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

In the eating area, there was an open outlet accessible to children 5 years of age or younger.

Corrected Corrected by Feb 9, 2026

Marked corrected in the state record.

3270.14/3270.21 · A facility shall be operated in conformity with applicable Federal and State laws and regulations. State agencies whose regulations may relate to the operation of a facility include the Department of Environmental Resources, the Department of Labor and Industry, the Department of Health, the Department of Education and the Department of Transportation. Conditions at the facility may not pose a threat to the health or safety of the children. Until such time as the required pre- service trainings are completed, staff person #2 and #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 #2 and #3, staff person #2 and #3 may not work in a child-care position at the facility.

Staff persons #2 and #3 were observed to be caring for children unsupervised. Staff persons #2 and #3 have not completed the following pre- service training required prior to caring for children unsupervised: health and safety topics and Pediatric First Aid and CPR.

Corrected Corrected by Mar 9, 2026

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.

The files for Staff person #1, #3, #6, and #7 lacked documentation of emergency plan training at the time of initial employment.

Corrected Corrected by Mar 9, 2026

Category: recordkeeping. Marked corrected in the state record.

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

The file for Staff person #4 contained current documentation of pediatric first aid and CPR training completed on 4/30/25 which was obtained after the previous pediatric first aid and CPR training expired in July 2024. The file for Staff person #5 contained documentation of current pediatric first aid and CPR training completed on 3/27/25 which was obtained after the previous pediatric first aid and CPR training expired in February 2025.

Corrected Corrected by Mar 9, 2026

Category: ratio. 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. Until such time as the required training has been completed, staff person #7 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 #7, staff person #7 may not work in a child-care position at the facility.

Staff person #7 has completed first aid and CPR training, however the training was not completed through a Pennsylvania Quality Assurance System (PQAS) approved curriculum and the trainer has not provided documentation that they are PQAS-certified in that training curriculum.

Corrected Corrected by Mar 9, 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 Main area lacked soap.

Corrected Corrected by Feb 9, 2026

Category: health medication. 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. Until such time as the required training has been completed, staff person #1, #3, and #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 #1, #3, and #6, staff person #1, #3, and #6 may not work in a child-care position at the facility.

Staff persons #1, #3, and #6 have not completed the following required pre- service training within 90 days of their date of hire (see LIS code sheet): Pediatric First Aid and CPR.

Corrected Corrected by Mar 9, 2026

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. Staff person #1, 2, 3, 6, and 8 may not work in a child care position at the facility.

The file for Staff person #1 lacked an NSOR certificate. (See LIS Code Sheet) The file for Staff person #2 lacked a PA Child Abuse clearance. The file for Staff person #2 lacked out of state clearances. (See LIS Code Sheet) The file for Staff person #3 lacked a PA State Criminal clearance. (See LIS Code Sheet) The file for Staff person #6 lacked a DHS FBI clearance; the file for Staff person #6 contained an FBI clearance from the Department of Education dated 8/31/23. The file for Staff person #6 lacked a PA Child Abuse clearance for the purpose of employment; the file for Staff person #6 contained a PA Child Abuse clearance for the purpose of volunteering. (See LIS Code Sheet) The file for Staff person #8 contained a PA Criminal clearance that lacked the dissemination date. (See LIS Code Sheet).

Corrected Corrected by Mar 9, 2026

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.

The files for Staff person #9 and #10 lacked a current written staff evaluation. The most recent staff evaluation on file for Staff person #9 was dated 2/16/24. The most recent staff evaluation on file for Staff person #10 was dated 1/16/24.

Corrected Corrected by Mar 9, 2026

Category: recordkeeping. Marked corrected in the state record.

3270.34(c) · A director shall be employed by a facility and be present at the facility site a minimum of 30 hours per week.

Based on staff statements, the facility lacks a director present at the facility a minimum of 30 hours per week.

Corrected Corrected by Feb 9, 2026

Marked corrected in the state record.

3270.36(b)(5) · An assistant group supervisor shall have a high school diploma or a general educational development certificate and 2 years experience with children.

The file for Staff person #1 and #8, identified as Assistant Group Supervisors, lacked documentation of a high school diploma or a general educational development certificate. The files for Staff person #2 and #3, identified as Assistant Group Supervisors, lacked documentation of a high school diploma or a general educational development certificate and 2 years experience with children.

Corrected Corrected by Mar 9, 2026

Category: supervision. Marked corrected in the state record.

3270.62(a)/3270.62(c) · A facility shall provide outdoor or indoor play space to be used for large muscle activity which includes running, jumping, climbing and riding. Outdoor or indoor play space shall be safe for large muscle activity.

The facility lacked a usable indoor or outdoor space to be used for large muscle activity. The previously identified gross motor space was not safe for large muscle activity. The space was being utilized for storage.

Corrected Corrected by Feb 9, 2026

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

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

In the eating area, there was peeling paint next to the outlet. In the toddler area, there was peeling paint on the walls and window frames.

Corrected Corrected by Feb 9, 2026

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.

The plastic on the toy veterinarian station in the main room was broken exposing sharp edges.

Corrected Corrected by Feb 9, 2026

Category: physical safety. 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.

The refrigerator in the infant room lacked an operating thermometer.

Corrected Corrected by Feb 9, 2026

Category: nutrition. Marked corrected in the state record.

3270.123(a) · An agreement shall be signed by the operator and the parent.

The agreement form for Child #3 lacked the signature of the operator.

Corrected Corrected by Feb 9, 2026

Category: recordkeeping. Marked corrected in the state record.

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

The agreement form for Child #4 lacked arrival and departure times.

Corrected Corrected by Feb 9, 2026

Category: recordkeeping. Marked corrected in the state record.

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

The agreement form for Child #3 lacked persons designated by a parent to whom the child may be released.

Corrected Corrected by Feb 9, 2026

Category: recordkeeping. 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 agreement form for Child #3 lacked the date of the child's admission.

Corrected Corrected by Feb 9, 2026

Category: recordkeeping. Marked corrected in the state record.

3270.123(b)/3270.182(8) · A parent shall receive the original agreement. The facility shall retain a copy of the agreement. A child's record shall contain a copy of the initial agreement and subsequent written agreements between the parent and the operator. The parent receives the original agreement.

The file for Child #4 contained the original agreement form.

Corrected Corrected by Feb 9, 2026

Category: recordkeeping. Marked corrected in the state record.

3270.131(b)(2)/3270.182(1) · The operator shall require the parent to provide an updated health report at least every 12 months for an older toddler or preschool child. A child's record shall contain initial and subsequent health reports.

The most recent health report on file for Child #1, an older toddler, was dated 8/30/24 which was obtained more than 12 months ago. The most recent health report on file for Child #2 , a preschooler, was dated 2/26/24 which was obtained more than 12 months ago.

Corrected Corrected by Feb 9, 2026

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

3270.151(a) · A facility person providing direct care who comes into contact with the children or who works with food preparation shall have a health assessment conducted within 12 months prior to providing initial service in a child care setting and every 24 months thereafter. A health assessment is valid for 24 months following the date of signature, if the person does not contract a communicable disease or develop a medical problem.

The file for Staff person #2 contained a current health assessment dated 11/22/25 which was obtained after they started working in a child care position. The file for Staff person #3 contained a current health assessment dated 10/16/25 which was obtained after they started working in a child care position. The file for Staff person #8 contained a current health assessment dated1/8/26 which was obtained after they started working in a child care position. The file for Staff person #10 lacked a current health assessment; the most recent health assessment on file was dated 8/16/23.

Corrected Corrected by Feb 9, 2026

Category: ratio. Marked corrected in the state record.

3270.192(4) · 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 Disclosure Statement on file for Staff person #7 lacked the date of the employee's signature. (See LIS Code Sheet)

Corrected Corrected by Feb 9, 2026

Category: background checks. 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 for Staff person #2, and #3 lacked two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person. The file for Staff person #7 lacked one written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person.

Corrected Corrected by Mar 9, 2026

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.

The file for Staff person #9 contained 8 of the required annual 12 hours of child care training. The file for Staff person #10 contained 1 of the required annual 12 hours of child care training.

Corrected Corrected by Feb 9, 2026

Category: recordkeeping. Marked corrected in the state record.

3270.131(a)/3270.131(e) · 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. 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. Child #3 must be dismissed from care by close of business 1/13/26 and may only return to care when the immunization record is updated or when a parent provides a written, signed exemption letter.

The file for Child #3, enrolled more than 60 days, lacked a child health report.

Corrected Corrected by Feb 9, 2026

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

3270.191 · An individual record is required for each facility person.

There was no file provided for Staff #4 at the time of inspection.

Corrected Corrected by Dec 3, 2025

Category: recordkeeping. Marked corrected in the state record.

3270.192(1) · A facility person's record shall include the name, address and telephone number of the facility person.

The file for Staff #4 did not include the address and telephone number of the facility person.

Corrected Corrected by Dec 3, 2025

Category: recordkeeping. Marked corrected in the state record.

3270.192(2)(i) · A facility person's record shall include verification of age.

The file for Staff #4 did not include verification of age.

Corrected Corrected by Dec 3, 2025

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. Facility Person #4 may not work in a childcare position at the facility.

The file for Staff #4 lacked a PA State Police Clearance, PA Child Abuse Clearance, FBI Clearance, NSOR Certificate, and Disclosure Statement. Staff #4 was observed alone unsupervised caring for children.

Corrected Corrected by Dec 3, 2025

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 #4 was observed acting as an AGS in the Baby Space. The file for Staff #4, lacked verification of childcare experience, education and training prior to service at the facility, to qualify as an AGS.

Corrected Corrected by Dec 3, 2025

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.

A pack n play with an infant inside was observed taking up the whole doorway blocking the only exit from the Baby Space Classroom which had three infants and a staff person in the room.

Corrected Corrected by Oct 22, 2025

Category: recordkeeping. Marked corrected in the state record.

3270.113(a)(1) · TIERED LIS: 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 their assigned group. The staff person shall be physically present with the children in their group on the facility premises and on facility excursions off the facility premises. 2. The facility will create a written step-by-step transfer of care process to ensure that the primary care cards/ tags are transferred to the correct staff/ group when a child is transferred to a different care group. The written process will be submitted to the Regional Office for review and subsequently, current staff and staff hired going forward will sign off that they read and understand the process for transferring a child to a different care group. Documentation that all current staff have been provided with and trained on the process will be submitted to the Regional office upon completion. The facility is encouraged to consult with their Quality Coach at the Regional ELRC for assistance.

In the Main Classroom at approximately 10:15 AM Staff #1 identified 6 Older Toddler Aged children as part of their assigned group. At this time, Staff #2 identified 5 Preschool Aged children as part of their assigned group. Cert Rep observed 14 children receiving care in the classroom therefore leaving Child #1, #2, and #3 not identified as being in an assigned primary group. At approximately 10:25 AM, Staff #4 was observed in the Baby Space with three infants. Staff #4 when asked to identify their group, name the three infants in the Baby Space and also Child #4 who was observed in a pack n play outside the doorway in the Main Room. Therefore Staff #4 was not physically present with Child #4.

Corrected Corrected by Dec 8, 2025

Category: supervision. 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 for Staff #4 lacked a Health Assessment.

Corrected Corrected by Dec 3, 2025

Category: ratio. Marked corrected in the state record.

3270.151(c)(2)/3270.192(3) · An adult health assessment must include tuberculosis screening by the Mantoux method at initial employment. Subsequent tuberculosis screening is not required unless directed by a physician, physician's assistant, CRNP, the Department of Health or a local health department. A facility person's record shall include a written report of initial and subsequent health assessments, including the results of initial and subsequent tuberculin skin tests, x-rays or other medical documentation necessary to confirm freedom from communicable tuberculosis.

The file for Staff #4 did not contain the results of a tuberculin skin test, x-ray or other medical documentation necessary to confirm freedom from communicable tuberculosis.

Corrected Corrected by Dec 3, 2025

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

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

The file for Staff #4 lacked proof of qualifications for education in the form of a diploma, transcript, or letter signed by a representative or the experiential, educational or training entity.

Corrected Corrected by Dec 3, 2025

Category: recordkeeping. 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 for Staff #4, lacked two written, nonfamily references from individuals attesting to the suitability to serve as a facility person.

Corrected Corrected by Dec 3, 2025

Category: recordkeeping. Marked corrected in the state record.

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

Based on Fire Drill Log documentation, the last fire drill occurred more that 60 days prior to the current documented fire drill 6/9/25-10/2/25 (115 days).

Corrected Corrected by Oct 22, 2025

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 or (g)1-10. 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, primary staff person, or family child care home staff person) 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 the following required pre- service training within 90 days of their date of hire (see LIS code sheet): Health and Safety training, and Pediatric First Aid and CPR.

Corrected Corrected by Sep 4, 2025

Category: supervision. Marked corrected in the state record.

3270.32(a)/3270.192(2)(iii) · 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/facility person #3 must be supervised, when interacting with children at a minimum by, an (AGS, primary staff person, or family child care home staff person) 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/facility person #3, staff person/facility person #3 may not work in a child- care position at the facility.

Staff person #3 has not completed mandated reporter training within 90 days of their date of hire (see LIS code sheet).

Corrected Corrected by Sep 22, 2025

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). 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 # -- 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.

The file for Staff #1 (See LIS Code Sheet) contained an FBI clearance from the Department of Education dated 8/15/24. The file for Staff #5 (See LIS Code Sheet) contained an NSOR certificate dated 6/16/20 which was obtained over 60 months ago.

Corrected Corrected by Sep 4, 2025

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.

The file for Staff #4 lacked a copy of their High School Diploma/GED.

Corrected Corrected by Sep 4, 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.

There was an open outlet in the gross motor play area accessible to children 5 years of age or younger.

Corrected Corrected by Sep 4, 2025

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.

In the large restroom, on the lower shelf under the changing table, were sunscreen and diaper cream labeled "Keep out of reach of children" accessible to children.

Corrected Corrected by Sep 4, 2025

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

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

The water temperature in both the small and large restrooms was 123°F.

Corrected Corrected by Sep 4, 2025

Category: physical safety. 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.

The emergency exit from the main room was obstructed by a sink/cabinet. The walkway to the emergency exit near the restrooms was partially obstructed by cots laying in the hallway.

Corrected Corrected by Sep 4, 2025

Category: physical safety. 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 most recent health assessment of file for Staff #2 was dated 11/15/22 which was more than 24 months ago.

Corrected Corrected by Sep 30, 2025

Category: ratio. Marked corrected in the state record.

3270.192(4) · 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 #--- may not work in a child care position at the facility.

The file for Staff #1 (See LIS Code Sheet) lacked a disclosure form.

Corrected Corrected by Sep 4, 2025

Category: background checks. 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 for Staff #2 lacked two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person.

Corrected Corrected by Sep 4, 2025

Category: recordkeeping. Marked corrected in the state record.

3270.61 · Measurement and use of indoor child care space.

The Activity Room, located through the large restroom, was being used as a storage area and not set up to care for children (no required postings; no first aid kit; etc.).

Corrected Corrected by Sep 4, 2025

Category: health medication. 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.

Documentation of the fire alarm system test shows more than 30 days between testing. (3/20/25 and 4/23/25; 5/6/25 and 6/9/25).

Corrected Corrected by Sep 4, 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 Emergency Plan did not address Continuity of Operations as required by Announcement C-22-04 which states to maintain full compliance with 45 CFR § 98.41(a)(1)(vii), child care facilities must have requirements for continuity of operations including information regarding how they will pay for repairs, pay staff, and pay bills during the aftermath of the disaster.

Corrected Corrected by Mar 27, 2025

Category: ratio. Marked corrected in the state record.

3270.31(e)(4)(i)/3270.31(f) · Competence is the completion of training by a professional in the field of first-aid and cardiopulmonary resuscitation (CPR). All staff persons shall renew their certification in pediatric first aid and pediatric cardiopulmonary resuscitation (CPR) on or before the expiration of the most current certification. Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10.

The file for Staff Person #3 (see LIS Code Sheet) contained a current First Aid and CPR certification dated 1/22/25; the prior First Aid and CPR training was dated 5/8/22 which expired in May 2024. The file for Staff Person #4 (see LIS Code Sheet) lacked pediatric First Aid and CPR. The file for Staff Person #5 (see LIS Code Sheet) contained pediatric First Aid and CPR completed on 7/6/22 which expired in July 2024.

Corrected Corrected by Mar 27, 2025

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 facility lacked a policy and procedure to identify the prevention of shaken baby syndrome, abusive head trauma, and child maltreatment as per Announcement C-22-03.

Corrected Corrected by Mar 27, 2025

Category: ratio. Marked corrected in the state record.

3270.27(a)(4) · The facility shall have an emergency plan that provides for 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.

The facility's emergency plan did not provide a method for informing parents that the emergency has ended and how they can reunite with their child(ren).

Corrected Corrected by Mar 27, 2025

Category: physical safety. 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.

The emergency plan on site was documented as having last been reviewed 9/30/21 which exceeds the annual requirement.

Corrected Corrected by Mar 27, 2025

Category: recordkeeping. Marked corrected in the state record.

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

The files for Staff Person #1, #2, #3, #4, and #6 lacked documentation of emergency plan training.

Corrected Corrected by Mar 27, 2025

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 parent letter explaining the emergency procedures lacked the following: lockdown information; accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions; method on how to communicate with parents at the beginning and end of an emergency situation, including how to reunite with their children.

Corrected Corrected by Mar 27, 2025

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

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

The files for Staff Person #1, #2, #3, #4, #5, and #6 (See LIS Code Sheet) lack documentation of annual fire safety training.

Corrected Corrected by Mar 27, 2025

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. Staff Persons #1, #4, and #6 may not work in a child care position at the facility.

The file for Staff Person #1 (See LIS Code Sheet) lacked a PA State Criminal Clearance and a Disclosure statement; The file for Staff Person #4 (See LIS Code Sheet) lacked a PA State Criminal Clearance; The file for Staff Person #6 (See LIS Code Sheet) lacked a PA State Criminal Clearance and a Disclosure statement.

Corrected Corrected by Mar 27, 2025

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

3270.32(a)/3270.192(2)(iii) · The operator shall comply with the CPSL and with Chapter 3490 (relating to Child Protective Services). Staff persons #4 and #6 will have until February 18, 2025 to complete the mandated reporter training. Until such time as the required training has been completed, staff persons #4 and #6 must be supervised, when interacting with children, by at least an AGS who has completed the required training related to this citation. If there are no staff person(s) available to supervise staff persons #4 and #6, staff persons #4 and #6 may not work in a child-care position at the facility.

Staff Person #4 and Staff Person #6 (See LIS Code Sheet) have not completed the mandated reporter training within 90 days of their date of hire (see LIS code sheet).

Corrected Corrected by Jan 27, 2025

Category: supervision. Marked corrected in the state record.

3270.33(a) · 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.

The files for Staff Person #1, #2 and #6 lacked documentation of the qualifications for the position they were performing.

Corrected Corrected by Jan 27, 2025

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.

The file for Staff Person #4, employed for more than 12 months, lacked a written evaluation.

Corrected Corrected by Jan 27, 2025

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.

There was wood splintering above the gate entering the toddler area. There were miscellaneous pieces of equipment outside the toddler area presenting a tripping hazard.

Corrected Corrected by Mar 21, 2025

Category: physical safety. 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 required staff:child ratios must be maintained at all times.

* At approximately 10:30am, Staff person #1 was observed in the unmeasured eating area with 9 children; 1 Infant, 1 Young Toddler, 5 Older Toddlers, 1 Preschool Aged and 1 School Aged. Staff Person #3 was observed in the Gross Motor Room with 12 children; 5 Preschool Aged and 7 School Aged. At approximately 10:40am, there were 9 children in the eating area with no staff present. Staff #1 who was assigned the responsibility for supervising the 9 children, left the eating area to accompany a child to the restroom located outside of the eating area

Corrected Corrected by Mar 21, 2025

Category: supervision. Marked corrected in the state record.

3270.52 · The Legal Entity will require all staff persons at the facility to attend a 2 hour in person training regarding maintaining ratio and supervision of children presented by ELRC 3 within 1 month of the approval of this plan of correction. The Legal Entity will submit the training to the Department for approval prior to implementation. The training may count towards the mandatory 12 training hours required by the Department. Proof of training of all staff persons will be submitted to the department within 10 days of the completion of the training.

**At approximately 10:30am, Staff person #1 was observed in the unmeasured eating area with 9 children; 1 Infant, 1 Young Toddler, 5 Older Toddlers, 1 Preschool Aged and 1 School Aged. Staff Person #3 was observed in the Gross Motor Room with 12 children; 5 Preschool Aged and 7 School Aged. At approximately 10:40am, there were 9 children in the eating area with no staff present. Staff #1 who was assigned the responsibility for supervising the 9 children, left the eating area to accompany a child to the restroom located outside of the eating area

Corrected Corrected by Mar 21, 2025

Category: supervision. Marked corrected in the state record.

3270.61(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.

From approximately 10:30am till 12:15pm, 10 children were observed being cared for in the unmeasured eating area.

Corrected Corrected by Mar 21, 2025

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

3270.62(b) · Outdoor or indoor play space shall be measured at 65 square feet per child.

The Gross Motor Room play space has a measured capacity of 3. From approximately 10:30am till 12:00pm, Staff Person #3 was observed in the Gross Motor Room with 12 children; 5 Preschool Aged and 7 School Aged.

Corrected Corrected by Jan 27, 2025

Category: ratio. 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.

In the restroom, Aquaphor, labeled "keep out of reach of children" was accessible to children. In the main room, Glade air freshener, labeled "keep out of reach of children" was in an unlocked cabinet accessible to children.

Corrected Corrected by Jan 27, 2025

Category: physical safety. 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 Main Room lacked soap and scissors. The first aid kits in the Gross motor room lacked soap, scissors, and tweezers.

Corrected Corrected by Jan 27, 2025

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

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

The toddler area had peeling paint on the walls and above the outlet. The paint around the windows was cracked and peeling. In the main room, there was peeling paint around several taped outlets.

Corrected Corrected by Jan 27, 2025

Category: physical safety. 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.

There was a urinal in the boys' restroom that lacked a handwashing sign.

Corrected Corrected by Jan 27, 2025

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.

There was a broken firetruck missing wheels in the toddler area. There was a sharp edge in the play house in the toddler area where the play phone support is broken. The dolls in the main room were stained and not in good condition.

Corrected Corrected by Mar 21, 2025

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 1:30pm, in the main room, 22 children were resting on cots and Port-a-cribs for naptime. All of the rest equipment lacked at least 2 feet of space on three sides.

Corrected Corrected by Jan 27, 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. 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.

At approximately 10:40am, there were 9 children in the eating area with no staff present. Staff #1 who was assigned the responsibility for supervising the 9 children, left the eating area to accompany a child to the restroom located outside of the eating area.

Corrected Corrected by Jan 27, 2025

Category: supervision. Marked corrected in the state record.

3270.123(a)(2) · An agreement shall specify the date on which the fee is to be paid.

The agreement form for Child #1 lacked the date on which the fee is to be paid.

Corrected Corrected by Jan 27, 2025

Category: recordkeeping. 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 files for Child #2, #3, and #5 lacked documentation on the Department's approved form to provide the family information about the child's growth and development.

Corrected Corrected by Mar 27, 2025

Category: recordkeeping. Marked corrected in the state record.

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

The agreement forms for Child #4 and Child #5 lacked the arrival and departure times.

Corrected Corrected by Jan 27, 2025

Category: recordkeeping. Marked corrected in the state record.

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

The agreement forms for Child #1, Child #4, and Child #5 lacked the persons designated by the parent to whom the child may be released.

Corrected Corrected by Jan 27, 2025

Category: recordkeeping. 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 for Child #1 lacked the date of admission.

Corrected Corrected by Jan 27, 2025

Category: recordkeeping. Marked corrected in the state record.

3270.123(b)/3270.182(8) · A parent shall receive the original agreement. The facility shall retain a copy of the agreement. A child's record shall contain a copy of the initial agreement and subsequent written agreements between the parent and the operator. The parent receives the original agreement.

The files for Child #1, Child #2, Child #3, Child #4, and Child #5 contained the original fee agreement forms.

Corrected Corrected by Jan 27, 2025

Category: recordkeeping. Marked corrected in the state record.

3270.124(b)(4)/3270.182(5) · Emergency contact information must include the written consent signed by a parent for emergency medical care. A child's record shall contain signed parental consent for administration of minor first-aid procedures by facility staff. Written consent is required prior to admission.

The file for Child #4 lacked written consent signed by the parent for emergency medical care and minor first-aid procedures.

Corrected Corrected by Jan 27, 2025

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 emergency contact forms for Child #1 and Child #4 lacked the address of the individual designated by the parent to whom the child may be released.

Corrected Corrected by Jan 27, 2025

Category: recordkeeping. 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 files for Child #2 and Child #5, each enrolled for more than 6 months, lacked documentation that the parent reviewed or updated the emergency contact information as well as the financial agreement as required.

Corrected Corrected by Jan 27, 2025

Category: recordkeeping. Marked corrected in the state record.

3270.131(b)(1)/3270.131(e)(3) · The operator shall require the parent to provide an updated health report at least every 6 months for an infant or young toddler. The facility shall implement dismissal policies in accordance with the Department of Health regulation in 28 Pa. Code § 27.77 (relating to immunization requirements for children in child care group settings). Child #2 must be dismissed from care by close of business February 10, 2025, and may only return to care when the immunization record is updated or when a parent provides a written, signed exemption letter.

The file for Child #2, a young toddler, lacked an updated health report. The most recent health report on file is dated 4/8/24, more than 6 months ago.

Corrected Corrected by Jan 27, 2025

Category: health medication. 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 for Staff Person #3 (See LIS Code Sheet) contained TB screening results dated 4/15/21 more than 12 months prior to starting in a child care position. The file lacked a current health assessment. The previous health assessment was dated 6/3/22. The file for Staff Person # 4 (See LIS Code Sheet) lacked an initial health report. The file for Staff Person #5 lacked a current health report. The previous health assessment was dated 6/4/21.

Corrected Corrected by Mar 21, 2025

Category: ratio. Marked corrected in the state record.

3270.166(1) · A written statement giving the formula and feeding schedule for an infant shall be obtained from the parent.

The file for Child #1, an infant, lacked a statement giving the formula and feeding schedule obtained from the parent.

Corrected Corrected by Jan 27, 2025

Category: nutrition. 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 for Staff Person #2 lacked one written nonfamily reference. The file for Staff Person #4 lacked two written nonfamily references.

Corrected Corrected by Jan 27, 2025

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's emergency plan lacked accommodations for infants and toddlers.

Corrected Corrected by Mar 27, 2025

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

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

The facility lacked a current annual emergency drill. The most recent emergency drill was recorded on 10/29/22, more than 12 months ago.

Corrected Corrected by Mar 21, 2025

Category: recordkeeping. Marked corrected in the state record.

3270.94(a)(5) · The Director 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 lower level of the building where the restrooms, gross motor room, and eating area are located lacked a posted evacuation route.

Corrected Corrected by Jan 27, 2025

Category: recordkeeping. Marked corrected in the state record.

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

The facility's current certificate of compliance was not posted in a conspicuous location used by parents.

Corrected Corrected by Jan 27, 2025

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 facility lacked documentation that the emergency plan was submitted to the local and county EMA.

Corrected Corrected by Mar 27, 2025

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 for Staff Person #2 (See LIS Code Sheet) lacked documentation for 2 of the 12 training hours completed between April 2023 and April 2024. The files for Staff Person #3 and Staff Person #4 (See LIS Code Sheet) lacked documentation for 12 of the 12 training hours to be completed between June 2023 and June 2024. The file for Staff Person #5 (See LIS Code Sheet) lacked documentation for 12 of the 12 training hours completed between December 2023 and December 2024. The file for Staff Person #6 lacked documentation of annual training hours.

Corrected Corrected by Mar 27, 2025

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.

The facility lacked a current annual notification to local traffic safety authorities of the location of the facility and the program's use of pedestrian and vehicular routes around the child care facility.

Corrected Corrected by Mar 27, 2025

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.

While Staff #1 wrote an incident report up for Child #1, it was not given to the parent on the day that the incident occurred.

Corrected Corrected by Aug 8, 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 for Staff #3 was lacking emergency plan training within 90 days of their date of hire. (See LIS code sheet)

Corrected Corrected by Feb 27, 2024

Category: recordkeeping. Marked corrected in the state record.

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

The file for Staff #3 was lacking a signed and dated disclosure statement.

Corrected Corrected by Apr 3, 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).

Upon arrival at the facility, Staff Person #1 was in a room with 3 Older Toddlers and 3 Young Toddlers putting Staff Person #1 out of ratio by 1 child. During time to prepare lunch Staff Person #1 and #2 combined their children. Staff Person #2 kept leaving Staff Person #1 alone in the room with one infant, 3 Young Toddlers and 3 Older Toddlers putting Staff Person #1 out of ratio

Corrected Corrected by Feb 27, 2024

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.

There were two missing receptacle covers in the gross motor room when you enter the room the wall on the left.

Corrected Corrected by Feb 27, 2024

Marked corrected in the state record.

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

The small room and the art room were both lacking first aid kits.

Corrected Corrected by Apr 2, 2024

Category: health medication. 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.

Emergency Contact form were not in the main room when the children were in there, they were not in the lunch room or art room when the children were in those spaces.

Corrected Corrected by Apr 2, 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 for Child #1, a preschool aged child, contained 2 Health Assessments that were more than 12 months apart.

Corrected Corrected by Feb 27, 2024

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

3270.94(a)(5) · The Director 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 did not have evacuation routes posted.

Corrected Corrected by Feb 27, 2024

Category: recordkeeping. Marked corrected in the state record.

3270.36(b)(5) · An assistant group supervisor shall have a high school diploma or a general educational development certificate and 2 years experience with children.

The file for Staff #1 was lacking proof of her education

Corrected Corrected by Oct 27, 2023

Category: supervision. Marked corrected in the state record.

3270.151(c)(2)/3270.192(3) · An adult health assessment must include tuberculosis screening by the Mantoux method at initial employment. Subsequent tuberculosis screening is not required unless directed by a physician, physician's assistant, CRNP, the Department of Health or a local health department. A facility person's record shall include a written report of initial and subsequent health assessments, including the results of initial and subsequent tuberculin skin tests, x-rays or other medical documentation necessary to confirm freedom from communicable tuberculosis.

The file for Staff #1 was lacking proof of TB testing and the results of that test.

Corrected Corrected by Oct 27, 2023

Category: health medication. 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 for Staff #1 was lacking 2 written non-family reference letters.

Corrected Corrected by Oct 27, 2023

Category: recordkeeping. Marked corrected in the state record.

3270.94(a)(5) · The Director 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 was lacking posted evacuation routes.

Corrected Corrected by Oct 27, 2023

Category: recordkeeping. Marked corrected in the state record.