3270.31(f) · Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)10. Until such time as the required training has been completed, staff person #6 must be supervised, when interacting with children at a minimum by, an AGS, who has completed all preservice trainings and has all qualifications to care for children unsupervised. If there are no staff person(s) available to supervise staff person #6, staff person #6 may not work in a child-care position at the facility.

Staff person #6 has not completed the following required pre-service training within 90 days of their date of hire (see code sheet for date of hire): Pediatric First Aid and Pediatric CPR Training. The training card provided for Staff #6 was an adult-specific course that was not conducted by a PQAS-approved trainer.

Corrected Corrected by Mar 14, 2026

Category: supervision. Marked corrected in the state record.

3270.32(a) · The operator shall comply with the CPSL and with Chapter 3490 (relating to Child Protective Services). Until such time as the required training has been completed, staff person #3 must be supervised, when interacting with children at a minimum by, an AGS who has completed all preservice trainings and has all qualifications to care for children unsupervised. If there are no staff person(s) available to supervise staff person #3, staff person #3 may not work in a child-care position at the facility.

Staff person #3 has not completed mandated reporter training within the last 60 months. This is evidenced by the previously documented mandated reporter training on file being dated 12/3/2020. During the inspection on 2/4/26, this staff was observed having routine interaction and direct contact with children.

Corrected Corrected by Feb 6, 2026

Category: supervision. Marked corrected in the state record.

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

The first aid kit in the Toddler Daycare Room and the Great Room (room with stage) was observed to be missing soap.

Corrected Corrected by Jun 3, 2025

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

3270.31(f)/3270.31(g) · Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-9. Completion of professional development shall be documented by the signature and title of a representative of the professional development entity and include the date professional development was completed. Documentation shall be retained in the facility person's file or maintained in an electronic system as designated by the Department. Documentation of the completion of the professional development under subsection (f) taken from September 30, 2016, forward satisfies this requirement. Until such time as the required training has been completed, staff person #1 must be supervised, when interacting with children at a minimum by, an AGS who has completed all preservice trainings and has all qualifications to care for children unsupervised. If there are no staff person(s) available to supervise staff person #1, staff person #1 may not work in a child-care position at the facility. Staff #1 and #5 are required to take PA Required Health and Safety for Centers-Group Child Care Parts 1 and 2.

There was no proof on file showing that Staff #1 (see code sheet for date of hire) had completed all of the required Health and Safety trainings. Only the one-hour Health and Safety Update training, dated 11/13/23, was on file. The file for Staff #5 had a 6-hour Health and Safety Basics: Requirements for Certification training dated 9/11/2015, which was not completed within an acceptable timeframe. This staff also had a Health and Safety Update 2022 training dated 9/5/2024. However, Staff #5 was required to retake a more updated version of the entire health and safety training. Currently, these required trainings are the PA Required Health and Safety for Centers-Group Child Care Parts 1 and 2.

Corrected Corrected by Jun 7, 2025

Category: supervision. Marked corrected in the state record.

3270.76/3270.77(a) · 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. Peeled or damaged paint or damaged plaster is not permitted on indoor or outdoor surfaces in the child care facility.

Two brown stained ceiling tiles were observed near the microwave in the Toddler C Room. One brown stained ceiling tile was observed near the refrigerator and a ceiling tile with a hole was observed near a clock in the Toddler C Room. There was a hole in the ceiling tile above the toilet in the Toddler C Restroom. Outside of the Toddler B Room, there was one cracked and one stained ceiling tile observed near the diaper changing table. The Toddler B Room had a ceiling vent that was surrounded by a cracked and bowed ceiling tile. The Toddler B Restroom and Primary A Boys' Restroom had one stained ceiling tile each. Outside of the Toddler B restroom, there was one bowed and one stained ceiling tile. The ceiling tile, that was located near the smoke detector in the Toddler Daycare Room, had a hole. Two brown stained ceiling tiles were observed near the radio in the Primary A Room. Peeling paint was observed on a bench in the Outdoor Toddler Play Area. Peeling paint was observed on a floor pipe in the Toddler B staff restroom.

Corrected Corrected by Jul 3, 2025

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

3270.82(i) · A toilet area, training chair area, diapering area and sink area shall be equipped with a clean, lidded waste receptacle.

The trash can near the sink in the Toddler B restroom was observed to be missing a lid.

Corrected Corrected by Jun 3, 2025

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

3270.102(a)/3270.104(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. Furniture must be durable, safe, easily cleaned and appropriate for the child's size, age and special needs.

One toilet in the Toddler A restroom was observed to have rough rust near its handle. The black foam covering the air conditioner pipes in the Outdoor Toddler Play Area were torn. The radiator in the Toddler B Nap Room was observed to be missing a part of its cover. One black office chair and four blue and green rest mats in the Toddler Daycare Room had torn plastic. The white shelf, located near a radio in the Primary A Room, had chipped wood.

Corrected Corrected by Jul 3, 2025

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

3270.113(a)/3270.113(a)(1) · 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. 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. TIERED LIS: 1. Children must be supervised at all times. This portion of the plan shall have an immediate correction date. 2. The Legal Entity/Director must update existing supervision policies/procedures. The policies and procedures must include the following requirements: Staff will be able to see, hear, direct and assess the children at all times. Staff will know the whereabouts of the children in their assigned group. Staff will be physically present with the children in their assigned group at all times. The policy must address that a separate staff member must be physically present in each room where children are receiving care, in accordance with the required staff: child ratios. The Legal Entity/Director will submit the updated policies/procedures to the Northeast Regional Office for approval. Once approved, all existing staff and new hires must review the approved policies and procedures, and it must be documented in their files. The operator shall provide a date by when this will be completed.

Three children were observed to be sleeping in the Nap Room and one child was sleeping in the Coat Room. Staff #13 was physically present in the Nap Room but only supervised the child in the Coat Room by viewing the child through a large opening in the wall between the two rooms. A second staff was required to be physically present within the Coat Room to provide proper supervision.

Corrected Corrected by Jun 3, 2025

Category: supervision. Marked corrected in the state record.

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

The emergency contact and financial agreement information on file for Child #1 were dated 6/13/24 and 1/8/25; for Child #2 were dated 5/31/24 and 3/31/25; for Child #4 were dated 6/11/24 and 1/6/25; and for Child #5 were dated 5/24/24 and 3/7/25. More than 6 months had passed since a parent last reviewed, updated, and signed the emergency contact and financial agreement forms.

Corrected Corrected by Jun 3, 2025

Category: recordkeeping. Marked corrected in the state record.

3270.94(a)(9) · The Director or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that a written record is maintained on file at the facility indicating the specific time of day of the drill, the hypothetical location of the fire, the evacuation time, and the names of the facility persons and the number of children who participate in the fire drill.

The facility's fire drill log for 12/10/2024 did not include the specific time of day of the drill, the hypothetical location of the fire, the evacuation time, and the names of the facility persons and the number of children who participated in the fire drill.

Corrected Corrected by Jun 3, 2025

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 fire detection system was not tested at least once every 30 days as indicated by the following fire detection system testing logs that were on file: 11/7/24 to 12/10/24, 12/10/24 to 1/29/25, and 3/28/25 to 4/28/25.

Corrected Corrected by Jun 3, 2025

Category: recordkeeping. 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.

A thermometer was not observed in the refrigerator for Toddler B.

Corrected Corrected by May 21, 2024

Category: nutrition. Marked corrected in the state record.

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

A written plan of daily activities and routines, including a time for free play, was not observed in the Great Room, Room 2, and Room 3.

Corrected Corrected by May 20, 2024

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. Until such time as the required pre-service trainings are completed, staff person #8 and staff person #9 must be supervised, when interacting with children, by an AGS who has completed the required training related to this citation. If there are no staff person(s) available to supervise staff person #8 and staff person #9, staff person #8 and staff person #9 may not work in a child-care position at the facility.

Staff person #8 and Staff person #9 were observed to be caring for children unsupervised. Staff person #8 has not completed the following pre-service training required prior to caring for children unsupervised: Health and Safety training. Staff person #9 has not completed the following pre-service training required prior to caring for children unsupervised: Health and Safety training, Pediatric First Aid/CPR, and Mandated Reporter training.

Corrected Corrected by May 10, 2024

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 OCDEL ANNOUNCEMENT C-22-04 requires facility emergency plans to include continuity of operations during and after an emergency that includes continuing daily operations, backing up or retrieving health and other key records/files and managing financial issues such as paying employees and bills during the aftermath of the disaster.

The emergency plan that was on file did not include a continuity of operations.

Corrected Corrected by May 21, 2024

Category: ratio. 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 OCDEL ANNOUNCEMENT C-22-03 requires child care providers to have a policy and procedure to identify the prevention of shaken baby syndrome, abusive head trauma, and child maltreatment.

The provider's written policy did not include the recognition of potential signs and symptoms of shaken baby syndrome and abusive head trauma, strategies for coping with a crying, fussing, or distraught child, or the prevention and identification of child maltreatment.

Corrected Corrected by May 20, 2024

Category: ratio. 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 #3 (see code sheet for date of hire) did not have initial emergency plan training conducted within 90 days of employment. The only emergency plan trainings on file for Staff persons #2 and #8 were dated 8/31/23, and there were no emergency plan trainings on file for Staff person #4 and #9. Staff persons #2, #4, #8, and #9 have all been employed at the facility for at least 3 years.

Corrected Corrected by May 21, 2024

Category: recordkeeping. Marked corrected in the state record.

3270.31(f) · Staff person(s) shall complete professional development in the topics of 3270.31(f)((1-10) within 90 days of hire. Staff person #2, #3, #4, #5, #8, #9, and #10 will have until June 1, 2024 to complete the required training. Until such time as the required training has been completed, Staff person #2, #3, #4, #5, #8, #9, and #10 must be supervised, when interacting with children, by an AGS who has completed the required training related to this citation. If there are no staff available to supervise Staff person #2, #3, #4, #5, #8, #9, and #10, then Staff person #2, #3, #4, #5, #8, #9, and #10 may not work in a child-care position at the facility.

Staff person #2, #3, #4, #5, #8, #9, and #10 had not completed the following required pre-service training within 90 days of their date of hire (see code sheet for date of hire): Health and Safety training. Staff person #9 does not have proof on file that they have completed the following required pre-service training and has been employed for more than do days: Pediatric First Aid/CPR.

Corrected Corrected by Jun 1, 2024

Category: supervision. 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 staff 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 #7 and Staff #9 may not work in a child care position until the completed clearances are on file at the facility.

The record for Staff person #4 contained current clearances, but there were no previous versions of the DHS FBI Clearance or NSOR certificates in the file. The CPSL requires that all clearance documentation be maintained during the course of employment at a facility. Staff person #7 (see code sheet for date of hire) did not have a Child Abuse Clearance on file. Staff person #9 (see code sheet for date of hire) did not have a Disclosure Statement on file.

Corrected Corrected by May 10, 2024

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

3270.32(a) · The operator shall comply with the CPSL and with Chapter 3490 (relating to Child Protective Services). Staff person #3 and Staff person #9 will have until June 1, 2024, to complete the mandated reporter training. Until such time as the required training has been completed, Staff person #3 and Staff person #9 must be supervised, when interacting with children, by an AGS who has completed the required training related to this citation. If there are no staff person(s) available to supervise Staff person #3 and Staff person #9, Staff person #3 and Staff person #9 may not work in a child-care position at the facility.

Staff person #3 and Staff person #9 did not have any mandated reporter trainings on file and have been working at the facility for more than 90 days. Staff person #4 had not completed mandated reporter training prior to the previous training expiring. This is evidenced by the documented mandated reporter trainings on file being dated 6/5/15 and 10/19/23.

Corrected Corrected by Jun 1, 2024

Category: supervision. Marked corrected in the state record.

3270.33(a)/3270.192(2)(ii) · A staff person or a substitute staff person shall meet one of the applicable staff qualifications for the position in which the person is performing. A facility person's record shall include verification of child care experience, education and training prior to service at the facility.

Staff person #9 had no proof on file which indicated that Staff person #9 had met the minimum education requirements for them to qualify as a staff.

Corrected Corrected by May 10, 2024

Category: recordkeeping. Marked corrected in the state record.

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

Staff person #2, Staff person #4, Staff person #9 did not have any written staff evaluations on file and have been working at the facility for more than one year.

Corrected Corrected by May 20, 2024

Category: recordkeeping. Marked corrected in the state record.

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

Three peace lily plants were observed, about waist height, and one orange tiger lily plant was observed to be about head height, in Toddler B. One peace lily plant was observed to be about shoulder height, on a window shelf, in Room 1. About twenty lily of the valley plants were observed in the outdoor Toddler Play Area, in a garden bed, that was at ground level.

Corrected Corrected by May 10, 2024

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

3270.67(d)/3270.82(h) · Trash that has been contaminated by human secretions or excrement shall be contained in closed, plastic-lined receptacles. A facility person and an able child shall wash his hands after toileting and before eating. A sign on which this requirement is written shall be posted at each toilet, training chair, diapering area and sink in the facility.

A handwashing sign was not observed by the sink in the Great Room or the Girls Restroom that is next to the Reception Area. The sink in Room 1, by the washing machine and bathroom, did not have a handwashing sign. Next to the Reception Area, there were two trash cans in the girl's restroom that were observed with no lid and contained used tissues. Also, the staff restroom near Room 1 was observed to have one trash can with no lid and contained used tissues.

Corrected Corrected by May 21, 2024

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

3270.75(a) · A first-aid kit shall be in a child care space.

A first-aid kit was not observed in Room 2 or Room 3.

Corrected Corrected by May 21, 2024

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

3270.76/3270.102(a) · 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. 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.

Two ceiling tiles in Primary B and three ceiling tiles in Toddler B were observed to have water damage stains. The same three ceiling tiles in Toddler B were also cracked. A hole, about ankle height, was observed on the wall near the sorting shelf in Room 2. Push pins were observed on a bulletin board, that was about shoulder height, in the Great Room.

Corrected Corrected by May 21, 2024

Category: physical safety. 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.

Child #3, child #4, and child #5 did not have documentation of an enrolling parent's work phone number.

Corrected Corrected by May 21, 2024

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.

A written plan identifying the means of transporting a child to emergency care and staffing provisions in the event of an emergency were not observed in the Great Room or Room 3.

Corrected Corrected by May 21, 2024

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.

The initial health assessment on file for child #1, which was dated 4/24/23, did not include a statement which indicated that the child is able to participate in child care and appears to be free from contagious or communicable disease.

Corrected Corrected by May 21, 2024

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

3270.171(c) · Written notification of safe routes shall be posted by the operator at a conspicuous location in the child care facility.

During the inspection, there were no posted notifications which indicated a safe route for parents to pick-up and drop-off their children.

Corrected Corrected by May 21, 2024

Marked corrected in the state record.

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

Staff person #7 (see code sheet for date of hire) does not have a health assessment or TB test on file. The files for Staff person #4 and Staff person #9 do not have any of the required initial or subsequent health assessments except for their current health assessment.

Corrected Corrected by May 20, 2024

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

3270.94(a)(9) · The Director or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that a written record is maintained on file at the facility indicating the specific time of day of the drill, the hypothetical location of the fire, the evacuation time, and the names of the facility persons and the number of children who participate in the fire drill.

The hypothetical location of the fire was missing from the following documented fire drill logs: 9/28/23, 10/11/23, 11/15/23, 12/21/23, 1/4/24, 2/8/24, 3/12/24, 4/4/24, and 4/14/24.

Corrected Corrected by May 21, 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 fire detection system was not tested every 30 days as evidenced by the following fire detection logs that were on file: 10/12/23 to 11/14/23, 12/14/23 to 1/16/24, and 2/15/24 to 3/19/24.

Corrected Corrected by May 21, 2024

Category: recordkeeping. 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.

Staff person #9 (see code sheet for date of hire) did not have 12 hours of childcare training completed and documented on file for the staff person's annual training year, from 10/19/2022 to 10/19/2023.

Corrected Corrected by May 21, 2024

Category: recordkeeping. Marked corrected in the state record.

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

There was no documentation on file indicating that the local traffic safety authorities were notified of the location of the facility and the program's use of pedestrian and vehicular routes around the child care facility.

Corrected Corrected by May 21, 2024

Category: recordkeeping. Marked corrected in the state record.

3270.52 · When children are grouped in mixed age levels, the age of the youngest child in the group determines the staff:child ratio and maximum group size in accordance with the requirements in § 3270.51 (relating to similar age level). The legal entity must create a policy regarding ratio which must include maintaining proper ratios when staff must leave the childcare space. The legal entity must submit the policy to regional office for approval. All staff must be trained and sign an acknowledgment that must be kept on file.

On 10/12/23, Certification representative observed staff person #2 with 7 young toddlers, alone, while additional staff person left the room to get another child.

Corrected Corrected by Dec 7, 2023

Category: ratio. Marked corrected in the state record.

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

On 10/12/23, Certification representative observed staff person #2 with 7 young toddlers, alone, while additional staff person left the room to get another child.

Corrected Corrected by Dec 11, 2023

Category: ratio. Marked corrected in the state record.

3270.31(f) · Staff person shall complete professional development in the topics of 3270.31(f)(1 -- 10) within 90 days of hire. Staff person #1 will have until 11/17/23 to complete the required training. Until such time as the required training has been completed, staff person #1 must be supervised, when interacting with children, by an AGS who has completed the required training related to this citation. If there are no staff available to supervise staff person #1, staff person #1 may not work in a child care position at the facility.

On 10/12/23, staff person #1 has not completed health and safety training within 90 days of their date of hire. (see code sheet).

Corrected Corrected by Nov 3, 2023

Category: supervision. 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 person #2 will have until 11/17/23 to complete the mandated reporter training. Until such time as the required training has been completed, staff person #2 must be supervised, when interacting with children, by an AGS who has completed the required training related to this citation. If there are no staff persons available to supervise staff person #2, staff person #2 may not work in a child care position at the facility.

On 10/12/23, Staff person #2 has not completed mandated reporter training within the last 60 months. This is evidenced by the previously documented mandated reporter training on file being dated 4/25/18.

Corrected Corrected by Oct 23, 2023

Category: supervision. Marked corrected in the state record.

3270.113(a)/3270.113(a)(1) · 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. 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. The Legal Entity will establish a supervision policy. The policy will include how the facility will demonstrate their knowledge and ability to adequately supervise children at all times. The policy must focus on ensuring that each child is seen, heard, assessed and able to be directed at all times. The policy must include how the facility will ensure appropriate supervision during transition times and while in the outdoor play area. The policy must also include a plan for each staff to be assigned the responsibility for supervision of specific children, including the requirement that the staff person know the names and whereabouts of the children in their assigned group and be physically present with the children in their group on the facility premises and on facility excursions off the facility premises. The legal entity must submit the policy to regional office for approval. All existing staff and new hires must be trained on the policy and sign an acknowledgment that must be kept on file.

On 10/12/23, staff person # 3 in the Toddler B classroom and staff person #4 in the Toddler A classroom could not identify or name all the children in their assigned groups.

Corrected Corrected by Nov 15, 2023

Category: supervision. Marked corrected in the state record.

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

On 10/12/23, staff person # 3 in the Toddler B classroom and staff person #4 in the Toddler A classroom could not identify or name all the children in their assigned groups.

Corrected Corrected by Dec 7, 2023

Category: supervision. Marked corrected in the state record.

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

On 10/12/23, the fire drill log did not list hypothetical locations of the fire that are rotated around the facility for each drill. The hypothetical locations were all listed as the same location.

Corrected Corrected by Nov 3, 2023

Category: recordkeeping. Marked corrected in the state record.

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

As of the renewal inspection on 5/11/23, there was no documentation of an emergency drill conducted in the past year.

Corrected Corrected by May 23, 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.

As of the renewal inspection on 5/11/23, there was no plan to address continuity of operations as required by 45 CFR 98.41(a)(1)(vii).

Corrected Corrected by May 23, 2023

Category: ratio. 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.

As of the renewal inspection on 5/11/23, there was no Shaken Baby/Abusive Head Trauma/Child Maltreatment policy as required by 45 CFR 98.41(a)(1)(vi).

Corrected Corrected by May 24, 2023

Category: ratio. 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.

As of the renewal inspection on 5/11/18, Staff #1, #2, #3, and #4 had not completed the 1 hour "Pennsylvania Health and Safety Update 2022" that was required by 12/30/22.

Corrected Corrected by May 22, 2023

Category: ratio. Marked corrected in the state record.

3270.31(f) · Staff person(s) shall complete professional development in the topics of 3270.31(f)(1 -- 10) within 90 days of hire. Staff person #1, #2, #3, #4, #5 and #6 will have until 6/2/23 to complete the required training. Until such time as the required training has been completed, Staff person #1, #2, #3, #4, #5 and #6 must be supervised, when interacting with children, by an AGS or above who has completed the required training related to this citation. If there are no staff available to supervise Staff person #1, #2, #3, #4, #5 and #6, Staff person #1, #2, #3, #4, #5 and #6 may not work in a child-care position at the facility.

Staff person #1, #2, #3, #4, and #5 have not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Pediatric First Aid/CPR from a PQAS approved trainer and a PQAS approved curriculum. Staff person #5 and #6 have not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Health and Safety topics.

Corrected Corrected by May 22, 2023

Category: supervision. 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. Facility Person #6 may not work in a child care position at the facility.

As of the renewal inspection on 5/11/23, Staff #6 did not have NSOR and must be removed from care (see code sheet for hire date).

Corrected Corrected by May 31, 2023

Category: background checks. 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.

As of the renewal inspection on 5/11/23, there was no documentation of a written evaluation of Staff #4 in the previous year.

Corrected Corrected by May 19, 2023

Category: recordkeeping. Marked corrected in the state record.

3270.35(b) · A group supervisor shall have attained one of the qualification levels specified at §3270.35(b)(1)-(4).

As of the renewal inspection on 5/11/23, Staff #6, identified as a Group Supervisor, did not have documentation on file to qualify for the Group Supervisor position. There was no qualification documentation on file at all.

Corrected Corrected by May 24, 2023

Category: supervision. Marked corrected in the state record.

3270.131(e) · The facility may not accept or retain an infant 2 months of age or older, a toddler or a preschool child at the facility for more than 60 days following the first day of attendance at the facility unless the parent provides written verification from a physician, physician's assistant, CRNP, the Department of Health or a local health department of the dates (month, day and year) the child was administered immunizations in accordance with the recommendations of the ACIP.

As of the renewal inspection on 5/18/23, there was no immunization record on file for child #1 who has been enrolled for greater than 60 days (see code sheet for start date). Child #1 must be removed from care until immunization record is on file.

Corrected Corrected by May 12, 2023

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

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

As of the renewal inspection on 5/11/23, there was no documentation provided to demonstrate that the operator had provided 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.

Corrected Corrected by May 23, 2023

Marked corrected in the state record.

3270.131(a)/3270.182(1) · The operator shall require the parent of an enrolled child, including a child, a foster child and a relative of an operator or a facility person, to provide an initial health report no later than 60 days following the first day of attendance at the facility. A child's record shall contain initial and subsequent health reports.

As of the renewal inspection on 5/11/23, there was no health assessment on file for child #1 who has been enrolled for more than 60 days (see code sheet for start date).

Corrected Corrected by May 12, 2023

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

3270.124(a) · Emergency contact information is required for each enrolled child. Emergency contact information must reference who shall be contacted in an emergency.

Child files #1 and #2 do not have emergency contact forms on file

Corrected Corrected by Jun 24, 2022

Category: recordkeeping. Marked corrected in the state record.

3270.14 · 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.

The facility does not have a policy statement on file in regards to Shaken Baby Syndrome, Traumatic Head Injury and the maltreatment of children. This requirement went into effect on 4/29/22.

Corrected Corrected by Aug 3, 2022

Category: ratio. 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 persons #1, 2, 3, 4 and 5 do not have documentation on file to verify that they have received annual emergency plan training

Corrected Corrected by Jun 24, 2022

Category: recordkeeping. Marked corrected in the state record.

3270.31(e)(4)(ii) · Staff persons shall participate, at least annually, in fire safety training conducted by a fire protection professional. Staff persons and volunteers shall receive training in maintenance of smoke detectors, the duties of facility persons during a fire drill and during a fire and the use of the facility's fire extinguishers, not including discharge of the fire suppressant agent.

Staff persons #1, 2, 3, 4 and 5 do not have documentation on file to verify that they have received annual fire safety training by a fire protection professional

Corrected Corrected by Jul 15, 2022

Category: recordkeeping. Marked corrected in the state record.

3270.31(f) · Staff persons shall complete professional development in the topics of 3270.31(f)(10) within 90 days of hire. Staff persons #1, 2, 3, 4 and 5 must do one of the following: provide documentation that the trainer has become PQAS-certified or at least is on the waiting list, request the instructor provide documentation, such as their Pediatric First-Aid/CPR Instructor Card from the PQAS-approved organization or the approved curriculum organization, that the instructor is approved to offer Pediatric First-Aid/CPR training on behalf of their organization, or receive pediatric first-aid/CPR training in an approved curriculum by a PQAS-certified trainer. Staff persons #1,2,3,4 and 5 will have until 7/27/22 to complete the required training if the instructor card is not provided.

Staff persons #1, 2, 3, 4 and 5 have pediatric first aid/CPR training in an approved curriculum taken prior to 4/29/22; however, the instructor has not provided documentation to verify that they are from a PQAS-certified organization in that training topic.

Corrected Corrected by Jul 14, 2022

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

3270.32(a) · Staff person #1 may not work in a child care position at the facility until all required documentation is on file.

Staff person #1 has an FBI clearance on file from the Department of Education. The FBI clearance must be requested through the Department of Human Services.

Corrected Corrected by Jul 12, 2022

Category: background checks. 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.

There are exposed bolts on the far corner of the fence located in the outdoor play space near the sidewalk

Corrected Corrected by Jun 1, 2022

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

3270.27(a)(5)/3270.27(a)(6) · The facility shall have an emergency plan that provides for accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions. Emergency drills shall be conducted annually. Annual emergency drills shall be documented and on file at the facility.

The facility emergency plan does not include a plan for accommodations to help assist infants, toddlers and children with disabilities or medical conditions in case of an emergency. The operator reports that an annual emergency lockdown drill has not been held.

Corrected Corrected by Jun 24, 2022

Category: recordkeeping. Marked corrected in the state record.

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

The operator does not have documentation on file to verify that the facility emergency plan is on file with Luzerne County EMA

Corrected Corrected by Jun 24, 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.

Facility persons #2 and #3 do not have documentation on file to verify that they have received annual emergency plan training

Corrected Corrected by Aug 13, 2021

Category: recordkeeping. Marked corrected in the state record.

3270.31(e)(4)(ii) · Staff persons shall participate, at least annually, in firesafety training conducted by a fire protection professional. Staff persons and volunteers shall receive training in maintenance of smoke detectors, the duties of facility persons during a fire drill and during a fire and the use of the facility's fire extinguishers, not including discharge of the fire suppressant agent.

Facility persons #1 and #2 do not have documentation on file to verify that they have received annual fire safety training

Corrected Corrected by Aug 13, 2021

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). Facility Person #1 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.

During annual renewal inspection conducted on 7/16/21 it was found that the director, facility person #1, has clearances on file that are over 60 months old. The child abuse clearance was dated 11/6/15, the FBI clearance was dated 7/8/15 and the required mandated reporter training was dated 5/13/15.

Corrected Corrected by Aug 13, 2021

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

3270.32(a)/3270.192(4) · The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Facility Person #1 may not work in a child care position at the facility until all required clearances are on file. A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL.

During annual renewal inspection conducted on 7/16/21 the director, facility person #1, had clearances on file that were over 60 months old. The child abuse clearance was dated 11/6/15, the FBI clearance was dated 7/8/15. The mandated reporter training was dated 5/13/15.

Corrected Corrected by Jul 16, 2021

Category: background checks. 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.

Facility persons #2 and #3 do not have annual evaluations on file. The last evaluation documented in the files for each staff person was in 2019.

Corrected Corrected by Aug 13, 2021

Category: recordkeeping. 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.

An electrical outlet plate is missing on the electrical outlet located in the toddler nap room

Corrected Corrected by Aug 13, 2021

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