Lancaster Ywca Child Enrichment Center

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.

Staff person #1's file did not contain a current Disclosure statement. Staff person #1's rap sheet, clearances, and disclosure statement were not sent to the Regional Office for review and has been caring for children at the facility (see Code Sheet).

Corrected by May 11, 2026

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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.

Upon onsite inspection of each childcare space, it was observed that a bottle of hand sanitizer labeled 'Keep out of reach of children' was placed on a table accessible to children in the school-aged childcare space. Further, in the hallway adjacent to the school-aged childcare space, a floor mop with a commercial cleaning product cartridge labeled 'Keep out of reach of children' was accessible.

Corrected by Jan 21, 2026

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3270.66(b) · Cleaning materials and other toxic materials shall be stored in an original labeled container or in a container that specifies the content. Toxics shall be stored away from food, food preparation areas and child care spaces.

Upon onsite inspection of each childcare space, it was observed that spray bottles containing an unknown/unlabeled product were placed in the following childcare spaces: Infants, One-year olds and Pre K #3.

Corrected by Jan 21, 2026

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3270.74 · The telephone number of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted by each telephone in the facility.

Upon onsite inspection of each childcare space, it was observed that the telephone number of the nearest hospital, police department, fire department, ambulance and poison control center were not posted in the school-aged childcare space.

Corrected by Jan 21, 2026

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

Upon onsite inspection of each childcare space, it was observed that the first aid kit in the Pre K #3 childcare space was missing sterile gauze.

Corrected by Jan 21, 2026

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

Upon onsite inspection of each childcare space, it was observed that the restroom in the Pre K #3 childcare space had visibly dirty floor and wall areas near the toilets.

Corrected by Jan 21, 2026

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

Upon onsite inspection of each childcare space, it was observed that there was peeled and/or damaged paint/caulking in the following areas: 1] on entry doorway, vertical column, stage & several walls on left side of the school-aged childcare space; 2] around the windowsills/frames of the infant childcare space; 3] multi-use restroom outside the PreK childcare space on wall to left of the sink; AND 4] wall outside the PreK childcare space. This demonstrates that the facility is not implementing the previously approved plan of corrective action dated 9.23.25 related to the same violation type.

Corrected by Jan 21, 2026

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

Upon onsite inspection of each childcare space, it was observed that a written plan of daily activities was not posted in the Pre K #3 childcare space.

Corrected by Jan 21, 2026

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3270.123(a)(3) · The services to be provided to the family and the child, including the Department's approved form to provide information to the family about the child's growth and development in the context of the services being provided. The operator shall complete and update the form and provide a copy to the family in accordance with the updates regarding emergency contact information in § 3270.124(f) (relating to emergency contact information). Directed Plan of Correction: Facility Director must submit a complete list of ALL enrolled children, along a properly signed regulatory compliant agreement form for each child enrolled at the facility.

Upon inspection of facility child files, it was found that the facility/parental agreement on file for Child #1, Child #2, Child #3, Child #4, Child #5 and Child #6 lack a description of the specific services to be provided to the family and the child. This was previously cited on 1.6.25 and recited on 2.4.25 for the same regulatory noncompliance, with an approved plan of correction being accepted on 2.17.25 including a regulatory compliant form presented by the facility at that time. This demonstrates that the facility is not implementing their approved plan of corrective action.

Corrected by Jan 21, 2026

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3270.123(a)(6)/3270.182(2) · An agreement shall specify the date of the child's admission. A child's record shall contain the dates of application, admission and withdrawal of the child.

Upon inspection of child files, it was found that the same date of admission was utilized for Child #1, Child #2, Child #3, Child #4, Child #5 and Child #6, regardless of their actual date of admission to the childcare program, which was factually inconsistent with other records.

Corrected by Jan 21, 2026

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3270.123(a)(7) · An agreement shall specify the services which are to be considered as extra. Directed Plan of Correction: Facility Director must submit a complete list of ALL enrolled children, along a properly signed regulatory compliant agreement form for each child enrolled at the facility.

Upon inspection of facility child files, it was found that the facility/parental agreement on file for Child #1, Child #2, Child #3, Child #4, Child #5 and Child #6 lack a description of the services which are to be considered extra to the family and the child. This was previously cited on 1.6.25 and recited on 2.4.25 for the same regulatory noncompliance, with an approved plan of correction being accepted on 2.17.25 including a regulatory compliant form presented by the facility at that time. This demonstrates that the facility is not implementing their approved plan of corrective action.

Corrected by Jan 21, 2026

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

Upon onsite inspection of each childcare space, it was observed that a written plan identifying the means of transporting a child to emergency care and staffing provisions in the event of an emergency was not posted in the gymnasium [large group play-space].

Corrected by Jan 21, 2026

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3270.131(d)(5)/3270.131(e)(1) · A health report shall include a review of the child's immunized status according to recommendations of the ACIP. The facility shall require the parent to provide updated written verification from a physician, physician's assistant, CRNP, the Department of Health or a local health department of ongoing vaccines administered to an infant, toddler or preschool child in accordance with the schedule recommended by the ACIP.

Upon inspection of facility child files, it was found that the health assessment on file for Child #2 was missing 1 dose of the HIB immunization or an approved exemption on file. Further, it was found that the health assessment on file for Child #4 was missing 1 dose of the Hepatitis B immunization, 3 doses of Pneumococcal immunization and 2 doses of Polio immunization. A parental exemption form was presented with the file, which was not dated, nor specific as to which immunization and exemption[s] were being claimed.

Corrected by Jan 21, 2026

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3270.134(a) · A staff person shall ensure that a child's hands are washed before meals and snacks, after toileting and after being diapered.

Upon onsite inspection of each childcare space, it was observed that lunch was served to the children in the Pre K #3 childcare space and no child was observed to have washed their hands prior to being seated with food.

Corrected by Jan 21, 2026

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3270.135(b) · Diaper changing surfaces shall be cleaned after each use by wiping the surface with a sanitizing solution or by changing a pad or other surface covering.

Upon onsite inspection of each childcare space, it was observed that under and around the changing surface of the diaper changing table in the 2-year-old childcare space contained a buildup of foreign matter.

Corrected by Jan 21, 2026

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

Upon inspection of staff records, it was found that the health assessment on record for Staff Person #1 was dated 5.30.19 [expired 5.31.24]. Staff Person #1 was observed to have handled prepared food for the children in care.

Corrected by Jan 14, 2026

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3270.152 · A facility person shall wash his hands before meals and snacks, and after toileting and after diapering a child.

Upon onsite inspection of each childcare space, it was observed that lunch was served to the children in the Pre K #3 childcare space and the staff persons were not observed to have washed their hands prior to handling and serving food to children.

Corrected by Jan 21, 2026

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

Upon inspection of the required facility records on file, it was found that the required annual emergency drill had not been conducted since 2.5.24.

Corrected by Jan 14, 2026

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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. 1] Children must be supervised at all times. [immediate correction date required] 2] The facility must schedule and complete the participation of the Facility Director and each assistant director in the Existing Provider Orientation scheduled for January 2026. [Correction date to be set as the date of orientation completion].

It was verified through multiple written and verbal statements that Child #1 was left unsupervised on a bus for a total period of 22 minutes as a result of Staff Person #1 and #2 not completing name/face checks of each primary care group and not completing a thorough visual check of the bus seats after unloading children. The initial directed plan of correction for inspection #00269297 [7.8.25] resulted in approved plan of correction from the provider. However, on 10.9.25 the provider did not satisfy the requirements of that directed and accepted plan that multiple specific staff positions were mandated to attend.

Corrected by Jan 15, 2026

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3270.14/3270.21 · A facility shall be operated in conformity with applicable Federal and State laws and regulations. State agencies whose regulations may relate to the operation of a facility include the Department of Environmental Resources, the Department of Labor and Industry, the Department of Health, the Department of Education and the Department of Transportation. Conditions at the facility may not pose a threat to the health or safety of the children. Staff person #1 must complete (PA Required Health and Safety for Centers-Group Child Care Parts 1 and 2).

Staff person #1 has completed the health and safety course titled (Get Started with Center-Based Care: Building Blocks for Quality (10 hours)) but has not completed the required health and safety update course titled Pennsylvania Health and Safety Update 2022 (1 hour) training.

Corrected by Sep 15, 2025

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3270.31(f) · Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10 or (g)1-10. Until such time as the required training has been completed, staff person #2 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, staff person #2 may not work in a child-care position at the facility. 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) 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 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 #4 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 #4, staff person #4 may not work in a child-care position at the facility. 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 #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 #2 has not completed the following required pre- service training within 90 days of their date of hire (see LIS code sheet): Pediatric First Aid/CPR training. Staff person #3 has completed Pediatric first aid and CPR training, however (the training was not completed through a Pennsylvania Quality Assurance System (PQAS) approved curriculum/ the trainer has not provided documentation that they are PQAS-certified in that training curriculum). Staff person #4 has not completed the following required pre- service training within 90 days of their date of hire (see LIS code sheet): Required Health and Safety training topics training AND Pediatric First Aid/CPR training. Staff person #7 has completed Pediatric first aid and CPR training, however (the training was not completed through a Pennsylvania Quality Assurance System (PQAS) approved curriculum/ the trainer has not provided documentation that they are PQAS-certified in that training curriculum).

Corrected by Sep 10, 2025

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3270.32(a)/3270.192(4) · Facility person #1 must be removed from a childcare position by the close of business because she/he does not have all the required clearances [effective 9.2.25]. Facility employee #4 must be removed from childcare position by close of business [effective 9.2.25]. All required clearances must be obtained before facility person#4 may resume a childcare position. Facility person #5 must be removed from a childcare position by the close of business because she/he does not have all the required clearances [effective 9.2.25]. Facility person #6 must be removed from a childcare position by the close of business because she/he does not have all the required clearances [effective 9.2.25].

The file of facility person #1 contains a National Sexual Offender Registry dated 3.3.20 which is more than 60 months old. The file for facility person # 4 does not contain a completed National Sexual Offender Registry [NSOR]. Although the LE could hire this person provisionally, the requirement to have the NSOR on file prior to begin working with children under the CPSL has not been met. The file of facility person #5 contains a National Sexual Offender Registry dated 3.3.20 which is more than 60 months old. The file of facility person #6 contains a PA Child Abuse Clearance dated 3.24.20 which is more than 60 months old. The file also does not contain a completed PA State Police Criminal Clearance.

Corrected by Sep 12, 2025

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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.

Upon completion of an unannounced monitoring inspection, it was observed that a bottle of hand sanitizer [labeled 'Keep out of Reach of Children'] was left accessible to children in care in the school-aged childcare space.

Corrected by Sep 2, 2025

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

Upon completion of an unannounced monitoring inspection, it was observed that 2-3 damaged ceiling tiles were in the Pre K #4 childcare space AND damage drywall along the right side of the room was also observed.

Corrected by Aug 29, 2025

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

Upon completion of an unannounced monitoring inspection, it was observed that there were multiple areas [at least 20+] of peeling paint around the perimeter of the school-aged childcare space.

Corrected by Aug 24, 2025

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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. Tiered Lis: 1] Children must be supervised at all times. [immediate correction date required] 2] The facility must schedule and complete the participation of the Facility Director and each assistant director in the Existing Provider Orientation scheduled for October 9, 2025. [Correction date to be set as the date of orientation completion]. 3] Provider agrees to periodic unannounced visits by DHS representative in order to monitor supervision and regulatory compliance for a period of 3 months. [The correction date for this portion of the plan shall be a minimum 3 months from the date the Regional Office approves the plan of corrections].

It was verified through multiple written and verbal statements that Child #1 was left unsupervised on a bus for a total period of 22 minutes as a result of Staff Person #1 and #2 not completing name/face checks of each primary care group and not completing a thorough visual check of the bus seats after unloading children.

Corrected by Nov 11, 2025

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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. TIERED LIS: 1. 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. [Provider must specifically provide an immediate correction date for this required plan] 2. The legal entity must submit documentation in a format approved by DHS proving that the facility procedure for counting children [name-to-face recognition] is followed at each transition point throughout the day [e.g., a checklist] for each childcare space. The legal entity will confirm continuing compliance by sending copies of the documentation to the Regional Office of Child Development and Early Learning on a weekly basis for a period of three months after DHS approves the documentation format. [Provider must provide a correction date which falls 3 months from the approval of this plan of correction].

It has been confirmed by both verbal statements/internal investigation results provided by Staff Person #2 and Staff Person #3, as well as by direct observation of the incident from facility video footage that Staff Person #1 did in fact leave Child #1 unsupervised in the childcare space while she was sleeping for 2:45.

Corrected by Oct 24, 2025

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3270.14/3270.21 · A facility shall be operated in conformity with applicable Federal and State laws and regulations. State agencies whose regulations may relate to the operation of a facility include the Department of Environmental Resources, the Department of Labor and Industry, the Department of Health, the Department of Education and the Department of Transportation. Conditions at the facility may not pose a threat to the health or safety of the children. Until such time as the required pre- service trainings are 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 person #1 was observed to be caring for children unsupervised. Staff person #1 has not completed the following pre- service training required prior to caring for children unsupervised: 1. Required Health & Safety training; 2. Pediatric First Aid/CPR.

Corrected by Jun 10, 2025

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3270.21/3270.66(a) · Conditions at the facility may not pose a threat to the health or safety of the children. Cleaning materials and other toxic materials shall be kept in an area or container that is locked or made inaccessible to children.

Upon re-inspection of the physical site to verify implementation of correction plan, it was found that in the Gymnasium play space, a construction area remained unsecured/accessible, which contained chemicals, tools and other items of a hazardous nature.

Corrected by Jan 31, 2025

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3270.25(b) · The operator shall post a copy of each inspection summary issued by the Department in a conspicuous location used by parents. The inspection summary shall remain posted until an agent of the Department verifies that each regulatory noncompliance item cited on the inspection summary has been corrected.

Upon inspection of the facility to verify the implementation of corrective plans, it was found that a copy of the currently open and active renewal inspection summary was not posted in a conspicuous location used by parents.

Corrected by Jan 17, 2025

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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.

Upon re-inspection of the physical site to verify implementation of corrective plans, it was found that in the large group room, hand sanitizer and disinfecting wipes remained accessible to children in care.

Corrected by Jan 17, 2025

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

Upon re-inspection of the children's files to verify implementation of corrective plans, it was found that the admission agreement document for Child #1 - Child #6 continued to lack a description of the specific services to be provided to the family and the child.

Corrected by Feb 3, 2025

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3270.123(a)(7) · An agreement shall specify the services which are to be considered as extra.

Upon re-inspection of the children's files to verify implementation of corrective plans, it was found that the admission agreement document for Child #1 - Child #6 continued to lack the services which are to be considered as extra.

Corrected by Feb 3, 2025

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3270.21/3270.66(a) · Conditions at the facility may not pose a threat to the health or safety of the children. Cleaning materials and other toxic materials shall be kept in an area or container that is locked or made inaccessible to children.

Upon inspection of the physical site, it was found that in the Gymnasium play space, a construction area was unsecured/accessible, which contained chemicals, tools and other items of a hazardous nature.

Corrected by Dec 12, 2024

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3270.27(a)(3) · The facility shall have an emergency plan that provides for a method for facility persons to contact parents as soon as reasonably possible when an emergency situation arises.

Upon inspection of the facility's most up-to-date Emergency Plans, it was found that a specific method for facility persons to contact parents as soon as reasonably possible when an emergency situation arises was not included.

Corrected by Jan 16, 2025

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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.

Upon inspection of the facility's most up-to-date Emergency Plans, it was found that a specific 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 was not included.

Corrected by Jan 20, 2025

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

Upon inspection of the facility's letter to parents regarding emergency procedures, it was found that specific methods of communication in the event of an emergency and at the conclusion of an emergency were not included in the information provided in the letter.

Corrected by Jan 21, 2025

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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 will have until January 17, 2025 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. Staff person(s) shall complete professional development in the topics of 3270.31(f)(1 -- 10) within 90 days of hire. Staff person #2 will have until January 17, 2025 to complete the required 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 available to supervise staff person #2, staff person #2 may not work in a child-care position at the facility. Staff person(s) shall complete professional development in the topics of 3270.31(f)(1 -- 10) within 90 days of hire. Staff person #3 will have until January 17, 2025 to complete the required training. Until such time as the required training has been completed, staff person #3 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 #3, staff person #3 may not work in a child-care position at the facility.

Staff person #1 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Pediatric First Aid/CPR training. Staff person #2 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Pediatric First Aid/CPR training [documentation on file expired on 11.9.24]. Staff person #3 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Pediatric First Aid/CPR training.

Corrected by Jan 17, 2025

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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.

Upon inspection of the physical site, it was found that in the 1-year-old room, there was non-prescription skin cream in one child's cubby; floor cleaner accessible and an unlocked cabinet with cleaning chemicals. In addition, it was found that in the large group room, hand sanitizer and disinfecting wipes were accessible to children in care.

Corrected by Jan 10, 2025

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

Upon inspection of the physical site, it was found that in the school-aged AND preschool childcare space, the first aid kit was missing tweezers.

Corrected by Jan 20, 2025

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

Upon inspection of the physical site, it was found that in the Infant childcare space that three ceiling tiles were damaged and one was missing; in the older toddler childcare space that four ceiling tiles were damaged; in the 1-year-old childcare space that one ceiling tile was damaged.

Corrected by Jan 17, 2025

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

Upon inspection of the physical site, it was found that in the older toddler childcare space that there was chipping paint around the columns; in the 1-year-old childcare space that there was chipped paint on the outside perimeter wall area.

Corrected by Jan 10, 2025

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3270.81 · A visual strip or other visual identification shall be placed on glass located in a traffic area, a child care space or a play space.

Upon inspection of the physical site, it was found that in the large group room, no visual strips or other visual identification was placed on the glass located within the space.

Corrected by Jan 13, 2025

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

Upon inspection of the physical site, it was found that in the school-aged childcare space that a table was placed in front of and was blocking a viable exit from the space.

Corrected by Jan 3, 2025

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

Upon inspection of the children's files, it was found that the admission agreement document for Child #1 - Child #6 did not contain a description of the specific services to be provided to the family and the child.

Corrected by Jan 24, 2025

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3270.123(a)(7) · An agreement shall specify the services which are to be considered as extra.

Upon inspection of the children's files, it was found that the admission agreement document for Child #1 - Child #6 did not specify the services which are to be considered as extra.

Corrected by Jan 24, 2025

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

Upon inspection of personnel files, it was found that Facility Person #2 had a health assessment dated 5.26.22 [expired on 5.26.24].

Corrected by Jan 17, 2025

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3270.166(3) · Disposable nursers shall be used for infants unless bottles are provided by the parent or unless a commercial dishwasher is used by the facility.

Upon inspection of the physical site, it was observed that in the infant childcare space, bottles were being hand-washed for later use and the staff in that space confirmed that a commercial dishwasher was not used.

Corrected by Jan 27, 2025

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

During the time of inspection, the facility could not provide documentation of an annual emergency drill being conducted at the facility.

Corrected by Feb 5, 2024

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3270.14/3270.21 · A facility shall be operated in conformity with applicable Federal and State laws and regulations.State agencies whose regulations may relate to the operation of a facility include the Department of Environmental Resources, the Department of Labor and Industry, the Department of Health, the Department of Education and the Department of Transportation. Conditions at the facility may not pose a threat to the health or safety of the children. POC REQUIRED AND DIRECTED PLAN: Staff member 1, staff member 2 and staff member 4 shall complete professional development topics 3270.31 (f)(1-10) within 90 days of hire. Staff member 1, staff member 2, and staff member 4 have until 1/17/24 to complete the required training. Until such time as the required training has been completed, staff member 1, staff member 2 and staff member 4 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 member 1, staff member 2 and staff member 4, staff member 1, staff member 2 and staff member 4 may not work in a child-care position at the facility.

Staff member 1 and staff member 4 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 Staff member 2 and staff member 4 have not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Health and Safety (CCDBG) Training

Corrected by Jan 19, 2024

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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 file did not include an annual review.

Corrected by Jan 5, 2024

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

Documentation on file for staff member 1, staff member 2, staff member 4 and staff member 10 did not include emergency plan training.

Corrected by Jan 19, 2024

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3270.31(e)(1)(ii) · Training conducted by an entity that is licensed or certified professionally competent in the training topic is acceptable and may count toward the annual requirement for 12 clock hours of child care training.

Documentation of 12 annual training hours was not on file for staff member 7 and staff member 10.

Corrected by Jan 19, 2024

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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.

Documentation of annual fire safety training was not on file for staff member 7, staff member 8 and staff member 10.

Corrected by Jan 19, 2024

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3270.32(a)/3270.192(4) · The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Staff member 7 may not work in a child care position at the facility.

Documentation of the disclosure statement on file for staff member 2 did not include a date in which the disclosure statement was signed by the staff member and witness. Documentation of the disclosure statement on file for staff member 8 was not signed by a witness. Documentation of the child abuse clearance on file for staff member 5 was obtained after the staff members first day caring for children. Updated child abuse clearance and FBI clearance were not on file for staff member 7. The original child abuse clearance on file was dated 9/17/18 and the original FBI clearance was dated 10/6/18. The state police clearance for staff member 7 was updated after the 60-month time frame. The state police clearance expired on 12/7/18 and was updated on 12/8/23. All clearances are to be updated every 60 months.

Corrected by Jan 19, 2024

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3270.36(b)(5)/3270.192(2)(ii) · An assistant group supervisor shall have a high school diploma or a general educational development certificate and 2 years experience with children. A facility person's record shall include verification of child care experience, education and training prior to service at the facility.

Documentation on file for staff member 2, staff member 5 and staff member 6 did not include documentation of two years' experience working with children. Documentation of two years' experience working with children was obtained and placed on file for staff member 2 during the inspection.

Corrected by Jan 19, 2024

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

During the time of inspection, it was observed that outlet covers were missing in a power strip located in the Pre K classroom and Sensory Classroom. This was corrected during the inspection.

Corrected by Jan 19, 2024

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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.

During the time of inspection, it was observed that the cleaning solution in the swiffer power mop was within reach of children. The cleaning solution was removed from the mop during the inspection.

Corrected by Jan 19, 2024

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

During the time of inspection, it was observed that the first aid kit in the school age classroom was missing gloves, soap and scissors. The first aid kit in the toddler classroom was missing scissors and there was only one band aid in the first aid kit in the Pre K classroom. All items were added to the first aid kit in the school age classroom, toddler classroom and pre-k classroom during the inspection.

Corrected by Jan 19, 2024

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

During the time of inspection, it was observed that ceiling tiles in the infant classroom and toddler classroom had significant water marks on them indicating a leak.

Corrected by Jan 19, 2024

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

During the time of inspection, it was observed that there was peeling plaster in the older toddler classroom. This was covered with tape during the inspection.

Corrected by Jan 19, 2024

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

During the time of inspection, it was observed that a toilet was covered with a trash bag in the older toddler classroom and not able to be used and the tank of the toilet in the pre k classroom was covered in a trash bag.

Corrected by Jan 26, 2024

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

Documentation of the agreement on file for child 4 did not include persons designated by a parent to whom the child may be released.

Corrected by Jan 26, 2024

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3270.123(a)(6)/3270.182(2) · An agreement shall specify the date of the child's admission. A child's record shall contain the dates of application, admission and withdrawal of the child.

Documentation of the agreement on file for child 1 and child 4 did not include the date of the child's admission.

Corrected by Jan 26, 2024

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

During the time of inspection, it was observed that the emergency transportation plan was not posted in the sensory room.

Corrected by Jan 26, 2024

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3270.131(d)(5)/3270.131(e)(3) · A health report shall include a review of the child's immunized status according to recommendations of the ACIP. The facility shall implement dismissal policies in accordance with the Department of Health regulation in 28 Pa. Code § 27.77 (relating to immunization requirements for children in child care group settings).

Documentation of the influenza vaccine was not on file for child 3. Documentation on file for child 2 did not include the recommended 15-18 month dose of the DTAP vaccine.

Corrected by Jan 26, 2024

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3270.133(4) · Medication shall be stored in a locked area of the facility or in an area that is out of the reach of children.

During the time of inspection, it was observed that the medication for child 1 was in the child's bookbag which was within the reach of children.

Corrected by Jan 26, 2024

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3270.133(7) · An operator is responsible to establish and maintain a medication log if prescription or nonprescription medication is administered.

During the time of inspection, it was observed that medication for child 5 was at the facility but didn't have documentation of a medication log.

Corrected by Jan 26, 2024

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

Documentation on file for staff member 1, staff member 2, staff member 3, and staff member 9 did not include two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person. This was corrected on site for staff member 2.

Corrected by Jan 19, 2024

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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.

Documentation of the letter that the parents receive about the emergency plan did not include accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions.

Corrected by Jan 26, 2024

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

During the time of inspection, the facility could not provide documentation of an annual emergency drill being conducted at the facility.

Corrected by Jan 26, 2024

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

A copy of the emergency plan on file was not sent to the county emergency management agency,

Corrected by Feb 2, 2024

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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. TIERED LIS: Children must be supervised at all times.

Direct statement from staff person #2, as well as footage from the CC video clearly showed that child #1 was left in the childcare space unsupervised by staff person #1 for a period of time in excess of 9 minutes. Footage indicated that staff person #1 was only 6-8 feet from the sleeping child prior to leaving them unsupervised, and that she also re-entered the childcare space for an unrelated reason and still did not notice the child. Child was observed to be sleeping for part of the time, but then awoke and wandered about the space for a period of time.

Corrected by Sep 22, 2023

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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. TIERED LIS: Children must be supervised at all times. Facility must participate in a Technical Assistance program to review, evaluate and update a process for supervision of children during transitions, which should include something in the way of a formal checklist conduct by childcare staff to ensure that all children are accounted for and being properly supervised. Other processes or modifications can be made, as needed, as part of the Technical Assistance program to ensure that supervision of children is improved. This checklist should be submitted weekly to the Central Regional Certification Representative for a period of two months.

Direct statement from staff person #2, as well as footage from the CC video clearly showed that child #1 was left in the childcare space unsupervised by staff person #1 for a period of time in excess of 9 minutes. Footage indicated that staff person #1 was only 6-8 feet from the sleeping child prior to leaving them unsupervised, and that she also re-entered the childcare space for an unrelated reason and still did not notice the child. Child was observed to be sleeping for part of the time, but then awoke and wandered about the space for a period of time.

Corrected by Nov 15, 2023

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

Upon inspection of complaint allegations regarding facility field excursions, it was found that an individual volunteer file had not been created for multiple 'chaperones' prior to these excursions.

Corrected by Sep 19, 2023

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3270.32(a)/3270.192(4) · The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). LACKING REQUIRED HIRING DOCUMENTS: Each facility chaperone/volunteer file must contain all the clearances/registry required by CPSL. 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.

Upon investigation of complaint allegations, it was found that the facility had not created a regulatory compliant volunteer file, including CPSL required clearances/registry, for multiple 'chaperones' prior to off-site excursions.

Corrected by Nov 22, 2023

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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.

Upon the investigation of complaint allegations, it was found that child #1 was participating in an off-site field trip, during which time they were separated from the primary supervision group for an undetermined amount of time greater than 10 minutes. It was determined that the child remained within the excursion location with a related chaperone, while the primary care group and adult were aboard the transportation bus.

Corrected by Sep 19, 2023

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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. The legal entity must arrange for TA support to address the specific area of off-site excursions, the policies and procedures required for compliance with these events as well as the review and revision of the facility procedures for compliance related to volunteer/chaperone files.

Upon the investigation of complaint allegations, it was found that child #1 was participating in an off-site field trip, during which time they were separated from the primary supervision group for an undetermined amount of time greater than 10 minutes. It was determined that the child remained within the excursion location with a related chaperone, while the primary care group and adult were aboard the transportation bus.

Corrected by Oct 31, 2023

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

Upon inspection of facility personnel files, it was found that staff person #3 did not have a record of training on the emergency plan at the time of initial employment.

Corrected by Feb 28, 2023

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3270.31(f) · Staff person(s) shall complete professional development in the topics of 3270.31(f)(1 -- 10), 3280.31(f) (1-10), or 3290.31(g) (1-10) within 90 days of hire. Staff person #1 will have until 4.3.23 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. Staff person(s) shall complete professional development in the topics of 3270.31(f)(1 -- 10), 3280.31(f) (1-10), or 3290.31(g) (1-10) within 90 days of hire. Staff person #3 will have until 4.3.23 to complete the required training. Until such time as the required training has been completed, staff person #3 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 #3, staff person #1 may not work in a child-care position at the facility.

Staff person #1 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Pre-Service Health and Safety training topics course. Staff person #3 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Pre-Service Health and Safety training topics course.

Corrected by Mar 20, 2023

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3270.32(a)/3270.192(4) · Facility person #1 must be removed from a childcare position by the close of business [2.28.23]. Facility person #2 must completed the required training immediately.

The file of facility person #1 does not contain a completed out of state clearances [MD child abuse]. The file for facility person #2 does not contain a valid mandated reporter training certificate [unapproved course 4.21.22].

Corrected by Mar 10, 2023

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3270.74 · The telephone number of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted by each telephone in the facility.

Upon inspection of the physical childcare spaces, it was found that emergency contact phone numbers were not posted in the sensory and school-aged rooms.

Corrected by Feb 28, 2023

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

Upon inspection of the physical childcare spaces, it was found that a damaged ceiling tile was in evidence in the toddler 1 room.

Corrected by Mar 6, 2023

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

Upon inspection of the physical childcare spaces, it was found that there was peeling/flaking paint in the PreK 3 room [pillars & doorframes] AND in the PreK 4 room [windowsills].

Corrected by Mar 6, 2023

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

Upon inspection of the physical childcare spaces, it was found that a written plan of daily activities was not posted in the sensory and school-aged rooms.

Corrected by Feb 28, 2023

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

Upon inspection of the physical childcare spaces, it was found that a written plan identifying the means of transporting a child to emergency care and staffing provisions in the event of an emergency were not posted in the sensory and school-aged rooms.

Corrected by Feb 28, 2023

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

Upon inspection of the children's files, it was found that the Emergency contact and financial agreement forms for child #2 were last reviewed on 8.8.22 AND the financial agreement form for child #3 was last reviewed on 8.10.22.

Corrected by Mar 1, 2023

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3270.133(2) · A staff person shall administer a prescription medication only if written instructions are provided from the individual who prescribed the medicine. Instructions for administration contained on a prescription label are acceptable.

Upon inspection of the childcare spaces, it was found that a prescription medication was present for child #1 in the PreK 3 room without any written instructions.

Corrected by Mar 1, 2023

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3270.161(d) · Potentially hazardous food brought from the child's home or provided by the facility shall be refrigerated.

Upon inspection of the physical childcare spaces, it was found that a box of yogurt snacks was placed on the table of the school-aged room at 12:00, which required refrigeration. No staff were present in the room at the time of discovery.

Corrected by Feb 28, 2023

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3270.95(a) · Fire detection devices or systems must be in compliance with standards established under section 1016(c) of the act (62 P.S. §  1016(c)).

Upon inspection of the fire safety records for the facility, it was found that an purchase attestation statement was not available. Further, upon inspecting the system testing dates, the following dates were provided: 1.2022, 2.2022, 3.31.2022, 4.13.22, 5.16.2022, 6.13.22, 7.11.2022, 8.12.2022, 9.20.2022, 10.18.2022, 11.3.22,12.11.2022 and 1.31.23 - which is evidence that the maximum 30 interval between testing was exceeded on several occasions.

Corrected by Mar 7, 2023

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

Upon inspection of the facility, it was found that an annual written notification to local traffic safety authorities regarding the program's use of pedestrian and vehicular routes around the child care facility had not been submitted for the past year [20022-2023].

Corrected by Mar 2, 2023

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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 will have until 12.3.22 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, primary staff person) 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.

Staff person #1 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Pediatric First Aid/CPR

Corrected by Nov 12, 2022

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3270.32(a)/3270.192(4) · The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Facility person # must be1emoved from a child care position by the close of business [11.8.22]

The file of facility person #1 does not contain a completed PA Criminal Clearance.

Corrected by Nov 8, 2022

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

Upon inspection of facility person #1 file during complaint investigation, it was found that no health assessment was on file.

Corrected by Nov 8, 2022

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3270.113(b) · A facility person may not use any form of physical punishment, including spanking a child. Provider will continue to conduct and document Director supervision for an additional two months time. As part of this directed plan, it should be updated to include staff observations utilizing video monitoring [instead of in-classroom format] at least 2-3 times per week, each for a period of 15 minutes per childcare space. Documentation should continue to be submitted to Regional Certification Representative as previously established. Supervision training shall be conducted in a targeted 1:1 series of sessions with facility person #1 to establish best practices in childcare AND with Facility Director to focus on recognizing inappropriate staff conduct and the most appropriate actions to be taken.

Directly observed via video that facility person #1 did physically grab and harshly pull child #2 by the arm during the course of care.

Corrected by Jan 20, 2023

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3270.113(b) · A facility person may not use any form of physical punishment, including spanking a child. Facility Chief Program Impact Officer and Facility Site Director will both participate in and complete the Existing Provider Orientation with the Office of Child Development and Early Learning - Central Region on October 6, 2022.

Upon review of the video footage of the specific incident under investigation, staff person #1 can be seen to be roughly moving child #1 in her seat and then making physically inappropriate/rough contact with the child's face area. A full review of the entire day's video footage for that childcare space on 8.23.22 showed staff person #1 use inappropriate physical/rough contact with child #2 - #7.

Corrected by Oct 7, 2022

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