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

Staff evaluations were not completed on a regular basis at a minimum annually. The file for staff person #8 included documentation of a written evaluation on 2.2.25.

Corrected Corrected by Jul 14, 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.

Staff emergency plan training was not updated annually. The file for staff person #1 , Staff person # 2 , staff person #3 , staff person #5 , staff person 6included documentation of emergency plan training on 5.2.24 without an annual review. The file for staff person #4 included documentation of emergency plan training on 5.4.24 without an annual review. The file for staff person #7 included documentation of emergency plan training on 5.13.24 without an annual review.

Corrected Corrected by Jun 5, 2025

Category: recordkeeping. Marked corrected in the state record.

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

Staff fire safety planning training was not conducted annually. The file for staff person #5 included documentation of fire safety training on 10.23.23 with an update on 11.26.24.

Corrected Corrected by Jul 14, 2025

Category: recordkeeping. 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.

It was observed in the seeds (infant) room, that the facility person did not wash their hands after a diaper change. (Corrected on Site)

Corrected Corrected by Jun 5, 2025

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

3270.124(b)(2) · Emergency contact information must include the name, address and telephone number of the child's physician or source of medical care.

Upon inspection of the children's files, it was found that the address for the physician / medical care facility was missing on the emergency contact form for child #1 .

Corrected Corrected by Jul 14, 2025

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

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

Upon inspection of the children's files, it was found that the enrolling parent's work address and work phone number were missing on the emergency contact form for child #1 and child #4.

Corrected Corrected by Jul 14, 2025

Category: recordkeeping. Marked corrected in the state record.

3270.124(b)(6) · Emergency contact information must include health insurance coverage and policy number for a child under a family policy or Medical Assistance benefits, if applicable.

Upon inspection of the children's files, it was found that the health insurance coverage and policy number were missing on the emergency contact form for child #1 and child #6.

Corrected Corrected by Jul 14, 2025

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

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

Upon inspection of the children's files, it was found that the release person's complete address was missing on the emergency contact form for child #1 and child #4.

Corrected Corrected by Jul 14, 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.

Upon inspection of children's files, it was found that for Child #1, the agreement and emergency contact forms had both been last reviewed/signed on 9.9.24 AND for Child #2, the emergency contact form did not include a date of review. It was found that for Child #3, the agreement was last reviewed / signed on 8.08.24 and emergency contact form had been last reviewed/signed on 4.14.24 and again on 5.1.25, the agreement had last been reviewed/signed on 1.23.24.

Corrected Corrected by Jul 14, 2025

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.

Upon inspection of children's files, it was found that for Child #3, the health reports were not updated within a 12 month period as evidenced by reports dated 1.2.24 and 3.14.25.

Corrected Corrected by Jul 14, 2025

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

3270.182(6) · A child's record shall contain signed parental consent for transportation, walking excursions, swimming and wading.

Upon inspection of the children's files, it was found that parent consent for swimming and wading were not listed or obtained on the emergency contact forms for Child#1, Child #2 , Child #3, Child #4, Child #5, and Child #6.

Corrected Corrected by Jul 14, 2025

Category: transportation. 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.

Upon inspection of the facility fire safety records, it was found that the following smoke alarm test dates exceeded the maximum of 30-days between required tests: 3.7.25 / 4.7.25 [31d]..

Corrected Corrected by Jul 14, 2025

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). Facility Person #3 may not work in a childcare position at the facility but can performing other duties i.e. office , kitchen until NSOR clearance results are obtained.

Clearances on file for facility person #1 and facility person #2 were not updated within the 60-month timeframe required under CPSL. The file for facility #3 contained a DHS FBI clearance dated 2/07/2025 was obtained beyond the 45-day timeframe (141 days) and the NSOR clearance was not on file. The file for facility person #1 contained State Police clearances dated 11/19/2019 with an update on 12/5/2024, and DHS- FBI Clearances dated 11/20/2019 with an update on 12/4/2024. The file for facility person #2 contained State Police clearances dated 9/23/2019 with an update on 10/30/2024; Child Abuse Clearances dated 9/16/2019 with an updated on 11/24/2024 and DHS -- FBI Clearances dated 9/21/2019 with an update on 1/30/2025.

Corrected Corrected by Mar 7, 2025

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

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

Upon inspection of the facility fire drill logs, it was found that drills were conducted on 12/11/2024 and 2/10/2025 (61 days) were greater than 60 days between drills.

Corrected Corrected by Mar 7, 2025

Category: recordkeeping. Marked corrected in the state record.

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

Upon inspection of the facility fire detection testing log, it was found that fire detection tests were conducted on 1/02/2025 and 2/10/2025 (39 days) were greater than 30 days between testing dates.

Corrected Corrected by Mar 7, 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. Until such time as the required pre-service trainings are completed, facility person # 3, #4 and #7 - must be supervised, when interacting with children, by an (AGS) who has completed the required training related to this citation. If there are no staff person(s) available to supervise staff persons #3, #4 and #7 staff persons #3, #4 and #7 may not work in a child-care position at the facility.

The file for facility person #1 did not contain the required Health and Safety training update as outlined in Announcement C-22-06. Facility persons #3 and #4 - have not completed the following pre-service training required prior to caring for children unsupervised: Pediatric First Aid and Pediatric CPR and Get Started with Center-Based Care-Revised 2022. Facility persons #3 and #4 - were observed to be caring for children unsupervised. Facility person #7 does not have current pediatric first-aid/CPR training. This is evidenced by the previously documented pediatric first-aid/CPR training expiration date of February 2022. Facility person #7 was observed to be caring for children unsupervised.

Corrected Corrected by Apr 10, 2024

Category: supervision. 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.Staff person(s) shall complete professional development in the topics of 3270.31(f)(10),) Pediatric First Aid and Pediatric CPR within 90 days of hire. Staff persons #1, #2, #4 and #7 will have until 5/13/2024 to complete the required training. Until such time as the required training has been completed, staff persons #1, #2, #4 and #7 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 persons #1, #2, #4 and #7, staff persons #1, #2, #4, and #7 may not work in a child-care position at the facility.

Facility person #1, #2, #4 and #7 have not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Pediatric First Aid & Pediatric CPR.

Corrected Corrected by Apr 10, 2024

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).

Facility person #1 has not completed mandated reporter training within the last 60 months. This is evidenced by the previously documented mandated reporter training on file dated 3.21.19.

Corrected Corrected by Apr 6, 2024

Category: recordkeeping. 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.

Upon inspection of the facility, Infant cribs had less than two feet of space on 3 sides while in use.

Corrected Corrected by Apr 10, 2024

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

3270.94(a)(1)/3270.95(b) · The Director or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that fire drills are conducted at least once every 60 days. The Director or designated staff person who is responsible for compliance with this chapter shall ensure the requirements under subsection (a) are met.

Upon inspection of the facility fire drill logs, it was found that drills were conducted on 10.26.23 and 2.1.24, which demonstrates that greater than 60 days elapsed between fire drills.

Corrected Corrected by Apr 4, 2024

Category: recordkeeping. Marked corrected in the state record.

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

Upon inspection of the facility, the facility did not have evidence of testing the fire detection system every 30 days as required.

Corrected Corrected by Apr 4, 2024

Category: recordkeeping. Marked corrected in the state record.

3270.31(f) · Staff person(s) shall complete professional development in the topics of 3270.31(f)(1 -- 10) within 90 days of hire. Staff person # 2 will have until September 12, 2023 to complete the required training. Until such time as the required trainings has been completed, staff person #2 must be supervised, when interacting with children, by an AGS who has completed the required trainings 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.

Facility person #2 has not completed the following required pre-service training within 90 days of their date of hire: Basic Health and Safety Topics including pediatric first aid/CPR from a PQAS approved trainer and a PQAS approved curriculum and Get Started with Center-Based Care-Revised 2022.

Corrected Corrected by Sep 15, 2023

Category: supervision. Marked corrected in the state record.

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

It was observed that fire drills were not conducted at least once every 60 days. The documented fire drills at the facility occurred 3.31.23, 5.12.23, and 6.20, 2023. The last documented fire drill at the facility occurred in 6.20.2023.

Corrected Corrected by Aug 29, 2023

Category: recordkeeping. Marked corrected in the state record.

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

It was observed that staff person #1 did not conduct smoke detector testing every 30 days.

Corrected Corrected by Aug 29, 2023

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). Staff person #3- will have until 7/13/2023 to complete the mandated reporter 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 person(s) available to supervise staff person # 3, staff person #3 may not work in a child-care position at the facility.

Staff person #3 has not completed mandated reporter training within the last 60 months. This is evidenced by the previously documented mandated reporter training on file being dated 5/15/2018.

Corrected Corrected by Jul 7, 2023

Category: supervision. 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 information for Child #5 did not have a complete address for release persons. The address did not include a city and zip code.

Corrected Corrected by Jun 28, 2023

Category: recordkeeping. Marked corrected in the state record.

3270.131(c) · A health report must be written and signed by a physician, physician's assistant or a CRNP. The signature must include the individual's professional title.

The health report for child #1 did not include a physician signature.

Corrected Corrected by Jul 7, 2023

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

3270.131(d)(2) · A health report shall include a list of the child's allergies.

The health report on file for child #1 did not include information regarding the child's allergies.

Corrected Corrected by Jul 7, 2023

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

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

The health report on file for child #1 did not include a statement that the child is able to participate in child care and appears to be free from contagious or communicable disease.

Corrected Corrected by Jul 7, 2023

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

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

The health report/immunization record on file for child #1 was received on 6.14.23 which was 60 days after the child's start date.

Corrected Corrected by Jul 7, 2023

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 included health assessments dated 8.6.2020 and 3.20.2023. The file for staff person #3 included health assessments dated 8.26.2020 and 4.6.2023. The file for staff person #4 included health assessments dated 8.3.2020 and 6.12.2023. Updated health assessments were not obtained within 24 months of the prior assessment.

Corrected Corrected by Jun 28, 2023

Category: ratio. Marked corrected in the state record.

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

It was observed that the financial agreements and emergency contact forms on file for child #4 and child #5 were reviewed and updated after the 6-month timeframe. The emergency contact and agreement forms for Child #4 had the date of 9.27.22 with an update on 6.8.23. The emergency contact and agreement forms for Child #5 had the date of 9.23.22 with an update on 6.8.23.

Corrected Corrected by Jun 28, 2023

Category: recordkeeping. Marked corrected in the state record.