3280.32(a)/3280.192(4) · The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). 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. Staff Person #3 may not work in a in a childcare position with direct contact with children until the missing clearances (State police, DHS FBI and National Sex Registry Offender (NSOR) are completed and on file at the facility.

On 4/17/2025, Staff #3 a new hire was observed to be in the facility working with children. Staff #3 did not have the clearances or the clearance requests on file for the following clearances: State police, DHS FBI and National Sex Registry Offender (NSOR).

Corrected Corrected by Jun 5, 2025

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

3280.51/3280.61(c) · No more than 12 children unrelated to the operator may simultaneously receive care except in a facility serving older school-age children. In a facility serving only older school-age children, a certificate of compliance may be issued for up to 15 children unrelated to the operator. Indoor childcare space is measured within permanent stationary partitions or walls. The allowable number of children in a space is determined by dividing the total square feet in a space by 40. TIERED LIS: 1. No more than 11 children unrelated to the operator may be present in the facility one time. No more 8 children may occupy the front room of the facility at one time. This portion of the plan shall have an immediate correction date. 2. The Legal Entity/Operator shall submit a list to the Northeast Regional Office of all children who are enrolled at the facility as well as the weekly attendance schedule and scheduled hours for all enrolled children for a period of 3 months. The weekly schedule shall include the scheduled days and hours of care for each enrolled child. The schedule for the enrolled children shall be sent to the Northeast Regional Office by the close of business each Friday for the following week going from Saturday to Friday. The correction date for this portion of the plan shall be at minimum 3 months from the date the regional office receives acceptable plans of correction.

On 4/17/2025 at 5:10 PM, 16 children were observed to be in the front room of the facility. The front room of the facility only has a measured capacity for 8 children. In addition, the facility only has a measured capacity for 11 children.

Corrected Corrected by Aug 22, 2025

Category: ratio. Marked corrected in the state record.

3280.52(c) · When children are grouped in mixed age levels, the age of the youngest child in the group determines the staff:child ratio and maximum group size in accordance with the requirements at §3280.52(b). The required staff: child ratios must be maintained at all times. TIERED LIS: 1. The required staff: child ratios must be maintained at all times. This portion of the plan shall have an immediate correction date. 2. The legal entity shall submit a weekly staff schedule to the Northeast Regional Office for a period of 3 months. The weekly staff schedule shall document the staff that are scheduled to work daily for the 1st, 2nd and 3rd shifts. The weekly staff schedule shall be sent to the Northeast Regional Office by the close of business each Friday for the following week going from Saturday to Friday. The correction date for this portion of the plan shall be at minimum 3 months from the date the regional office receives acceptable plans of correction.

On 4/17/2025 at 5:10 PM, Staff #2 and Staff #3 were observed providing care for a mixed age group of 16 children. There was 1 infant, 1 young toddler, 1 older toddler and a combination 13 preschool and young school age children. This mixed age group of children requires three staff to maintain the required staff to child ratios.

Corrected Corrected by Aug 22, 2025

Category: ratio. Marked corrected in the state record.

3280.151(a)/3280.151(c)(2) · 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 childcare 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. 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.

On 4/17/2025, Staff #3 did not have a completed health assessment or tuberculosis screening on file. See LIS code sheet.

Corrected Corrected by Jun 12, 2025

Category: ratio. Marked corrected in the state record.

3280.94(a)(1)/3280.95(a) · The primary staff person 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. 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 fire alarm system must be manually tested at least once every 30 days.

On 4/17/2025, the Fire Drill/Fire Detection log showed that the last fire drill and manual system check of the fire alarm system was done on 2/15/2025.

Corrected Corrected by Apr 17, 2025

Category: recordkeeping. Marked corrected in the state record.

3280.31(e)(4)(i) · Competence is the completion of training by a professional in the field of first-aid and 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.

During the Renewal Inspection on 1/3/2025, Staff #1, #2 and #3 all had current certification pediatric first aid and pediatric cardiopulmonary resuscitation (CPR) on file as of 9/24/2024. However, the previous certification on file for Staff #1, #2 and #3 expired at the end of July 2024.

Corrected Corrected by Sep 24, 2024

Category: ratio. Marked corrected in the state record.

3280.61(c) · Indoor child care space is measured within permanent stationary partitions or walls. The allowable number of children in a space is determined by dividing the total square feet in a space by 40.

During the Renewal Inspection on 1/8/2025, 12 children were observed to be in the front two rooms of the facility. The front two rooms of the facility only have a measured capacity for 8 children. In addition, the facility only has a measured capacity for 11 children.

Corrected Corrected by Jan 22, 2025

Category: ratio. Marked corrected in the state record.

3280.76 · 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.

During the Renewal Inspection on 1/3/2025, a hole about the size of a mini basketball was observed in the bathroom door.

Corrected Corrected by Jan 6, 2025

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

3280.131(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.

During the Renewal Inspection on 1/3/2025, the most recent health report on file for Child #1, a preschool child was dated 7/28/2023.

Corrected Corrected by Jan 6, 2025

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

3280.14/3280.20 · 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. Childcare providers must ensure that federal requirements @ 45 CFR 98.41(a)(l)(vi). Certified childcare providers must have a policy and procedure to identify the prevention of shaken baby syndrome, abusive head trauma and child maltreatment.

The facility does not have a policy in place to identify the prevention of shaken baby syndrome, abusive head trauma and child maltreatment.

Corrected Corrected by Dec 23, 2023

Category: ratio. Marked corrected in the state record.

3280.14/3280.20 · 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 facility does not have a plan to address continuity of operations.

Corrected Corrected by Dec 20, 2023

Category: ratio. Marked corrected in the state record.

3280.26(b) · The operator shall review the emergency plan at least annually and update the plan as needed. Each review and update of the emergency plan shall be documented in writing and kept on file at the facility.

Operator has not reviewed and/or updated the emergency plan annually, date of last review 11/30/22.

Corrected Corrected by Dec 20, 2023

Category: recordkeeping. Marked corrected in the state record.

3280.26(f) · The operator shall send a copy of the emergency plan and subsequent plan updates to the local municipality and to the county emergency management agency.

The operator has not sent a copy of the emergency plan and subsequent plan updates to the local municipality and to the county emergency management agency annually.

Corrected Corrected by Dec 20, 2023

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

3280.32(a)/3280.192(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 has a state police clearance dated 4/17/17 and another 12/19/23 which exceeds the requirement of updating clearances every 60 months.

Corrected Corrected by Dec 19, 2023

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

3280.191 · An individual record is required for each facility person.

Cert Rep observed staff person #1 working with children on 5/23/23. Operator admitted staff person #1 does not have a file.

Corrected Corrected by May 23, 2023

Category: recordkeeping. Marked corrected in the state record.

3280.20/3280.65 · Conditions at the facility may not pose a threat to the health or safety of the children. Protective receptacle covers shall be placed in electrical outlets accessible to children 5 years of age or younger.

Child #1 put a toy into an uncovered outlet and Staff #1 witnessed a spark. At the time of the unannounced monitoring visit on 2/7/23 Cert Rep observed 3 outlets that were missing protective outlet covers, one was the outlet Child #1 put a toy into.

Corrected Corrected by Feb 18, 2023

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

3280.113(a) · Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Children must be supervised at all times.

Child #1 put a toy into an uncovered outlet and Staff #1 witnessed a spark.

Corrected Corrected by Feb 14, 2023

Category: supervision. Marked corrected in the state record.

3280.182(7) · A child's record must 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.

Child #1 put a toy into an uncovered outlet and Staff #1 witnessed a spark. Staff #1 did not create a written report for the incident therefor the parent never received one. Also, Staff #1 could not recall if they verbally told the parent about the incident. When questioned, Staff #2, the owner, reported that they were never notified of the incident by Staff #1.

Corrected Corrected by Feb 18, 2023

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

3280.95(b) · The primary staff person or designated staff person who is responsible for compliance with this chapter shall ensure the requirements in subsection (a) are met.

Operator has not been conducting fire system checks every 30 days. A system check was completed on 10/19/22 and another on 11/19/22 this is a span of 31 days. A system check was completed on 12/16/22 at the time of inspection.

Corrected Corrected by Dec 16, 2022

Category: recordkeeping. Marked corrected in the state record.

3280.95(b) · The primary staff person or designated staff person who is responsible for compliance with this chapter shall ensure the requirements in subsection (a) are met.

Operator has not been conducting fire system checks every 30 days. A system check was completed on 1/12/22 and another on 2/15/22 this is a span of 34 days. A system check was completed on 3/17/22 and another on 4/21/22 this is a span of 35 days.

Corrected Corrected by May 21, 2022

Category: recordkeeping. Marked corrected in the state record.

3280.26(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.

Staff person #1, 2 & 3 do not have proof of annual emergency plan training, date of last training 12/2/20.

Corrected Corrected by Dec 6, 2021

Category: recordkeeping. Marked corrected in the state record.

3280.32(a)/3280.192(4) · The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). LACKING REQUIRED HIRING DOCUMENTS: Facility Person #3 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.

Staff person #3 does not have an updated FBI clearance on file, date of last FBI 7/23/15. Staff person #3 does not have a NSOR clearance on file. Staff person #3 has an expired mandated reporter training dated 6/18/15. Staff person #3's date of hire 12/5/18.

Corrected Corrected by Dec 3, 2021

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

3280.123(a) · An agreement shall be signed by the operator and the parent.

Child #1 & 3 are missing the operator's signature on the agreement.

Corrected Corrected by Dec 3, 2021

Category: recordkeeping. Marked corrected in the state record.

3280.123(a)(3) · An agreement shall specify 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 at § 3280.124(f).

Child #1 & 3 are missing services to be provided to the family and the child.

Corrected Corrected by Dec 3, 2021

Category: recordkeeping. Marked corrected in the state record.

3280.123(a)(4) · An agreement shall specify the child's arrival and departure times.

Child #1 & 3 are missing the child's arrival and departure times.

Corrected Corrected by Dec 3, 2021

Category: recordkeeping. Marked corrected in the state record.

3280.123(a)(5) · An agreement shall specify the persons designated by a parent to whom the child may be released.

Child #1 & 3 are missing the persons designated by a parent to whom the child may be released.

Corrected Corrected by Dec 3, 2021

Category: recordkeeping. Marked corrected in the state record.

3280.123(a)(6)/3280.182(2) · An agreement shall specify the date of the child's admission.A child's record must contain the dates of application, admission and withdrawal of the child.

Child #1 & 3 are missing the child's date of admission.

Corrected Corrected by Dec 3, 2021

Category: recordkeeping. Marked corrected in the state record.

3280.124(b)(4)/3280.182(3) · Emergency contact information must include the written consent signed by a parent for emergency medical care. A child's record must contain signed parental consent for emergency medical care for the child. Written consent is required prior to admission.

Child #2 is missing signed parental consent for emergency medical care.

Corrected Corrected by Dec 3, 2021

Category: recordkeeping. Marked corrected in the state record.

3280.131(d)(5)/3280.182(1) · A health report shall include a review of the child's immunized status according to recommendations of the ACIP. A child's record must contain initial and subsequent health reports.

Child #2 does not have an initial health assessment or immunizations on file, date of admission 10/2/21.

Corrected Corrected by Dec 20, 2021

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

3280.182(5) · A child's record must contain signed parental consent for administration of minor first-aid procedures by facility staff. Written consent is required prior to admission.

Child #2 is missing signed parental consent form minor first aid.

Corrected Corrected by Dec 3, 2021

Category: ratio. Marked corrected in the state record.

3280.182(6) · A child's record must contain signed parental consent for transportation, walking excursions, swimming and wading.

Child #2 is missing signed parental consent for walking excursions.

Corrected Corrected by Dec 3, 2021

Category: transportation. Marked corrected in the state record.

3280.182(8) · A child's record must contain a copy of the initial agreement and subsequent written agreements between the parent and the operator. The parent receives the original agreement.

Child #2 does not have an initial agreement on file.

Corrected Corrected by Dec 6, 2021

Category: recordkeeping. Marked corrected in the state record.

3280.192(2)(ii)/3280.192(2)(iv) · A facility person's record shall include verification of child care experience, education and training prior to service at the facility.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.

Staff person #3 does not have proof of education on file.

Corrected Corrected by Dec 6, 2021

Category: recordkeeping. Marked corrected in the state record.

3280.26(a)(6) · Emergency drills shall be conducted annually. Annual emergency drills shall be documented and on file at the facility.

Operator admitted that she has not conducted an annual emergency drill.

Corrected Corrected by Dec 6, 2021

Category: recordkeeping. Marked corrected in the state record.

3280.94(a)(5) · The primary staff person or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that evacuation routes are posted in a conspicuous location on each floor of the facility.

The facility does not have evacuation routes posted in a conspicuous location within the child care space.

Corrected Corrected by Dec 3, 2021

Category: recordkeeping. Marked corrected in the state record.

3280.24(a) · The facility's current certificate of compliance shall be posted in a conspicuous location used by parents. The operator shall provide the parent of each child enrolled with information on how to access the regulations in this chapter electronically and with instructions for contacting the appropriate regional child care office.

The facility does not have information posted in a conspicuous location used by the parents on how to access the regulations in this chapter electronically and with instructions for contacting the appropriate regional child care office.

Corrected Corrected by Dec 3, 2021

Marked corrected in the state record.