and safety update on 8/3/23.

Corrected Corrected by Aug 8, 2025

Category: ratio. Marked corrected in the state record.

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

The file of Staff #3 lacked a written evaluation on a regular basis, a minimum of one evaluation every 12 months. The file of Staff #3 contained a written evaluation dated 7/23/25 with a previous one dated 6/9/24.

Corrected Corrected by Aug 8, 2025

Category: recordkeeping. Marked corrected in the state record.

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

On 7/17/25 observed an electrical outlet which lacked a protective receptacle cover to the left of the block area in the Rainbow Room.

Corrected Corrected by Jul 17, 2025

Marked corrected in the state record.

3270.69(b) · Hot water temperature, in areas accessible to children, may not exceed 110° F.

On 7/17/25 the hot water temperature at the sink in the Yellow Room was 120° F. On 7/17/25 the hot water temperature at the sink by the changing table in the Orange Room was 122° F. On 7/17/25 the hot water temperature at the sink by the changing table in the Blue Room was 119° F. On 7/17/25 the hot water temperature at the first sink in the Hall Bathroom was 121° F. On 7/17/25 the hot water temperature at the 2nd and 3rd sinks in the Hall Bathroom was 122° F. On 7/17/25 the hot water temperature at the two sinks in the bathroom by the outdoor play spaces was 120° F.

Corrected Corrected by Aug 8, 2025

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

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

On 7/17/25 observed a metal grate in the Preschool/School-Age Outdoor Play Space creating rough edges and pinch points.

Corrected Corrected by Aug 8, 2025

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

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

On 7/17/25 observed cracked magna tiles in the Yellow Room. On 7/17/25 observed a LEGO base with approximately a 3-inch crack in the Rainbow Room.

Corrected Corrected by Jul 17, 2025

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

3270.102(c) · Outdoor equipment that requires embedded mounting must be mounted over a loose-fill or unitary playground protective surface covering that meets the recommendations of the United States Consumer Product Safety Commission. The equipment must be anchored firmly and be in good repair.

On 7/17/25 observed embedded equipment in the Preschool/School-Age Outdoor Play Space with approximately 4 inches of mulch. The Consumer Product Safety Commission recommends 9 inches of mulch as protective surface covering.

Corrected Corrected by Aug 8, 2025

Category: physical safety. 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 of Staff #3 lacked a health assessment conducted every 24 months. The file of Staff #3 contained a current health assessment dated 5/14/24 with a previous one dated 3/22/22.

Corrected Corrected by Aug 8, 2025

Category: ratio. Marked corrected in the state record.

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

On 10/23/24 observed 10 paring knives in the 1st drawer closest to the Blue Room in the kitchen which were accessible to children.

Corrected Corrected by Oct 23, 2024

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

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

The file of Volunteer #2 lacked documentation of training regarding the emergency plan on an annual basis (SEE LIS Code Sheet). The file of Volunteer #2 contained documentation of emergency plan training on 8/20/24.

Corrected Corrected by Oct 23, 2024

Category: recordkeeping. Marked corrected in the state record.

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

The letter provided to the parents explaining emergency procedures did not address a method for facility persons to contact parents as soon as reasonably possible when an emergency situation arises and a method for facility persons to inform parents that the emergency has ended and to provide instruction as to how parents can safely be reunited with their children.

Corrected Corrected by Nov 1, 2024

Category: physical safety. 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). LACKING REQUIRED HIRING DOCUMENTS: Facility Person #1 and #2 may not work in a child care position at the facility. 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 and #2 may not work in a child care position at the facility.

The file of Staff #1 lacked a valid State Police Clearance because it did not have a "disseminated on" date. The file of Volunteer #2 lacked a State Police Clearance and DHS FBI Clearance updated every 60 months. The file of Volunteer #2 contained a State Police Clearance dated 11/17/22 with a previous one dated 9/26/17. The file of Volunteer #2 contained DHS FBI Clearances dated 10/31/17 and 10/31/19.

Corrected Corrected by Oct 23, 2024

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

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

On 10/23/24 observed a first-aid kit in the cabinet under the sink in the Blue Room which was accessible to children.

Corrected Corrected by Oct 23, 2024

Marked corrected in the state record.

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

On 10/23/24 observed a blue large tote in the hallway leading to the outdoor play spaces containing large LEGOs with approximately 1-inch crack on two sides of it. On 10/23/24 observed a caterpillar tunnel with rough edges on both the front and back in the Toddler Play Space. On 10/23/24 observed a Little Tykes Cozy Coupe with a cracked gas cap creating rough edges in the Toddler Play Space. On 10/23/24 observed a mat labeled #1 with approximately a 1-inch tear in the Blue Room. On 10/23/24 observed a cracked blue square Magna Tile with an exposed magnet in the SACC Room. On 10/23/24 observed cracked LEGOS with rough edges in the SACC Room. On 10/23/24 observed a red and orange climbing wedge with approximately a 1-inch hole in the Orange Room. On 10/23/24 observed a blue and green rectangular climbing block with approximately 1/2-inch tears on the corners in the Orange Room. On 10/23/24 observed wooden blocks with rough edges in the Yellow Room.

Corrected Corrected by Oct 23, 2024

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

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.

On 10/23/24 observed foam blocks with bite marks on a shelf in the hallway leading to the outdoor play spaces.

Corrected Corrected by Oct 23, 2024

Category: physical safety. 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.

Emergency contact information for Child #1 did not include the health insurance policy number for a child under a family policy or Medical Assistance benefits, if applicable.

Corrected Corrected by Nov 1, 2024

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

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

Emergency contact information for Child #2 did not include the address of the individual designated by the parent to whom the child may be released.

Corrected Corrected by Nov 1, 2024

Category: recordkeeping. Marked corrected in the state record.

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

The file of Child #3 lacked an updated health report at least every 12 months for an older toddler or preschool child. The file of Child #3 contained a health report dated 1/15/24 with a previous one dated 12/14/23.

Corrected Corrected by Oct 23, 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 files of Volunteer #2 and Staff #3 lacked a health assessment conducted every 24 months (SEE LIS Code Sheet). The file of Volunteer #2 contained only a health assessment dated 10/26/23. The file of Staff #3 contained a current health assessment dated 10/18/24 with a previous one dated 9/6/22.

Corrected Corrected by Oct 23, 2024

Category: ratio. Marked corrected in the state record.

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

The emergency contact and agreement for Child #3 were not reviewed and updated at least once in a 6-month period. Child #3's emergency contact was reviewed on 4/2/23, 3/22/24, and 8/21/24. Child #3's agreement was reviewed on 5/19/23, 3/22/24, 5/29/24, and 8/16/24.

Corrected Corrected by Oct 23, 2024

Category: recordkeeping. Marked corrected in the state record.

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

The facility was unable to provide documentation that the fire detection system was inspected by a fire safety professional annually. The facility provided documentation the fire detection system was inspected by a fire protection professional on 4/19/23 and 9/27/24.

Corrected Corrected by Oct 23, 2024

Category: recordkeeping. Marked corrected in the state record.

3270.27(a)(2) · The facility shall have an emergency plan that provides for accommodations for evacuation of children from the facility building and evacuation of children to a location away from the facility premises. The evacuation routes and evacuation plans to exit the building may be the same as those required by §3270.94 (relating to fire drills).

The facility's emergency plan did not provide for accommodations for evacuation of children to a location away from the facility premises.

Corrected Corrected by Nov 1, 2024

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

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

The file of Staff #3 lacked documentation of obtaining an annual minimum of 12 clock hours of child care training.

Corrected Corrected by Dec 30, 2024

Category: recordkeeping. Marked corrected in the state record.

3270.31(e)(4)(iv) · Competence in water safety instruction is demonstrated by the completion of basic instruction in water safety from a certified lifeguard.

The file of Staff #1 lacked documentation of completing basic instruction in water safety from a certified lifeguard.

Corrected Corrected by Jul 16, 2024

Category: recordkeeping. Marked corrected in the state record.

3270.27(b) · The operator shall review the emergency plan at least annually and update the plan as needed. The operator shall document in writing each review and update of the emergency plan and kept on file at the facility.

At the time of the inspection, upon reviewing the emergency plan, it was determined the plan had not been updated with the new director.

Corrected Corrected by Dec 13, 2023

Category: recordkeeping. Marked corrected in the state record.

3270.91(a) · Stairways, hallways, exits from rooms, exits from the facility and other means of egress serving as an exit shall be unobstructed.

At the time of the inspection, one of the interior doors in the gross motor space that leads to an unmeasured, uncertified office was blocked with cabinets.

Corrected Corrected by Dec 18, 2023

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

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

At the time of the inspection, observed in the preschool room foam building blocks with bite barks.

Corrected Corrected by Dec 9, 2023

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

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

At approximately 12:35 pm, observed in the toddler room, children #6 and #7 sleeping on rest equipment 1 foot 8 inches apart from each other.

Corrected Corrected by Dec 8, 2023

Category: physical safety. 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.

At the time of the inspection, the file of child #1 lacked an emergency contact form with the address of the child's physician or source of medical care. At the time of the inspection, the files of children #2 and #4 lacked emergency contact forms with phone numbers of the child's physician or source of medical care.

Corrected Corrected by Dec 14, 2023

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

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

The file of child #2 lacked an emergency contact form with the enrolling parent's work address. The files of children #1 and #2 lacked an emergency contact forms with the enrolling parents' work phone numbers.

Corrected Corrected by Dec 14, 2023

Category: recordkeeping. Marked corrected in the state record.

3270.124(b)(5)/3270.182(4) · 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. A child's record shall contain signed parental consent for administration of medications or special dietary needs.

The file of child #1 lacked an emergency contact form with 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 or NA if not applicable.

Corrected Corrected by Dec 14, 2023

Category: ratio. 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 file of children #1 and #4 lacked emergency contact forms with the full addresses of the individuals designated by the parents to whom the children may be released.

Corrected Corrected by Dec 14, 2023

Category: recordkeeping. Marked corrected in the state record.

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

At the time of the inspection, there were not copies of the emergency contact forms present in the classroom where children # and #5 were receiving care.

Corrected Corrected by Dec 8, 2023

Category: recordkeeping. Marked corrected in the state record.

3270.66(d) · Toxic plants are not permitted in a child care space.

Observed a green vine plant with red egg-shaped berries located in the outdoor play space used for pre-school and school age children. Based on research of the plant, it is identified as Bittersweet Nightshade and is poisonous when consumed.

Corrected Corrected by Sep 6, 2023

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

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

Observed in the playground used by pre-school and school-age children, a partially broken large tree limb which hangs over the play space; a thorn bush with limbs through the chain link fencing, accessible to children; and thorny weeds throughout the back half of the play space.

Corrected Corrected by Aug 29, 2023

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

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

Observed a 6 outlet extension cord in on the windowsill in the preschool/school- age room that lacked 1 receptacle cover.

Corrected Corrected by Aug 29, 2023

Marked corrected in the state record.

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

Observed Barbasol brand shaving cream labeled, "keep out of the reach of children" stored in a cabinet with other crafts items. Upon conversation with staff, it was determined the toxic is used by chidlren.

Corrected Corrected by Aug 29, 2023

Category: ratio. Marked corrected in the state record.

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

Observed in the outdoor play space used by toddlers, a table with splintering wood on the base.

Corrected Corrected by Aug 29, 2023

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

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

Staff #2 and #3 had not completed the required 1 hour Health and Safety update by 12-30-23 due to the fact staff #2 completed it on 1-31-23; staff #3 completed it on 3-13-23 (see LIS code sheet).

Corrected Corrected by Jun 30, 2023

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). SAFETY PLAN: The operator is required to submit to the Children and Youth Agency a plan of supervision or alternate arrangement as required by the Child Protective Services Law. LACKING REQUIRED HIRING DOCUMENTS: Facility Person # 1 may not work in a child care position at the facility. PROVISIONAL HIRE UNSUPERVISED: A provisional employee may not be permitted to work alone with children and must work within the vicinity of a permanent employee. 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 may not work in a child care position at the facility.

The file of staff #1 had documentation of living in West Virgina in the last 5 years, but lacked clearances from West Virginia.

Corrected Corrected by Jun 27, 2023

Category: supervision. Marked corrected in the state record.

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

Observed in the toddler room at the end of the hallway on the left, a wooden table with a broken leg.

Corrected Corrected by Jun 26, 2023

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

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

Observed an Epi-Pen labeled for child #1 with an expiration date of 1/2023. Observed an Epi-Pen labeled for child #2 with an expiration date of 2/2023..

Corrected Corrected by Jun 27, 2023

Category: ratio. Marked corrected in the state record.

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

The following staff were listed as present for fire drills on the fire drill log for the dates: 12-8-22, 1-6-23, 2-3-23, and 2-21-23, staff #1, #2, and #3. However, timecards gathered for the above dates show the staff were not present at the time the fire drill was listed as taking place on said dates.

Corrected Corrected by Mar 31, 2023

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.

The file of staff #1 lacked documentation of completing the required 1 hour Health and Safety update training by 12-20-22, due to the fact it was completed on 3-13-23.

Corrected Corrected by Apr 25, 2023

Category: ratio. Marked corrected in the state record.

20.71(a)(7) · The Department may deny, refuse to renew or revoke a certificate of compliance for fraud or deceit in obtaining or attempting to obtain a certificate of compliance.

During an unannounced inspection, the following information was gathered. Nearly all staff stated they had not participated in a fire drill since the Fall of 2022. During interviews with staff, it was disclosed that one staff person overheard staff person #2 direct staff person #3 to lie to the department and just "play dumb teenager." Staff person #2 admitted during interviews that she fudged the fire drill log because she was just trying to do a good job. She insisted no administration told her to falsify the document.

Corrected Corrected by Apr 25, 2023

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 file of child #1 lacked an agreement with the enrollment date.

Corrected Corrected by Nov 29, 2022

Category: recordkeeping. Marked corrected in the state record.

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

The file of child #3 lacked an agreement with the child's arrival and departure times.

Corrected Corrected by Nov 29, 2022

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.

Staff person #1 did not complete the following required pre-service training within 90 days of their date of hire (see LIS code sheet): emergency plan training.

Corrected Corrected by Nov 29, 2022

Category: recordkeeping. Marked corrected in the state record.

3270.31(e)(1)(iv) · Training conducted with audio-visual materials recognized by childcare professionals is acceptable and may count toward the annual requirement for 12 clock hours of childcare training.

At the time of reviewing the file, the file of staff #3 lacked documentation of completing the annual requirement for 12 clock hours of childcare training. (see LIS code sheet)

Corrected Corrected by Nov 2, 2022

Category: recordkeeping. Marked corrected in the state record.

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

At the time of reviewing files, staff person #3 did not complete the following required pre-service training within 90 days of their date of hire (see LIS code sheet): 10 hours health and safety training.

Corrected Corrected by Nov 29, 2022

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

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

The file of staff #3 lacked an evaluation, (see LIS code sheet).

Corrected Corrected by Dec 9, 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 files of children #2 and #3 lacked emergency contact forms with information on the child's special needs or NA if not applicable.

Corrected Corrected by Nov 29, 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 of child #3 lacked an emergency contact form with the policy number for a child under a family policy or Medical Assistance benefits, if applicable.

Corrected Corrected by Nov 29, 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 file of child #3 lacked an emergency contact form with the address of the individual designated by the parent to whom the child may be released.

Corrected Corrected by Nov 29, 2022

Category: recordkeeping. Marked corrected in the state record.

3270.151(a)/3270.192(3) · A facility person providing direct care who comes into contact with the children or who works with food preparation shall have a health assessment conducted within 12 months prior to providing initial service in a child care setting and every 24 months thereafter. A health assessment is valid for 24 months following the date of signature, if the person does not contract a communicable disease or develop a medical problem. A facility person's record shall include a written report of initial and subsequent health assessments, including the results of initial and subsequent tuberculin skin tests, x-rays or other medical documentation necessary to confirm freedom from communicable tuberculosis.

The file of staff #2 lacked health assessment within 24 months due to the fact the health assessments on file were dated 7-30-20 and 9-6-22.

Corrected Corrected by Nov 29, 2022

Category: ratio. 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.

At the time of the inspection, there was not documentation the emergency plan was sent to the local municipality.

Corrected Corrected by Nov 29, 2022

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

3270.36(b)(5)/3270.192(2)(iii) · 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 following the outset of service at the facility.

Second citation, previously cited on 5-17-22. The file of staff #6, an Assistant Group Supervisor, lacked documentation to support the position due to the fact the documentation of experience provided by staff #6 was not verified by the Human Resource Department of the facility.

Corrected Corrected by Sep 28, 2022

Category: supervision. Marked corrected in the state record.

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

The files of staff #1, #2, #3, #4, #5, #6, #7, #8, and #9 lacked Pediatric First Aide and CPR training completed by a qualified instructor. The operator has 30 days to inform the trainer to become PQAS certified or get all staff trained by a PQAS certified trainer.

Corrected Corrected by Jul 26, 2022

Category: ratio. Marked corrected in the state record.

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

*Based on interviews with staff, it was found that staff #1 and staff #2 have been observed pulling children by the lower and upper arms. It was disclosed that staff #1 has grabbed younger toddler aged children by the shoulders and shook the child. It was also disclosed that on another occasion staff #1 yanked the arm of one younger aged toddler and dragged the child by the wrist across the floor approximately 3 feet.

Corrected Corrected by May 24, 2022

Marked corrected in the state record.

3270.113(b) · The operator will contact ELRC 6 and arrange for all facility staff to complete a book study regarding powerful interactions. This book study should be followed up by role modeling and TA conducted by ELRC 6 staff.

**Based on interviews with staff, it was found that staff #1 and staff #2 have been observed pulling children by the lower and upper arms. It was disclosed that staff #1 has grabbed younger toddler aged children by the shoulders and shook the child. It was also disclosed that on another occasion staff #1 yanked the arm of one younger aged toddler and dragged the child by the wrist across the floor approximately 3 feet.

Corrected Corrected by Sep 24, 2022

Marked corrected in the state record.

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

The file of staff #1 had a Child Abuse clearance for the purpose of volunteer.

Corrected Corrected by Jul 27, 2022

Category: background checks. 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.

At approximately 11:30, observed staff #2 with 11 preschool aged children in the "purple room." The preschool age children were 3, 4, and 5 years old. Staff #2 reported that staff #3 had 6 preschool children at the restroom.

Corrected Corrected by Jul 27, 2022

Category: ratio. Marked corrected in the state record.

3270.119 · Infants shall be placed in the sleeping position recommended by the American Academy of Pediatrics unless there is a medical reason an infant should not sleep in this position. The medical reason shall be documented in a statement signed by a physician, physician's assistant or CRNP and placed in the child's record at the facility.

At approximately 11:45, observed in the infant room child #1 sleeping in a pea pod swing rather than placed in the sleeping position recommended by the American Academy of Pediatrics.

Corrected Corrected by Jul 27, 2022

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

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

Observed in the Red Room, expired diaper cream: child #2 Desitin expired 10-21. Observed in the Orange Room, expired Children's Motrin for child #3 expired 3-22.

Corrected Corrected by May 13, 2022

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

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

The file for staff person #7 was observed not to contain documentation of completion of Mandated Reporter Training within the first 90 days of hire (See LIS CODE SHEET).

Corrected Corrected by May 27, 2022

Category: recordkeeping. Marked corrected in the state record.

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

The file for staff person #8 was observed not to contain documentation of a Disclosure Statement at time of hire (See LIS CODE SHEET).

Corrected Corrected by May 27, 2022

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

3270.36(b)(5)/3270.192(2)(iii) · 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 following the outset of service at the facility.

The file of staff #6, an Assistant Group Supervisor, lacked documentation to support the position due to the fact there was only 100 hours of experience with children on file.

Corrected Corrected by May 27, 2022

Category: supervision. Marked corrected in the state record.

3270.82(j) · A source of running water for handwashing shall be present in infant and toddler diapering areas. If the running water does not flow directly into a drain that is connected to a sewage system, a receptacle shall be provided to contain the water used for washing. The receptacle shall be emptied into an approved sewage system at least once a day.

Observed in the Yellow room and in the SACC room sinks that drained into a bucket. Based on conversations with staff, the bucket is not emptied into an approved sewage system at least once a day.

Corrected Corrected by May 9, 2022

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

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.

Observed outside the Blue Room, rest mat #11 not in good repair due to the fact it was torn along the side. Observed outside the Green Room, rest mats #5, #15, #13, #4, #7, #11, and another #5 not in good repair due to the fact each were torn; some in many places.

Corrected Corrected by May 13, 2022

Category: physical safety. 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 file of child #1 lacked an emergency contact form with the full address of the individual designated by the parent to whom the child may be released.

Corrected Corrected by May 13, 2022

Category: recordkeeping. Marked corrected in the state record.

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

The files for staff persons #1, #2, #6, and #8 were observed not to have completed pre-service training within 90 days of hire (See LIS CODE SHEET). The file for staff person #4, was observed not to have completed pre-service training within 90 days of hire (See LIS CODE SHEET). The pre-service training on file for staff person # 4 was dated 9-1-16.

Corrected Corrected by Jul 22, 2022

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

3270.31(e)/3270.192(2)(iii) · A staff person shall obtain an annual minimum of 12 clock hours of child care training. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

The files of staff #2 and #5 lacked documentation of completing the annual minimum of 12 clock hours of child care training due to the fact there were no transcripts in the files.

Corrected Corrected by May 27, 2022

Category: recordkeeping. 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. TIERED LIS: Children must be supervised at all times. The legal entity must arrange for all facility staff to receive a minimum of two hours of training regarding supervision of children. The legal entity must receive DHS approval of the training content prior to scheduling the training. The legal entity must submit documentation in a format approved by DHS proving that the facility procedure for counting children is followed at all times e.g., a checklist. The legal entity will confirm continuing compliance by sending copies of the documentation to the Regional Office of Child Development and Early Learning on a weekly basis for a period of three months after DHS approves the documentation format.

On 4-7-22, staff did not observe when and how child #1 was bitten. Staff #1 was in the kitchen area of the orange room and staff #2 was on the floor in the childcare space. Staff #1 and staff #2 had checked child #1 and found the bite. Staff #2 reported she didn't see anything happen. She heard child #1 cry and staff #1 said, "I think child #2 just bit child #1." Staff #2 picked up child #1. Staff #2 and staff #1 checked child #1 all over, noticed a wet mark on child's sleeve and noticed the mark, applied ice, and then, "···it looked like it disappeared."

Corrected Corrected by Sep 24, 2022

Category: supervision. Marked corrected in the state record.

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

An incident report was not written on 4-7-22 after child #1 was bitten. Also, on at least 2 other occasions staff person #1 did not write incident reports or tell parents when a child has been bitten in the classroom. It was reported that staff #1 had lied on incident reports to make the fault of other staff. This started in December 2021 and has been ongoing. It was reported 12 bites happened in the course of 16 days during the months of March and April. Staff #1 was present in the classroom for all incidents; and for at least 2 of the incidents, staff #1 did not write incident reports or tell the parents.

Corrected Corrected by Jun 14, 2022

Category: health medication. 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. Children must be supervised at all times.

*Video footage shows child #1 falling approximately 2 feet 7 inches over the railing of the loft in the orange room at approximately 10:30 am on 4/20/2022. Child #1 sustained an injury from this fall. At the time of the incident, staff person #1 can be seen on video standing with their back to all of the children in the room and staff person #2 is sitting on the floor with their head turned in the opposite direction from which child #1 and the loft are located. Neither staff person #1 or staff person #2 was able to effectively supervise all of the children in the classroom from their positions. Neither staff person #1 or staff person #2 attended to child #1 at the time of the fall. Approximately 1 minute passes before child #1 got up off of the ground and walked over to staff person #1. Also, neither staff person in the classroom was able to identify the children whom they were assigned the specific responsibility to supervise. At approximately 10:34 am staff messaged the mother of child #1 stating that the child was crying uncontrollably and don't know why. It was not until approximately 3:27 pm that staff notified the mother of child #1 to pick their child up because the child was favoring their left arm. Facility staff did not know how the child sustained their injury until the morning of 4/21/2022 when they had to watch the video in the classroom to find out what had happened to child #1 to cause them to sustain an injury.

Corrected Corrected by May 24, 2022

Category: supervision. Marked corrected in the state record.

3270.113(a) · The legal entity will contact ELRC 6 to arrange for all staff to take in person supervision training presented by ELRC 6 staff.

**Video footage shows child #1 falling approximately 2 feet 7 inches over the railing of the loft in the orange room at approximately 10:30 am on 4/20/2022. Child #1 sustained an injury from this fall. At the time of the incident, staff person #1 can be seen on video standing with their back to all of the children in the room and staff person #2 is sitting on the floor with their head turned in the opposite direction from which child #1 and the loft are located. Neither staff person #1 or staff person #2 was able to effectively supervise all of the children in the classroom from their positions. Neither staff person #1 or staff person #2 attended to child #1 at the time of the fall. Approximately 1 minute passes before child #1 got up off of the ground and walked over to staff person #1. Also, neither staff person in the classroom was able to identify the children whom they were assigned the specific responsibility to supervise. At approximately 10:34 am staff messaged the mother of child #1 stating that the child was crying uncontrollably and don't know why. It was not until approximately 3:27 pm that staff notified the mother of child #1 to pick their child up because the child was favoring their left arm. Facility staff did not know how the child sustained their injury until the morning of 4/21/2022 when they had to watch the video in the classroom to find out what had happened to child #1 to cause them to sustain an injury.

Corrected Corrected by Sep 24, 2022

Category: supervision. Marked corrected in the state record.

3270.113(a) · The legal entity will contact ELRC 6 to arrange for Start up TA to conduct a minimum of 1 classroom observation in the orange room per month over a period of 4 months. The legal entity will work with ELRC staff to implement any recommendations made from classroom observations.

***Video footage shows child #1 falling approximately 2 feet 7 inches over the railing of the loft in the orange room at approximately 10:30 am on 4/20/2022. Child #1 sustained an injury from this fall. At the time of the incident, staff person #1 can be seen on video standing with their back to all of the children in the room and staff person #2 is sitting on the floor with their head turned in the opposite direction from which child #1 and the loft are located. Neither staff person #1 or staff person #2 was able to effectively supervise all of the children in the classroom from their positions. Neither staff person #1 or staff person #2 attended to child #1 at the time of the fall. Approximately 1 minute passes before child #1 got up off of the ground and walked over to staff person #1. Also, neither staff person in the classroom was able to identify the children whom they were assigned the specific responsibility to supervise. At approximately 10:34 am staff messaged the mother of child #1 stating that the child was crying uncontrollably and don't know why. It was not until approximately 3:27 pm that staff notified the mother of child #1 to pick their child up because the child was favoring their left arm. Facility staff did not know how the child sustained their injury until the morning of 4/21/2022 when they had to watch the video in the classroom to find out what had happened to child #1 to cause them to sustain an injury.

Corrected Corrected by Sep 24, 2022

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.

*Video footage shows child #1 falling approximately 2 feet 7 inches over the railing of the loft in the orange room at approximately 10:30 am on 4/20/2022. Child #1 sustained an injury from this fall. At the time of the incident, staff person #1 can be seen on video standing with their back to all of the children in the room and staff person #2 is sitting on the floor with their head turned in the opposite direction from which child #1 and the loft are located. Neither staff person #1 or staff person #2 was able to effectively supervise all of the children in the classroom from their positions. Neither staff person #1 or staff person #2 attended to child #1 at the time of the fall. Approximately 1 minute passes before child #1 got up off of the ground and walked over to staff person #1. Also, neither staff person in the classroom was able to identify the children whom they were assigned the specific responsibility to supervise. At approximately 10:34 am staff messaged the mother of child #1 stating that the child was crying uncontrollably and don't know why. It was not until approximately 3:27 pm that staff notified the mother of child #1 to pick their child up because the child was favoring their left arm. Facility staff did not know how the child sustained their injury until the morning of 4/21/2022 when they had to watch the video in the classroom to find out what had happened to child #1 to cause them to sustain an injury.

Corrected Corrected by May 24, 2022

Category: supervision. Marked corrected in the state record.

3270.113(a)(1) · The operator will develop and implement a physical means of assigning children to staff for the purpose of maintaining compliance with staff to child ratio and the supervision of children. OCDEL will approve the plan before its implementation. (Example: photo name tags with the child's ratio category that a staff person can keep while the child is assigned to them.)

**Video footage shows child #1 falling approximately 2 feet 7 inches over the railing of the loft in the orange room at approximately 10:30 am on 4/20/2022. Child #1 sustained an injury from this fall. At the time of the incident, staff person #1 can be seen on video standing with their back to all of the children in the room and staff person #2 is sitting on the floor with their head turned in the opposite direction from which child #1 and the loft are located. Neither staff person #1 or staff person #2 was able to effectively supervise all of the children in the classroom from their positions. Neither staff person #1 or staff person #2 attended to child #1 at the time of the fall. Approximately 1 minute passes before child #1 got up off of the ground and walked over to staff person #1. Also, neither staff person in the classroom was able to identify the children whom they were assigned the specific responsibility to supervise. At approximately 10:34 am staff messaged the mother of child #1 stating that the child was crying uncontrollably and don't know why. It was not until approximately 3:27 pm that staff notified the mother of child #1 to pick their child up because the child was favoring their left arm. Facility staff did not know how the child sustained their injury until the morning of 4/21/2022 when they had to watch the video in the classroom to find out what had happened to child #1 to cause them to sustain an injury.

Corrected Corrected by Sep 24, 2022

Category: supervision. Marked corrected in the state record.

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

An incident report was not filed the day of the injury based on conversation with staff #3 who stated, "An incident report wasn't done until the next day, 4-21-22 because they had to review the classroom video to determine how child #1 got injured."

Corrected Corrected by May 24, 2022

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

3270.113(a) · **The facility will contact ELRC 6 to arrange for start up TA to assess the environment to ensure supervision can be maintained during nap time.

**3rd citation. Previously cited on 10/20/21 and 12/2/21. At approximately 12:00 PM Certification Staff observed 1 child lying on rest equipment between 2 bookcases in the Blue Classroom which did not allow critical oversight in which the supervisor could see, hear, direct, and assess the activity of the supervisee. At approximately 12:15 PM Certification Staff observed 1 child lying on rest equipment behind a bookcase in the Yellow Classroom which did not allow critical oversight in which the supervisor could see, hear, direct, and assess the activity of the supervise

Corrected Corrected by Feb 7, 2022

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. Children must be supervised at all times.

*3rd citation. Previously cited on 10/20/21 and 12/2/21. At approximately 12:00 PM Certification Staff observed 1 child lying on rest equipment between 2 bookcases in the Blue Classroom which did not allow critical oversight in which the supervisor could see, hear, direct, and assess the activity of the supervisee. At approximately 12:15 PM Certification Staff observed 1 child lying on rest equipment behind a bookcase in the Yellow Classroom which did not allow critical oversight in which the supervisor could see, hear, direct, and assess the activity of the supervise

Corrected Corrected by Dec 27, 2021

Category: supervision. 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.

2nd citation. Previously cited on 10/20/21. Staff #2 lacked documentation of training regarding the emergency plan on an annual basis. Staff #2 had documentation of training regarding the emergency plan completed on 7/16/19.

Corrected Corrected by Dec 10, 2021

Category: recordkeeping. Marked corrected in the state record.

3270.37(c) · An aide or a combination of aides shall be supervised at all times by a staff person qualified at minimum as an assistant group supervisor.

At approximately 1:00 PM Certification Staff observed Staff #1, who was designated as an aide, caring for 4 young toddlers and 1 older toddler without being supervised by a staff person qualified at minimum as an assistant group supervisor in the Orange Classroom.

Corrected Corrected by Dec 10, 2021

Category: supervision. Marked corrected in the state record.

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

2nd citation. Previously cited on 10/20/21. Observed approximately a 6 inch hole in the building wall with exposed foam to the right of the door in the Preschool/School-Age Outdoor Play Space.

Corrected Corrected by Dec 10, 2021

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

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

2nd citation. Previously cited on 10/20/21. Observed rest mats with tears and exposed foam in the Orange and Blue Classrooms.

Corrected Corrected by Dec 10, 2021

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

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

2nd citation. Previously cited on 10/20/21. At approximately 1:15 PM Certification Staff observed 1 child lying on rest equipment behind a bookcase in the Yellow Classroom which did not allow critical oversight in which the supervisor could see, hear, direct, and assess the activity of the supervisee.

Corrected Corrected by Dec 10, 2021

Category: supervision. Marked corrected in the state record.

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

2nd citation. Previously cited on 10/20/21. Child #1 lacked a health report which included a statement that the child is able to participate in child care and appears to be free from contagious or communicable disease.

Corrected Corrected by Dec 10, 2021

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

3270.105 · High chairs shall have a wide base and a T-shaped safety strap.

On 10/20/21 observed one high chair in the Red/Pink Classrooms which lacked a T-shaped safety strap.

Corrected Corrected by Nov 12, 2021

Marked corrected in the state record.

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

On 10/20/21 the refrigerators in the Red/Pink and Purple Classrooms lacked a thermometer.

Corrected Corrected by Nov 12, 2021

Category: nutrition. Marked corrected in the state record.

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

On 10/20/21 observed adult scissors on the counter to the right of the sink in the Green Classroom which were accessible to children. On 10/20/21 observed adults scissors in a metal bucket on top of a plastic bin by the teacher's desk and adult scissors in the top drawer of the plastic bin in the Yellow Classroom which were accessible to children.

Corrected Corrected by Oct 20, 2021

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

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

The files of Staff #9 and #10 lacked documentation of training regarding the emergency plan on an annual basis. The file of Staff #9 contained documentation of training regarding the emergency plan completed on 5/15/19. The file of Staff #10 contained documentation of training regarding the emergency plan completed on 7/16/19.

Corrected Corrected by Nov 12, 2021

Category: recordkeeping. Marked corrected in the state record.

3270.31(f) · Staff persons shall complete professional development in the following topics within 90 days of hire:

The files of Staff #2, #3, #5, #7 and #11 lacked documentation of completing the health and safety training within 90 days of hire. Staff #2 had a hire date of 3/23/21 with documentation of completing health and safety training on 7/6/21. Staff #3 had a start date of 1/11/21 with no documentation of completing the health and safety training. Staff #5 had a hire date of 5/6/21 with documentation of completing the health and safety training on 10/4/21. Staff #7 had a hire date of 12/23/20 with documentation of completing the health and safety training on 7/30/21. Staff #11 had a hire date of 6/18/21 with no documentation of completing the health and safety training.

Corrected Corrected by Nov 12, 2021

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

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

The file of Staff #2 lacked a dated disclosure statement. The files of Staff #4 and #5 lacked a valid FBI clearance at the time of initial hire. The file of Staff #4, with a start date of 12/14/20, contained a Department of Education FBI Clearance dated 11/12/20 with a DHS FBI Clearance dated 9/27/21. The file of Staff #5, with a start date of 5/6/21, contained a Department of Education FBI Clearance dated 9/2/20 with a DHS FBI Clearance dated 10/1/21. The file of Staff #6 lacked a FBI Clearance dated prior to or on the date of initial hire. The file of Staff #6, with a start date of 6/7/21, contained a FBI Clearance dated 7/13/21. The file of Staff #11 lacked a FBI Clearance dated prior to or on the date of initial hire. The file of Staff #11, with a start date of 6/23/21 contained a FBI Clearance dated 7/8/21.

Corrected Corrected by Nov 12, 2021

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

3270.37(b)(3) · An aide shall have a minimum of an 8th grade education and 2 years of experience with children.

The file of Staff #8, who was designated as an aide, lacked documentation of a minimum of an 8th grade education.

Corrected Corrected by Oct 27, 2021

Category: recordkeeping. Marked corrected in the state record.

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

On 10/20/21 while Certification Staff was in the Green Classroom, Staff #1 left 3 preschoolers alone in the classroom while Staff #1 went into the hall to look for a child's coat in the cubbies.

Corrected Corrected by Oct 20, 2021

Category: ratio. Marked corrected in the state record.

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

On 10/20/21 the electrical outlet above the book case in the art station was missing a protective receptacle cover in the Green Classroom.

Corrected Corrected by Oct 20, 2021

Marked corrected in the state record.

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

On 10/20/21 observed Ginger Pear Hand Sanitizer which indicated "keep out of the reach of children" in the top drawer to the right of the refrigerator which was accessible to children in the Green Classroom. On 10/20/21 observed Mr. Clean Multi Surface Cleaner and Dawn Dish Detergent on the 2nd shelf from the bottom in the cabinet by the windows which were accessible to children in the School-Age Classroom.

Corrected Corrected by Oct 20, 2021

Marked corrected in the state record.

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

On 10/20/21 observed a first-aid kit on the bottom shelf of the wooden closet located to the left of the door which was accessible to children in the Green Classroom. On 10/20/21 observed a first-aid kit in a backpack on the floor beside the teacher's desk which was accessible to children in the Yellow Classroom.

Corrected Corrected by Oct 20, 2021

Marked corrected in the state record.

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

On 10/20/21 observed a red frayed area rug in the dress up area in the Purple Classroom. On 10/20/21 observed approximately a 6 inch hole in the building wall with exposed foam to the right of the door in the Preschool/School-Age Outdoor Play Space. On 10/20/21 observed loose weed fabric around the tree across from the Little Tykes House creating a potential tripping hazard in the Preschool/School-Age Outdoor Play Space.

Corrected Corrected by Nov 29, 2021

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

3270.82(g) · Toilet areas and fixtures shall be cleaned daily and be in good repair.

On 10/20/21 observed 2 toilets in the large bathroom which were not operable.

Corrected Corrected by Oct 29, 2021

Marked corrected in the state record.

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

On 10/20/21 the last stall in the large bathroom lacked a hand washing sign.

Corrected Corrected by Oct 20, 2021

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

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

On 10/20/21 observed rest mats with tears and exposed foam in the Orange Classroom, the Green Classroom, and the Blue Classroom. On 10/20/21 observed approximately a 12 inch tear with exposed foam on the seat of the blue child's sofa in the Green Classroom. On 10/20/21 observed a torn cloth block with exposed foam in the Blue Classroom. On 10/12/21 observed a collapsible fire truck with approximately a 2 by 2 inch tear at the bottom and a collapsible bus with approximately a 2 by 2 inch tear at the front and approximately a 1 by 1 inch tear in the back in the Blue Classroom. On 10/20/21 observed cracked red and green triangle magna tiles in the School-Age Classroom. On 10/20/21 observed interconnecting plastic links that were cracked with rough edges in the Purple Classroom. On 10/20/21 observed a broken locking mechanism, crack at the circle, and broken off knob on the green base for gears in the Purple Classroom. On 10/20/21 observed a cracked red square Magna Tile in the Yellow Classroom. On 10/20/21 observed a metal cabinet with loose knobs and rust along the base in the Gross Motor Room. On 10/20/21 observed approximately an 8 inch crack on the back board of the basketball hoop in the Preschool/School-Age Outdoor Play Space. On 10/20/21 observed a protruding screw on the roof of the Step 2 House in the Infant/Toddler Outdoor Play Space. On 10/20/21 observed a red, yellow, and blue tricycle with rust on the bar between the handle and seat and exposed foam on the handle in the Infant/Toddler Outdoor Play Space.

Corrected Corrected by Nov 12, 2021

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

3270.102(c) · Outdoor equipment that requires embedded mounting must be mounted over a loose-fill or unitary playground protective surface covering that meets the recommendations of the United States Consumer Product Safety Commission. The equipment must be anchored firmly and be in good repair.

On 10/20/21 observed embedded equipment in the Preschool/School-Age Outdoor Play Space with approximately 2 to 7 inches of mulch. The Consumer Product Safety Commission recommends 9 inches of mulch as protective surface covering.

Corrected Corrected by Nov 12, 2021

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

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.

On 10/20/21 observed plastic garbage bags under the sink in the Orange Classroom which were accessible to children. On 10/20/21 observed paper clips in the top drawer to the left of the refrigerator in the Blue Classroom which were accessible to children.

Corrected Corrected by Nov 12, 2021

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 10/20/21 while Certification Staff was in the Green Classroom, Staff #1 left 3 preschoolers alone in the classroom while Staff #1 went into the hall to look for a child's coat in the cubbies.

Corrected Corrected by Nov 12, 2021

Category: supervision. Marked corrected in the state record.

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

The file of Child #4 lacked the services to be provided to the family and child on the agreement.

Corrected Corrected by Nov 12, 2021

Category: recordkeeping. Marked corrected in the state record.

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

On 10/20/21 emergency contact information was not present for Child #5 while he/she was receiving care in the Orange Classroom.

Corrected Corrected by Nov 12, 2021

Category: recordkeeping. Marked corrected in the state record.

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.

On 10/20/21 the Yellow Classroom lacked a written plan identifying the means of transporting a child to emergency care and staffing provisions in the event of an emergency displayed conspicuously.

Corrected Corrected by Nov 12, 2021

Category: transportation. Marked corrected in the state record.

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

Child #3 lacked a health report which included a statement that the child is able to participate in child care and appears to be free from contagious or communicable diseases.

Corrected Corrected by Nov 12, 2021

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

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

Child #1 lacked a current influenza immunization in accordance with the schedule recommended by the ACIP. Child #2, an 18 month old, lacked DTAP/DTP/TD immunizations in accordance with the schedule recommended by the ACIP. The file of Child #2 contained documentation of 3 DTAP/DTP/TD immunizations.

Corrected Corrected by Nov 12, 2021

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 of Staff #6 lacked a health assessment conducted within 12 months prior to providing initial service in a child care setting. Staff #6 had a start date of 6/7/21 with a health assessment dated 7/15/21. The files of Staff #9 and #10 lacked a health assessment conducted every 24 months. The file of Staff #9 contained a current health assessment dated 4/23/21 with the previous one dated 4/22/19. The file of Staff #10 contained a current health assessment dated 6/28/21 with the previous one dated 6/26/19.

Corrected Corrected by Nov 12, 2021

Category: ratio. Marked corrected in the state record.

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

The file of Staff #12 lacked two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person. The file of Staff #12 contained only one reference from a nonfamily member.

Corrected Corrected by Nov 12, 2021

Category: recordkeeping. Marked corrected in the state record.

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

The facility did not have an emergency plan that provided for accommodations for infants, toddlers, and children with chronic medical conditions.

Corrected Corrected by Nov 12, 2021

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

3270.31(f)(10) · Pediatric first aid and pediatric cardiopulmonary resuscitation.

The file of Staff #3, #7, #8, and #11 lacked documentation of completing professional development in pediatric first aid and pediatric cardiopulmonary resuscitation within 90 days of hire. Staff #3 had a hire date of 1/11/21 with documentation of pediatric first aid and pediatric cardiopulmonary resuscitation being completed on 6/8/21. Staff #7 had a hire date of 12/23/20 with documentation of pediatric first aid and pediatric cardiopulmonary resuscitation being completed on 6/8/21. Staff #8 had a hire date of 1/26/21 with documentation of pediatric first aid and pediatric cardiopulmonary resuscitation being completed on 6/8/21. Staff #11 had a hire date of 6/23/21 with no documentation of completing pediatric first aid and pediatric cardiopulmonary resuscitation.

Corrected Corrected by Nov 12, 2021

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

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

The Director or designated staff person did not ensure that fire drills were conducted at least once every 60 days. Fire drills were conducted on 10/9/20, 12/14/20, 2/12/21, 3/10/21, 5/10/21, 7/9/21, and 9/10/21. The facility was closed from 11/26/20 through 12/10/20.

Corrected Corrected by Nov 12, 2021

Category: recordkeeping. Marked corrected in the state record.