3270.20(e) · Copies of reports of injury, death or fire shall be kept in a file at the facility.

During the complaint investigation on 03/26/25 director was unable to produce incident report upon request.

Corrected Corrected by Apr 3, 2025

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.

During the complaint investigation on 03/26/25 it was determined that staff person #1 failed to properly supervise children which resulted in an injury to a child.

Corrected Corrected by Apr 3, 2025

Category: supervision. 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.

During the unannounced monitoring visit on 03/26/25 the file reviewed for staff person #1 and staff person #2 did not contain an initial health assessment.

Corrected Corrected by Apr 3, 2025

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). A provisional employee may not be permitted to work alone with children and must work within the vicinity of a permanent employee. 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 and #2 may not work in a childcare position at the facility.

During the unannounced monitoring on 03/18/25 the file reviewed for staff person #1 contained a FBI clearance that was more that 60 months old. FBI clearance was dated 01/08/20. Staff person #2, identified as a provisional hire did not have any clearances to review.

Corrected Corrected by Mar 31, 2025

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.

During the unannounced monitoring on 03/18/25 there were uncovered electrical outlets observed on 1st floor, 2nd floor, and downstairs play area.

Corrected Corrected by Mar 31, 2025

Marked corrected in the state record.

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

During the unannounced monitoring visit there was no file available for staff person #2.

Corrected Corrected by Mar 31, 2025

Category: recordkeeping. Marked corrected in the state record.

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

During the renewal inspection on 9/18/24 file reviewed for staff person #1 hired (see code sheet) did not contain a NSOR certificate. No receipt confirming NSOR was requested was in the file.

Corrected Corrected by Sep 25, 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.

During the renewal inspection on 9/18/24 missing electrical outlet covers were observed in childcare space accessible to children.

Corrected Corrected by Sep 18, 2024

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

3270.107 · A facility shall have an operable, clean refrigerator used to store potentially hazardous foods. The refrigerator shall be capable of maintaining food at 45° F or below. An operating thermometer shall be placed in the refrigerator.

During the renewal inspection on 9/18/24 the refrigerator in the kitchen area did not contain a thermometer.

Corrected Corrected by Sep 18, 2024

Category: nutrition. 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.

During the renewal inspection on 9/18/24 the file reviewed for staff person #1 did not contain an initial health assessment conducted prior to providing childcare services.

Corrected Corrected by Sep 26, 2024

Category: ratio. Marked corrected in the state record.

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

During the renewal inspection on 9/18/24 children's lunches were observed sitting out on the table and not refrigerated.

Corrected Corrected by Sep 18, 2024

Category: nutrition. Marked corrected in the state record.

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

During the renewal inspection on 10/17/23 there was no documentation of annual emergency drill.

Corrected Corrected by Oct 18, 2023

Category: recordkeeping. Marked corrected in the state record.

3270.183(a)/3270.193(a) · Child records are confidential and shall be stored in a locked cabinet. Facility persons' records are confidential and shall be stored in a locked cabinet.

During the renewal inspection on 10/17/23 child and staff files were observed being stored on a shelf and not in a locked cabinet.

Corrected Corrected by Oct 17, 2023

Category: recordkeeping. Marked corrected in the state record.

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

During the renewal inspection on 10/17/23 there were children's lunches observed in kitchen unrefrigerated.

Corrected Corrected by Oct 17, 2023

Category: nutrition. Marked corrected in the state record.

3270.166(4) · Disposable nursers and bottles shall be labeled with the child's name.

During the renewal inspection on 10/17/23 there were (4) bottles observed in the infant refrigerator without child's name labeled.

Corrected Corrected by Oct 17, 2023

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.

During the renewal inspection on 10/17/23 there were missing outlet covers observed in infant room, toddler room, preschool room. and play space.

Corrected Corrected by Oct 17, 2023

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

3270.66(a) · Cleaning materials and other toxic materials shall be kept in an area or container that is locked or made inaccessible to children.

During the renewal inspection on 10/17/23 there was disinfectant observed behind unlocked closet in the play space accessible to children.

Corrected Corrected by Oct 17, 2023

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

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

During the renewal inspection on 10/17/23 the first aid kit in the infant room and toddler room was missing scissors. The first aid kit in the preschool room was missing soap and tape.

Corrected Corrected by Oct 17, 2023

Category: health medication. 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.

During the renewal inspection on 10/17/23 there were highchairs observed stacked up in the toddler room bathroom posing possible hazard to children.

Corrected Corrected by Oct 18, 2023

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

3270.82(h) · A facility person and an able child shall wash his hands after toileting and before eating. A sign on which this requirement is written shall be posted at each toilet, training chair, diapering area and sink in the facility.

During the renewal inspection on 10/17/23 there was no handwashing signs posted by sink in the infant room.

Corrected Corrected by Oct 17, 2023

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

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

During the renewal inspection on 10/17/23 there was no lidded trash can in the toddler room bathroom.

Corrected Corrected by Oct 17, 2023

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

3270.72(d) · Windows or doors above the ground floor that open directly to the outdoors and are accessible to children shall be constructed, modified or adapted to limit the opening to 6 or fewer inches. Make the necessary modifications to limit the opening to 6 or fewer inches.

Several windows on the upper level that open directly to the outdoors and are accessible were not modified to limit the opening to 6 or fewer inches.

Corrected Corrected by Jan 20, 2023

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

3270.51/3270.52 · When children are grouped in similar age levels, the following maximum child group sizes and ratios of staff persons apply: Infants 1:4 with a maximum group size of 8; Young toddlers 1:5 with a maximum group size of 10; Older toddlers 1:6 with a maximum group size of 12; Preschool children 1:10 with a maximum group size of 20; Young school-age children 1:12 with a maximum group size of 24; Older school-age children 1:15 with a maximum group size of 30. When children are grouped in mixed age levels, the age of the youngest child in the group determines the staff:child ratio and maximum group size in accordance with the requirements in § 3270.51 (relating to similar age level). The legal entity must arrange for all facility staff to receive DHS approved hands on training in proper staff/child ratios. Develop and submit a written staffing plan including provisions for staff shortages including but not limited to call outs, scheduling, terminations, resignations and operational tasks that impact staffing and times of transition to ensure ongoing compliance with staff/child ratios. Submit written verification of completed training for all facility staff persons and a copy of the written staffing plan.

On 12/22/22, at approximately 3:30pm, three staff persons (#1, #2 and #3) were observed caring for a mixed-age group of 16 infants, older toddlers and preschool age children (1 infant birth to 12 months) (5 older toddlers-1 to 2 years of age; 10 preschoolers- ages 3 years to first day of entering Kindergarten old) in the basement indoor play space. Staff persons verified the ages of the children in care.

Corrected Corrected by Jan 22, 2023

Category: ratio. Marked corrected in the state record.

3270.51/3270.52 · When children are grouped in similar age levels, the following maximum child group sizes and ratios of staff persons apply: Infants 1:4 with a maximum group size of 8; Young toddlers 1:5 with a maximum group size of 10; Older toddlers 1:6 with a maximum group size of 12; Preschool children 1:10 with a maximum group size of 20; Young school-age children 1:12 with a maximum group size of 24; Older school-age children 1:15 with a maximum group size of 30. 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 12/22/22, at approximately 3:30pm, three staff persons (#1, #2 and #3) were observed caring for a mixed-age group of 16 infants, older toddlers and preschool age children (1 infant birth to 12 months) (5 older toddlers-1 to 2 years of age; 10 preschoolers- ages 3 years to first day of entering Kindergarten old) in the basement indoor play space. Staff persons verified the ages of the children in care.

Corrected Corrected by Dec 22, 2022

Category: ratio. 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. Submit a copy of the revised letter.

The letter given to parents regarding the emergency plan did not explain the emergency procedure updates to the plan as required in 3270.27 subsection a. CONTINUING DEFICIENCY

Corrected Corrected by May 10, 2022

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

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

Several staff person's records did not contain written verification of annual fire safety training.(#1-not corrected) #2-corrected) (#3-not corrected )

Corrected Corrected by May 10, 2022

Category: recordkeeping. Marked corrected in the state record.

3270.32(a)/3270.192(4) · The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). SAFETY PLAN: The operator is required to submit to the Children and Youth Agency a plan of supervision or alternate arrangement as required by the Child Protective Services Law. LACKING REQUIRED HIRING DOCUMENTS: 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 until the required CPSL documents have been obtained and submitted as specified. Submit a copy of the completed CPSL clearance documents for the identified staff persons as specified. Ensure that all clearances are completed and submitted in accordance with the CPSL.

The facility was not in compliance with the CPSL and with Chapter 3490 (relating to protective services): Two facility person's records did not contain the required CPSL hiring documents. (#4-no proof of request for FBI prior to working with children, no proof of request for NSOR prior to working with children, no completed FBI, no completed NSOR; no mandated reporter training). (#5- no clearances presented for review)

Corrected Corrected by May 10, 2022

Category: supervision. 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. Obtain and submit a current up-to-date health assessment for the identified staff persons. Ensure that staff health assessments are completed within the required timeframes as specified in this regulation.

Several staff person's records did not contain a health assessment completed within 12 months prior to the date of hire or within the past 24 months. (#1) (#3) (#4)

Corrected Corrected by May 10, 2022

Category: ratio. Marked corrected in the state record.

3270.191 · An individual record is required for each facility person. Obtain and submit a copy of the completed file for the identified facility person. Ensure that each facility person has a completed individual record.

One facility persons did not have an individual record that was presented at the time of the inspection. (#5)

Corrected Corrected by May 10, 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. Obtain and submit written verification of annual minimum 12 hours of childcare training for the identified staff person.

Two staff person's records did not contain written verification of annual minimum 12 hours of childcare training. (#2) and (#3).

Corrected Corrected by May 10, 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. Obtain and submit written verification of annual minimum 12 hours of childcare training for the identified staff person.

Two staff person's records did not contain written verification of annual minimum 12 hours of childcare training. (#2) and (#3).

Corrected Corrected by Apr 10, 2022

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. Revise the letter given to parents to ensure that it explains the emergency procedures and updates to the plan as required in 3270.27 subsection a. plan. Submit a copy of the revised letter.

The letter given to parents regarding the emergency plan did not explain the emergency procedure updates to the plan as required in 3270.27 subsection a. CONTINUING DEFICIENCY

Corrected Corrected by Apr 10, 2022

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

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

Several staff person's records did not contain written verification of annual fire safety training.(#1-not corrected) #2-corrected) (#3-not corrected )

Corrected Corrected by Apr 10, 2022

Category: recordkeeping. Marked corrected in the state record.

3270.32(a)/3270.192(4) · The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). LACKING REQUIRED HIRING DOCUMENTS: 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 Persons #4 and #5 may not work in a child care position at the facility until the required CPSL documents have been obtained and submitted as specified. Submit a copy of the completed CPSL clearance documents for the identified staff persons as specified. Ensure that all clearances are completed and submitted in accordance with the CPSL.

The facility was not in compliance with the CPSL and with Chapter 3490 (relating to protective services): Two facility person's records did not contain the required CPSL hiring documents. (#4-no proof of request for FBI prior to working with children, no proof of request for NSOR prior to working with children, no completed FBI, no completed NSOR; no mandated reporter training). (#5- no clearances presented for review)

Corrected Corrected by Mar 10, 2022

Category: background checks. 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. Obtain and submit a current up-to-date health assessment for the identified staff persons. Ensure that staff health assessments are completed within the required timeframes as specified in this regulation.

Several staff person's records did not contain a health assessment completed within 12 months prior to the date of hire or within the past 24 months. (#1) (#3) (#4)

Corrected Corrected by Apr 10, 2022

Category: ratio. Marked corrected in the state record.

3270.191 · An individual record is required for each facility person. Obtain and submit a copy of the completed file for the identified facility person. Ensure that each facility person has a completed individual record.

One facility person did not have an individual record that was presented at the time of the inspection. (#5)

Corrected Corrected by Mar 10, 2022

Category: recordkeeping. Marked corrected in the state record.

3270.61(h) · The capacity established for an indoor space may not be exceeded. The capacity established for an indoor space may not be exceeded. Reduce the number of children to not exceed the established capacity in accordance with 3270 regulations. Ensure that the classroom capacity is not exceeded in accordance with 3270 regulations related to measurement and use of indoor childcare space. Develop a plan to ensure compliance with the established indoor capacity for each childcare space as specified in these regulations.

A group of 12 older toddlers were observed being cared for in a space that was measured for 8 children.

Corrected Corrected by Feb 3, 2022

Category: ratio. Marked corrected in the state record.

3270.27(a)(5) · The facility shall have an emergency plan that provides for accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions. Amend the facility emergency plan to include accommodations for infants, toddlers. Submit a written copy of the amended emergency plan.

The facility's emergency plan did not provide for accommodations for infants and toddlers. CONTINUING DEFICIENCY

Corrected Corrected by Mar 10, 2022

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

3270.27(a)(1) · The facility shall have an emergency plan that provides for accommodations for shelter of children during an emergency including lock-down, shelter in place at the facility and shelter at locations away from the facility premises.Amend the facility emergency plan to include lock down procedures. Submit a written copy of the amended emergency plan.

The facility's emergency plan did not provide for shelter of children during an emergency including lock down procedures. CONTINUING DEFICIENCY

Corrected Corrected by Apr 10, 2022

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

3270.161(b) · Food handling practices shall conform to the requirements of the Department of Health or the Department of Environmental Resources or its delegate agency where the child care facility is located. Remove the box of graham crackers and ensure that food is stored in accordance proper food handling practices as specified in this regulation.

A box of graham crackers were observed stored on the diaper changing table.

Corrected Corrected by Feb 3, 2022

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

3270.134(d)/3270.152 · Liquid or powdered soap shall be used for handwashing. A facility person shall wash his hands before meals and snacks, and after toileting and after diapering a child. The legal entity must arrange for all staff persons to be trained/to receive hands on training in proper hand washing procedures. Submit written verification of the completed training for all facility staff.

A staff person was observed changing a child's diaper and did not wash her hands after diapering the child. The staff person used hand sanitizer rather than soap.

Corrected Corrected by Mar 10, 2022

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

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. The legal entity must arrange for all staff persons to be trained in proper diaper changing procedures that includes sanitizing the diaper changing surface after each use to ensure proper sanitization. Submit written verification of the completed training for all facility staff.

A staff person was observed changing three children's diapers and did not sanitize the diaper changing surface after changing each child's diaper.

Corrected Corrected by Mar 3, 2022

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

3270.61(h) · The capacity established for an indoor space may not be exceeded. The capacity established for an indoor space may not be exceeded. Reduce the number of children to not exceed the established capacity in accordance with 3270 regulations. Ensure that the classroom capacity is not exceeded in accordance with 3270 regulations related to measurement and use of indoor childcare space. Develop a plan to ensure compliance with the established indoor capacity for each childcare space as specified in these regulations.

A group of 12 older toddlers were observed being cared for in a space that was measured for 8 children.

Corrected Corrected by Feb 3, 2022

Category: ratio. Marked corrected in the state record.

3270.18(a) · The legal entity shall have comprehensive general liability insurance to cover the persons who are on the premises. A current copy of the insurance policy shall be on file at the facility. Obtain and submit written verification of the facility's comprehensive general liability insurance. Ensure that a current copy of the insurance policy is on file at the facility.

The facility lacked written verification of comprehensive general liability insurance to cover the persons who are on the premises. A current copy of the insurance policy was not on file at the facility at the time of the inspection.

Corrected Corrected by Nov 1, 2021

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. Submit a copy of the revised letter.

The letter given to parents regarding the emergency plan did not explain the emergency procedure updates to the plan as required in 3270.27 subsection a. Revise the letter given to parents to ensure that it explains the emergency procedures and updates to the plan as required in 3270.27 subsection a.

Corrected Corrected by Nov 1, 2021

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

3270.31(f) · Staff persons shall complete professional development in the following topics within 90 days of hire: HEALTH AND SAFETY. Obtain and submit written verification of the required health and safety training for the identified staff persons.

Two staff person's records did not contain written verification of required health and safety training. (staff #7 and #8)

Corrected Corrected by Nov 1, 2021

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). LACKING REQUIRED HIRING DOCUMENTS: 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, #6, #7 and #8 cannot work in a childcare position at the facility until the required CPSL documents have been obtained, completed and submitted as specified. Submit a copy of the required , completed CPSL clearance documents for the identified staff persons. Ensure that all staff persons (new and existing) have the required CPSL clearance documents within the required timeframes in accordance with the CPSL.

The facility was not in compliance with the CPSL and with Chapter 3490 (relating to protective services): Several staff/facility person's record did not contain the required CPSL hiring documents. (#1- FBI-completed 8/28/15 updated 1/8/21 and CHILD ABUSE completed 9/14/13 updated 5/21/21-both were more than 60 months old when updated) (#4- hired 10/13/17- no completed NSOR) (#6-hired 5/10/21- hired more than 90 days and no proof of completed NSOR ((#7-hired 5-27-21- hired more than 90 days and no proof of completed NSOR ((#8-hired 6/1/21- hired more than 90 days and no proof of completed NSOR)

Corrected Corrected by Nov 1, 2021

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

3270.36(b)(5) · An assistant group supervisor shall have a high school diploma or a general educational development certificate and 2 years experience with children. Obtain and submit written verification of education for the identified staff person. Ensure that all staff records have written verification of education and experience for their positions.

One staff person's record did not contain written verification of education for their assistant group supervisor position. (staff #5)

Corrected Corrected by Nov 1, 2021

Category: supervision. Marked corrected in the state record.

3270.37(b) · An aide shall have attained one of the qualification levels specified in §3270.37(b)(1)-(3). Obtain and submit written verification of education for the identified staff person. Ensure that all staff records have written verification of education and experience for their positions.

One staff person's record did not contain written verification of education for their aide position. (staff #6)

Corrected Corrected by Nov 1, 2021

Category: recordkeeping. Marked corrected in the state record.

3270.27(a)(1) · The facility shall have an emergency plan that provides for accommodations for shelter of children during an emergency including lock-down, shelter in place at the facility and shelter at locations away from the facility premises. Amend the facility emergency plan to include lock down procedures. Submit a written copy of the amended emergency plan.

The facility's emergency plan did not provide for shelter of children during an emergency including lock down procedures.

Corrected Corrected by Nov 1, 2021

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

3270.134(a)/3270.134(d) · A staff person shall ensure that a child's hands are washed before meals and snacks, after toileting and after being diapered.Liquid or powdered soap shall be used for handwashing. The legal entity must arrange for all staff persons to be trained in/to receive hands on training in proper hand washing procedures. Submit written verification of the completed training for all facility staff.

On 10/1/21, at approximately 3:30pm, a staff person was observed changing a child's diaper and did not ensure that the child's hands were washed after being diapered. Hand sanitizer was used instead of soap.

Corrected Corrected by Nov 1, 2021

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

3270.135(a)(3) · If disposable diapers are provided by a parent or by a facility, a soiled diaper shall be discarded by immediately placing the diaper into a plastic-lined, hands-free covered can. All facility staff person must receive DHS approved training in the proper diapering procedures to include the proper disposal of soiled diapers. Submit written verification of the completed training for all facility staff.

On 10/1/21, at approximately 3:30pm, a staff person was observed changing a child's diaper and placed the soiled diaper into a plastic tie bag rather than immediately disposing the soiled diaper into a hands-free plastic-lined container. (staff #6)

Corrected Corrected by Nov 1, 2021

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. Obtain and submit a current up-to-date health assessment for the identified staff persons. Ensure that staff health assessments are completed within the required timeframes as specified in this regulation.

Several staff person's records did not contain a health assessment completed within 12 months prior to the date of hire or within the past 24 months. (staff #7 and #8- initial) (staff #2 and #3-within the past 24 months)

Corrected Corrected by Nov 1, 2021

Category: ratio. Marked corrected in the state record.

3270.27(a)(5) · The facility shall have an emergency plan that provides for accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions. Amend the facility emergency plan to include accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions. Submit a written copy of the amended emergency plan.

The facility's emergency plan did not provide for accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions.

Corrected Corrected by Nov 1, 2021

Category: physical safety. 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. Submit written documentation of proof of purchase and date of purchase of an interconnected fire detection device or system or a written attestation. Ensure that this document is retained with the facility's fire drill logs.

The facility lacked written documentation of proof of purchase and date of purchase of an interconnected fire detection device or system in accordance with standards established under the Act of July 14, 2020 (P.L. 639, NO. 62) (62 P.S. § 1016).

Corrected Corrected by Nov 1, 2021

Category: recordkeeping. Marked corrected in the state record.

3270.136(d) · A facility person who knows of a communicable disease for which 28 Pa. Code Chapter 27 (relating to communicable and noncommunicable diseases) requires reporting, or who knows of a group expression of an illness which may be of public concern, whether or not it is known to be of a communicable nature, shall report it promptly to the appropriate division of the Department of Health as specified in Chapter 27, or to a local department of health. Submit the required reporting information. Develop and submit plan to ensure proper reporting of communicable diseases to the Philadelphia Health Department as specified in this regulation.

The facility failed to report positive covid -19 cases to the Philadelphia Health Department as specified in this regulation.

Corrected Corrected by Oct 8, 2021

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

3270.14 · A facility shall be operated in conformity with applicable Federal and State laws and regulations. State agencies whose regulations may relate to the operation of a facility include the Department of Environmental Resources, the Department of Labor and Industry, the Department of Health, the Department of Education and the Department of Transportation. All individuals 2 years and older in school entities are required to wear a face covering while indoors in a school entity in accordance with the Order. The legal entity must implement policy and practices that require and ensure that all individual 2 years and older wear a mask or face covering while indoors at the facility. Submit written verification of the revised polices and practices.

On 10/1/21 at approximately 3pm, a total of 17 children ages older toddlers (2 years) to preschool ( 3- 1st day of kindergarten) were observed not wearing a mask or face covering in accordance with the Acting Secretary of Health's Order will be effective Sept. 7, 2021.

Corrected Corrected by Oct 1, 2021

Category: ratio. Marked corrected in the state record.

3270.18(a) · The legal entity shall have comprehensive general liability insurance to cover the persons who are on the premises. A current copy of the insurance policy shall be on file at the facility. Obtain and submit written verification of the facility's comprehensive general liability insurance. Ensure that a current copy of the insurance policy is on file at the facility.

The facility lacked written verification of comprehensive general liability insurance to cover the persons who are on the premises. A current copy of the insurance policy was not on file at the facility at the time of the inspection.

Corrected Corrected by Oct 1, 2021

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. Submit a copy of the revised letter.

The letter given to parents regarding the emergency plan did not explain the emergency procedure updates to the plan as required in 3270.27 subsection a. Revise the letter given to parents to ensure that it explains the emergency procedures and updates to the plan as required in 3270.27 subsection a.

Corrected Corrected by Oct 1, 2021

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

3270.31(f) · Staff persons shall complete professional development in the following topics within 90 days of hire: HEALTH AND SAFETY. Obtain and submit written verification of the required health and safety training for the identified staff persons.

Two staff person's records did not contain written verification of required health and safety training. (staff #7 and #8)

Corrected Corrected by Nov 1, 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). LACKING REQUIRED HIRING DOCUMENTS: 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, #6, #7 and #8 cannot work in a childcare position at the facility until the required CPSL documents have been obtained, completed and submitted as specified. Submit a copy of the required , completed CPSL clearance documents for the identified staff persons. Ensure that all staff persons (new and existing) have the required CPSL clearance documents within the required timeframes in accordance with the CPSL.

The facility was not in compliance with the CPSL and with Chapter 3490 (relating to protective services): Several staff/facility person's record did not contain the required CPSL hiring documents. (#1- FBI-completed 8/28/15 updated 1/8/21 and CHILD ABUSE completed 9/14/13 updated 5/21/21-both were more than 60 months old when updated) (#4- hired 10/13/17- no completed NSOR) (#6-hired 5/10/21- hired more than 90 days and no proof of completed NSOR ((#7-hired 5-27-21- hired more than 90 days and no proof of completed NSOR ((#8-hired 6/1/21- hired more than 90 days and no proof of completed NSOR)

Corrected Corrected by Oct 1, 2021

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

3270.36(b)(5) · An assistant group supervisor shall have a high school diploma or a general educational development certificate and 2 years experience with children. Obtain and submit written verification of education for the identified staff person. Ensure that all staff records have written verification of education and experience for their positions.

One staff person's record did not contain written verification of education for their assistant group supervisor position. (staff #5)

Corrected Corrected by Oct 1, 2021

Category: supervision. Marked corrected in the state record.

3270.37(b)(1) · An aide shall have a high school diploma or a general educational development certificate. Obtain and submit written verification of education for the identified staff person. Ensure that all staff records have written verification of education and experience for their positions.

One staff person's record did not contain written verification of education for their aide position. (staff #6)

Corrected Corrected by Oct 1, 2021

Category: recordkeeping. Marked corrected in the state record.

3270.134(a)/3270.134(d) · A staff person shall ensure that a child's hands are washed before meals and snacks, after toileting and after being diapered. Liquid or powdered soap shall be used for handwashing. The legal entity must arrange for all staff persons to be trained in/to receive hands on training in proper hand washing procedures. Submit written verification of the completed training for all facility staff.

On 10/1/21, at approximately 3:30pm, a staff person was observed changing a child's diaper and did not ensure that the child's hands were washed after being diapered. Hand sanitizer was used instead of soap.

Corrected Corrected by Nov 1, 2021

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

3270.135(a)(3) · If disposable diapers are provided by a parent or by a facility, a soiled diaper shall be discarded by immediately placing the diaper into a plastic-lined, hands-free covered can. All facility staff person must receive DHS approved training in the proper diapering procedures to include the proper disposal of soiled diapers. Submit written verification of the completed training for all facility staff.

On 10/1/21, at approximately 3:30pm, a staff person was observed changing a child's diaper and placed the soiled diaper into a plastic tie bag rather than immediately disposing the soiled diaper into a hands-free plastic-lined container. (staff #6)

Corrected Corrected by Nov 1, 2021

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. Obtain and submit a current up-to-date health assessment for the identified staff persons. Ensure that staff health assessments are completed within the required timeframes as specified in this regulation.

Several staff person's records did not contain a health assessment completed within 12 months prior to the date of hire or within the past 24 months. (staff #7 and #8- initial) (staff #2 and #3-within the past 24 months)

Corrected Corrected by Oct 1, 2021

Category: ratio. Marked corrected in the state record.

3270.27(a)(5) · The facility shall have an emergency plan that provides for accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions. Amend the facility emergency plan to include accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions. Submit a written copy of the amended emergency plan.

The facility's emergency plan did not provide for accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions.

Corrected Corrected by Oct 1, 2021

Category: physical safety. 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. Submit written documentation of proof of purchase and date of purchase of an interconnected fire detection device or system or a written attestation. Ensure that this document is retained with the facility's fire drill logs.

The facility lacked written documentation of proof of purchase and date of purchase of an interconnected fire detection device or system in accordance with standards established under the Act of July 14, 2020 (P.L. 639, NO. 62) (62 P.S. § 1016).

Corrected Corrected by Oct 1, 2021

Category: recordkeeping. Marked corrected in the state record.

3270.27(a)(1) · The facility shall have an emergency plan that provides for accommodations for shelter of children during an emergency including lock-down, shelter in place at the facility and shelter at locations away from the facility premises. Amend the facility emergency plan to include lock down procedures. Submit a written copy of the amended emergency plan.

The facility's emergency plan did not provide for shelter of children during an emergency including lock down procedures.

Corrected Corrected by Oct 1, 2021

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