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.

Current director (Staff person #1) is not present at the facility site for a minimum of 30 hours per week.

Corrected Corrected by Jan 2, 2026

Category: recordkeeping. 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 for child #2 does not include the date by which the fee is to be paid.

Corrected Corrected by Sep 2, 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 for child #1, #2, and #4 does not include arrival and departure times.

Corrected Corrected by Sep 2, 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 for child #2 does not include persons to whom the child may be released.

Corrected Corrected by Sep 2, 2025

Category: recordkeeping. Marked corrected in the state record.

3270.123(a)(6) · An agreement shall specify the date of the child's admission.

The agreement for child #1 and #5 does not include the date of admission.

Corrected Corrected by Sep 2, 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 #4 has current emergency plan training dated 6/26/25, which is more than 12 months after the previous training dated 3/13/24. Staff #6 has current emergency plan training dated 3/15/23, which is more than 12 months ago. Staff #2 has current emergency plan training dated 6/19/25, which is more than 12 months after the previous training dated 3/12/24.

Corrected Corrected by Sep 2, 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 #2, #3, #4, #5, #6, #7, and #8 have current annual fire safety training dated 11/7/23, which is more than 12 months ago.

Corrected Corrected by Oct 30, 2024

Category: recordkeeping. Marked corrected in the state record.

3270.32(a) · Staff #2 and #3 may not work in a childcare position at the facility until all clearances have been obtained.

The current NSOR certificate for staff person #2 is dated 4/13/20, which is more than 60 months ago. Staff person #3 has the following expired clearances: PA State Police clearance dated 5/4/20, Child Abuse clearance dated 4/14/20, current DHS FBI clearance dated 4/10/20, and current NSOR certificate dated 4/13/20.

Corrected Corrected by Sep 2, 2025

Category: background checks. 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.

The emergency contact information for child #1 and #2 does not have the address of the child's physician/medical care. The emergency contact information for child #2 did not include the phone number for the child's physician/medical care.

Corrected Corrected by Sep 2, 2025

Category: health medication. 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 persons #2 and #3 and volunteer #1 will have until 9/4/25 to complete the mandated reporter training. Until such time as the required training has been completed, staff persons #2 and #3 and volunteer #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 person(s) available to supervise staff person #2 and #3 and volunteer #1, staff persons #2 and #3 and volunteer #1 may not work in a child-care position at the facility.

Volunteer #1 has not completed the mandated reporter training within 90 days of their date of hire (see LIS code sheet) Staff person #2 has not completed mandated reporter training within the last 60 months. This is evidenced by the previously documented mandated reporter training on file being dated 1/17/19. 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 4/23/20.

Corrected Corrected by Sep 2, 2025

Category: supervision. 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 current staff evaluation for staff #2 is dated 1/16/24, which is more than 12 months ago. The current staff evaluation for staff #4 is dated 1/16/24, which is more than 12 months ago. The current staff evaluation for staff #8 is dated 1/15/24, which is more than 12 months ago. Staff evaluations for staff #5 exceed 12 months. The current is dated 11/15/24 and the previous is dated 1/6/23. The current staff evaluation for staff #6 is dated 1/6/23, which is more than 12 months ago.

Corrected Corrected by Sep 2, 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.

An electrical outlet between the toy shelves in the upstairs classroom space lacked a protective cover.

Corrected Corrected by Sep 2, 2025

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

3270.66(c) · Cleaning materials and other toxic materials shall be used in a way that does not contaminate play surfaces, food, food preparation areas and does not constitute a hazard to the children.

Cleaning products not in bins were stored on wire shelving above diapering areas in both the downstairs playroom and the infant room upstairs.

Corrected Corrected by Sep 2, 2025

Category: ratio. 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 kitchen lacked a thermometer.

Corrected Corrected by Sep 2, 2025

Category: nutrition. Marked corrected in the state record.

3270.123(a)(1) · An agreement shall specify the amount of the fee to be charged per day or per week.

The agreement for child #2 does not include the fee amount.

Corrected Corrected by Sep 2, 2025

Category: recordkeeping. 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.

The emergency contact information for child #2, #3, and #4 does not include the enrolling parent's work address or work telephone number.

Corrected Corrected by Sep 2, 2025

Category: recordkeeping. Marked corrected in the state record.

3270.124(b)(4)/3270.182(3) · 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 emergency medical care for the child. Written consent is required prior to admission.

The emergency contact information for child #3 and #5 did not include signed consent for emergency medical care.

Corrected Corrected by Sep 2, 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.

The emergency contact information for child #1 does not include the child's health insurance policy number.

Corrected Corrected by Oct 6, 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.

The emergency contact information for child #2 does not include the address of the release person.

Corrected Corrected by Oct 6, 2025

Category: recordkeeping. Marked corrected in the state record.

3270.131(b)(1) · The operator shall require the parent to provide an updated health report at least every 6 months for an infant or young toddler.

The updated health assessment for child #1, a young toddler is dated 6/20/25 which is more than 6 months after the previous health assessment dated 10/7/24. The updated health assessment for child #5, a young toddler is dated 6/4/25 which is more than 6 months after the previous health assessment dated 7/26/24.

Corrected Corrected by Sep 2, 2025

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.

Written verification of immunizations for child #4 is dated 7/29/25, which is more than 60 days after the child's date of enrollment (see LIS code sheet).

Corrected Corrected by Sep 2, 2025

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 current health assessment for staff #3 is dated 5/4/23, which is more than 24 months ago. The current health assessment for staff #4 is dated 3/23/23, which is more than 24 months ago. The current health assessment for staff #5 is dated 7/6/23, which is more than 24 months ago. The current health assessment for staff #6 is dated 9/7/22, which is more than 24 months ago. The current health assessment for staff #7 is dated 3/24/23, which is more than 24 months ago.

Corrected Corrected by Oct 6, 2025

Category: ratio. Marked corrected in the state record.

3270.182(5) · 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 emergency contact information for child #3, #4, and #5 does not include consent for minor first aid.

Corrected Corrected by Oct 6, 2025

Category: ratio. 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.

Volunteer #1 and staff #9 do not have two written, non-family references on file.

Corrected Corrected by Oct 6, 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.

Testing of fire-detection exceeded 30 days from 4/11/25-5/12/25 and 6/11/25-7/18/25.Testing of fire-detection exceeded 30 days from 4/11/25-5/12/25 and 6/11/25-7/18/25.

Corrected Corrected by Sep 2, 2025

Category: recordkeeping. Marked corrected in the state record.

3270.31(e) · A staff person shall obtain an annual minimum of 12 clock hours of child care training.

Staff #2, #3, #4, #5, #6, #7, and #8 do not have documentation of any clock hours of childcare training between December of 2023 and December of 2024

Corrected Corrected by Oct 6, 2025

Category: recordkeeping. Marked corrected in the state record.

3270.131(a) · 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 initial health assessment for child #4 is dated 7/29/25, which is more than 60 days after the child's date of enrollment (see LIS code sheet).

Corrected Corrected by Sep 2, 2025

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

3270.31(f) · Staff person shall complete professional development in the topics of 3270.31(f) within 90 days of hire. Staff person #2 will have until March 25, 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 #2 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.

Corrected Corrected by Apr 28, 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) LACKING REQUIRED HIRING DOCUMENTS: Staff person/volunteer # 2 may not work in a childcare position at the facility. .

Staff person #2 has not completed the mandated reporter training within 90 days of their date of hire (see LIS code sheet). The date of the current mandated reporter training for staff person #1 is 1/17/19. The training is required to be updated within 60 months of the previous training.

Corrected Corrected by Apr 28, 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 certificate of compliance that was posted in a conspicuous location used by parents was not the current certificate. The dates on the posted certificate were 10/11/23-10/11/24.

Corrected Corrected by Apr 5, 2025

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.

Staff persons #1, #3, #4, and #5 did not renew their certification in pediatric first aid and pediatric CPR on or before the expiration of the most current certification. The dates of the previous certifications were 6/13/22 and the current certifications were dated 6/26/24.

Corrected Corrected by Jun 26, 2024

Category: ratio. 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). LACKING REQUIRED HIRING DOCUMENTS: Facility Person # 3 may not work in a child care position at the facility. A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Facility Person #3 may not work in a child care position at the facility.

Staff person #3 did not have current copies of the following clearances in their file: PA State Police, Child Abuse, and FBI Clearance.

Corrected Corrected by Jul 31, 2024

Category: background checks. 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.

In the upstairs room with a fireplace and television, a protective outlet cover was missing from the outlet below the window.

Corrected Corrected by Jul 26, 2024

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

3270.66(c) · Cleaning materials and other toxic materials shall be used in a way that does not contaminate play surfaces, food, food preparation areas and does not constitute a hazard to the children.

A bottle of cleaning solution and disinfectant wipes were stored uncontained on a shelf above the diapers in the infant room.

Corrected Corrected by Jul 26, 2024

Category: ratio. 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 forms were not present with children who were receiving care in the outdoor play space.

Corrected Corrected by Jul 26, 2024

Category: recordkeeping. Marked corrected in the state record.

3270.133(3) · The label of a medication container shall identify the name of the medication and the name of the child for whom the medication is intended. Medication shall be administered to only the child whose name appears on the container.

The first-aid kit in the outdoor play space contained medication not labeled for individual use.

Corrected Corrected by Jul 26, 2024

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.

Staff person #5 had an initial health assessment dated 3/28/22, and did not have documentation of a health assessment within 24 months after.

Corrected Corrected by Aug 5, 2024

Category: ratio. 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 showed more than 30 days between testing of fire detection system on the following dates: 7/10/23-8/18/23, 9/12/23-10/27/23, 1/4/24-2/16/24, 3/15/24-4/27/24, 4/27/24-5/30/24

Corrected Corrected by Jul 26, 2024

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 operator did not provide a letter to the parent of each enrolled child explaining subsequent updates to the emergency plan.

Corrected Corrected by Aug 1, 2023

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

3270.67(d) · Trash that has been contaminated by human secretions or excrement shall be contained in closed, plastic-lined receptacles.

Trash that appeared to be contaminated by human secretions (nasal tissues) was contained in an open receptacle in the downstairs playroom.

Corrected Corrected by Jul 14, 2023

Marked corrected in the state record.

3270.71 · Hot water pipes and other sources of heat exceeding 110° F that are accessible to children shall be equipped with protective guards or shall be insulated to prevent direct contact.

An electric air fryer which is a source of heat exceeding 110° F was observed in use on the counter in the table activity room where it was accessible to children in care.

Corrected Corrected by Aug 4, 2023

Category: physical safety. 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 no wall plate on an electrical outlet in the downstairs playroom.

Corrected Corrected by Jul 14, 2023

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.

There was peeling paint observed on the outside of a door used by children to access the outdoor play space.

Corrected Corrected by Jul 19, 2023

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.

In the outdoor play space, the following equipment was accessible and posed a potential hazard for children in care: a piece of a plastic baby gate was broken off, which created a sharp edge, and a piece of a plastic children's kitchen playset was broken off, which created a sharp edge. In the downstairs playroom, there several tears observed on the vinyl covering of a pack n play mattress.

Corrected Corrected by Jul 17, 2023

Category: physical safety. 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 record for child #1, #2 and #5 did not contain a child service report or other Department approved form to provide information to the family about the child's growth and development in the context of the services being provided.

Corrected Corrected by Jul 31, 2023

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 emergency contact information for child #4 and #5 has not been reviewed at least once in a 6-month period.

Corrected Corrected by Jul 31, 2023

Category: recordkeeping. Marked corrected in the state record.

3270.131(b)(1)/3270.182(1) · The operator shall require the parent to provide an updated health report at least every 6 months for an infant or young toddler. A child's record shall contain initial and subsequent health reports.

The record for child #2, a young toddler, lacked a current health report.

Corrected Corrected by Jul 19, 2023

Category: health medication. 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 record for child #1 and #5, a preschool child, contained a current health report dated more than 12 months following the date of the previous health report.

Corrected Corrected by Jul 19, 2023

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 record for staff #1 lacked a current health assessment.

Corrected Corrected by Jul 19, 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.

The financial agreement for child #4 and #5 has not been reviewed at least once in a 6-month period.

Corrected Corrected by Jul 31, 2023

Category: recordkeeping. Marked corrected in the state record.

3270.14/3270.21 · A facility shall be operated in conformity with applicable Federal and State laws and regulations.State agencies whose regulations may relate to the operation of a facility include the Department of Environmental Resources, the Department of Labor and Industry, the Department of Health, the Department of Education and the Department of Transportation.Conditions at the facility may not pose a threat to the health or safety of the children.

The facility did not have a policy and procedure to identify the prevention shaken baby syndrome, abusive head trauma, and child maltreatment in compliance with the federal requirements at 45 CFR § 98.41(a)(1)(vi); and the facility's emergency plan did not include a continuity of operations plan in compliance with the federal requirements at 45 CFR § 98.41(a)(1)(vii).

Corrected Corrected by Oct 19, 2022

Category: ratio. 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.

The outside trim around the the door used by the children to access the outdoor play space was damaged and there was a nail protruding from the bottom of one of the wooden posts on the shelter in the outdoor play space.

Corrected Corrected by Sep 26, 2022

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

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

The upstairs bathroom was not equipped with a lidded waste receptacle.

Corrected Corrected by Sep 28, 2022

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 toy lawn mower and scooter with broken pieces/sharp edges in the outdoor play space, which posed a hazard to children using the equipment.

Corrected Corrected by Sep 23, 2022

Category: physical safety. 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 record for child #1 did not include a current health report.

Corrected Corrected by Oct 21, 2022

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

3270.135(c) · The diapering area may not be used for food preparation or food service.

The diapering area was being used for food preparation and service.

Corrected Corrected by Sep 23, 2022

Category: ratio. Marked corrected in the state record.

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

The operator did not use the emergency plan delivery documentation form (CD 355) or another document that contains the information in the emergency plan delivery documentation form (CD 355) to document the delivery of a copy of the emergency plan and subsequent plan updates to the local municipality and to the county emergency management agency.

Corrected Corrected by Sep 23, 2022

Category: physical safety. 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.

2nd CITATION: Staff person #5 lacked emergency plan training at initial hire (See LIS CODE SHEET). PREVIOUSLY CITED ON 11/9/21

Corrected Corrected by Mar 29, 2022

Category: recordkeeping. Marked corrected in the state record.

3270.31(f)/3270.31(h) · Staff persons shall complete professional development in the following topics within 90 days of hire:All staff persons shall complete the professional development under subsection (f).

2nd CITATION: Staff files #3 and #4 lacked documentation of the ten topics of professional development completed within 90 days of hire (See LIS CODE SHEET). PREVIOUSLY CITED ON 1/24/22

Corrected Corrected by Apr 30, 2022

Category: health medication. 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). The legal entity will develop a "staff file checklist" for each staff file and submit checklist to the DHS representative for approval. The legal entity will confirm continuing compliance by sending copies of the approved "staff file checklist" and all documents required to the DHS representative via email for approval prior to staff's first day at the facility for a period of no less than 4 months from the date of approval of plan of correction.

**2nd CITATION: Staff file #4 lacked copies of the PA State Police Criminal Clearance in the file (See LIS CODE SHEET). PREVIOUSLY CITED ON 11/9/21. Staff person #5 lacked copies of the disclosure statement, DHS FBI Clearance and the NSOR Verification in the file (See LIS CODE SHEET).

Corrected Corrected by Aug 25, 2022

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

3270.32(a)/3270.192(4) · The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). 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 and #5 may not work in a child care position at the facility.

2nd CITATION: Staff file #4 lacked copies of the PA State Police Criminal Clearance in the file (See LIS CODE SHEET). PREVIOUSLY CITED ON 11/9/21. Staff person #5 lacked copies of the disclosure statement, DHS FBI Clearance and the NSOR Verification in the file (See LIS CODE SHEET).

Corrected Corrected by Apr 7, 2022

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

3270.113(a) · 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.

2nd CITATION: on 3/29/22, a volunteer #5, who is not a staff person, was observed in the infant room with 1 infant and 2 young toddlers without a staff person present, (See LIS CODE SHEET). PREVIOUSLY CITED ON 11/1/2021

Corrected Corrected by Mar 30, 2022

Category: supervision. Marked corrected in the state record.

3270.113(a) · **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 develop a system to identify and designate staff persons who can and cannot supervise children and will submit the plan to DHS representative for approval. The legal entity will utilize the system for a period of 4 months after the system is approved.

**2nd CITATION: on 3/29/22, a volunteer #5, who is not a staff person, was observed in the infant room with 1 infant and 2 young toddlers without a staff person present, (See LIS CODE SHEET). PREVIOUSLY CITED ON 11/1/2021

Corrected Corrected by Sep 5, 2022

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.

Staff person #5 lacked a health assessment and results of Mantoux TB in the file prior to initial service at the facility.(See LIS CODE SHEET)

Corrected Corrected by Mar 31, 2022

Category: ratio. Marked corrected in the state record.

3270.151(c)(2) · 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.

Staff person #5 lacked results of Mantoux TB in the file prior to initial service at the facility. (See LIS CODE SHEET)

Corrected Corrected by Mar 31, 2022

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

3270.192(2)(ii) · A facility person's record shall include verification of child care experience, education and training prior to service at the facility.

2nd CITATION: Staff file #5 lacked verification of education and child care experience prior to service at the facility. PREVIOUSLY CITED ON 11/9/21

Corrected Corrected by Apr 1, 2022

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

2nd CITATION: Staff file #3, #4 and #5 lacked copies of two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person. PREVIOUSLY CITED ON 11/9/21

Corrected Corrected by Mar 30, 2022

Category: recordkeeping. Marked corrected in the state record.

3270.31(f)(10) · Staff persons shall complete professional development in pediatric first aid and pediatric cardiopulmonary resuscitation within 90 days of hire.

2nd CITATION: Staff file #3 and #4 lacked documentation of completion of pediatric first aid and pediatric cardiopulmonary resuscitation within 90 days of hire (See LIS CODE SHEET) PREVIOUSLY CITED ON 11/9/21.

Corrected Corrected by Apr 6, 2022

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

3270.31(f)/3270.31(h) · Staff persons shall complete professional development in the following topics within 90 days of hire: All staff persons shall complete the professional development under subsection (f).

Staff file #3 lacked documentation of completion of Getting Started with Center Based Care within 90 days of hire as required.

Corrected Corrected by Feb 28, 2022

Category: health medication. 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.

Staff # 2 was working as an assistant group supervisor without supporting documentation of qualifications in the staff file.

Corrected Corrected by Jan 27, 2022

Category: supervision. 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).

Child files #1 and #2 lacked documentation of completed child service reports completed every 6 months as required.

Corrected Corrected by Jan 30, 2022

Category: recordkeeping. 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.

The facility lacked copies of randomly selected emergency contact forms of children who where in care.

Corrected Corrected by Jan 25, 2022

Category: recordkeeping. Marked corrected in the state record.

3270.133(6)/3270.133(7) · A parent shall provide written consent for administration of medication or a special diet. An operator is responsible to establish and maintain a medication log if prescription or nonprescription medication is administered.

The facility had Tylenol for use for a child in care that lacked a medication log that included written consent from the parent.

Corrected Corrected by Feb 15, 2022

Category: ratio. Marked corrected in the state record.

3270.192(2)(ii) · A facility person's record shall include verification of child care experience, education and training prior to service at the facility.

Staff file #2 lacked documentation of prior education and experience in the file.

Corrected Corrected by Jan 25, 2022

Category: recordkeeping. Marked corrected in the state record.

3270.31(e) · A staff person shall obtain an annual minimum of 12 clock hours of child care training.

Staff file #1 lacked documentation of 12 hours of child care training completed annually.

Corrected Corrected by Feb 28, 2022

Category: recordkeeping. Marked corrected in the state record.

3270.113(a) · 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.

On 11/1/21, during lunchtime, Staff #1 was supervising 11 children of mixed Older Toddler and Preschool ages with Volunteer #2 when child #1 fell and staff #1 was not aware that the child received an injury.

Corrected Corrected by Nov 10, 2021

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.

Staff file's #1, #2, #3 and #4 all new hires lacked documentation of emergency plan training at initial hire.

Corrected Corrected by Jan 7, 2022

Category: recordkeeping. Marked corrected in the state record.

3270.31(f)/3270.31(h) · Staff persons shall complete professional development in the following topics within 90 days of hire: All staff persons shall complete the professional development under subsection (f).

Staff file #4 lacked documentation of the ten topics of professional development completed within 90 days of hire.

Corrected Corrected by Dec 7, 2021

Category: health medication. 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 #1, #2, #3 and #4 may not work in a child care position at the facility.

Staff file #1 lacked a signed, dated disclosure statement in the file. Staff #2 lacked copies of requests and all clearances as required by CPSL. Staff #3 lacked copies of the PA State Police Criminal Clearance, the Child Abuse Clearance and the DHS FBI Clearance in the file. Staff file #4 lacked copies of the PA State Police Criminal Clearance, the Child Abuse Clearance and the NSOR Verification form in the file and the disposition for the DHS FBI Clearance.

Corrected Corrected by Mar 18, 2022

Category: background checks. 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.

On 11/1/21, Staff #1 and Volunteer #2 were caring for a mix of 11 children ages Older Toddler and preschool age children.

Corrected Corrected by Nov 10, 2021

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.

Staff file #1 lacked the results of the initial tuberculin skin tests in the file.

Corrected Corrected by Nov 12, 2021

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

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

Staff #2 lacked an individual file with all of the required documents.

Corrected Corrected by Nov 10, 2021

Category: recordkeeping. Marked corrected in the state record.

3270.192(2)(ii) · A facility person's record shall include verification of child care experience, education and training prior to service at the facility.

Staff file #4 lacked documentation of verification of child care experience or education prior to hire in the file.

Corrected Corrected by Nov 10, 2021

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

Staff file #3 and #4 lacked copies of two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person.

Corrected Corrected by Jan 31, 2022

Category: recordkeeping. Marked corrected in the state record.

3270.31(f)(10) · Staff persons shall complete professional development in pediatric first aid and pediatric cardiopulmonary resuscitation within 90 days of hire.

Staff file #4 lacked documentation of completion of pediatric first aid and pediatric cardiopulmonary resuscitation within 90 days of hire.

Corrected Corrected by Mar 18, 2022

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