Brightside Academy/Hill-Hazelwood

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

The files for Staff Persons #2 and #5 contained documentation of emergency plan training dated more than 12 months apart. Staff Person #2: 2/6/24 and 8/21/25. Staff Person #3: 1/6/24 and 2/5/25.

Corrected by Mar 8, 2026

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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.

An operable thermometer was not placed in the refrigerator in Room 1 and Room 6.

Corrected by Mar 8, 2026

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

The file for Staff Person #4 does not have current fire safety training. The most current fire safety training on file was observed to be dated 10/3/24. The file for Staff Person #5 contained fire safety training dated more than 12 months apart: 10/24/23 and 8/26/25.

Corrected by Mar 8, 2026

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

The file for Staff Person #1 contained documentation of Child Abuse clearance results that were not renewed prior to the expiration date of the most current certification on file: 10/2/20 and 10/8/25. The file for Staff Person #1 who has lived in the state of New York during the previous five years of employment, contained the required Child Abuse and Sex Offender Registry clearance results for the state of New York dated 8/21/25 but were after the staff persons first day working in a child care setting (See LIS Code Sheet). The file is now current. The file for Staff Person #2 contained documentation of Child Abuse clearance results and Mandated Reporter training that were not renewed prior to the expiration date of the most current certification on file. Child Abuse clearance results: 11/15/20 and 11/17/25. Mandated Reporter training: 11/15/20 and 11/17/25. The file is now current. The for Staff Person #3 contained State Police, Child Abuse, and FBI clearance results but were dated after the staff person's first day working in a child care setting (See LIS Code Sheet). The file is now current.

Corrected by Mar 8, 2026

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

In Room 1, an electrical outlet near the refrigerator was observed to lack a protective receptacle cover. An electrical outlet on the back wall in the Indoor Gym was observed to lack a protective receptacle cover.

Corrected by Mar 8, 2026

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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.

A handwashing sign was not posted near the sink in the boy's restroom across from Room 2.

Corrected by Mar 8, 2026

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

A children's play kitchen set was observed obstructing an exit door from the Indoor Gym to Room 11.

Corrected by Mar 8, 2026

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

The emergency contact form in the file for child #3 lacked the enrolling parent's work telephone number.

Corrected by Mar 8, 2026

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

The emergency contact form and the financial agreement form in the file for child #2 have not been reviewed and updated by the parent within the last 6 months. The most recent review and update was on 7/17/25.

Corrected by Mar 8, 2026

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

The file for Staff Person #2 contained health assessments dated more than 24 months apart: 12/2/22 and 8/18/25.

Corrected by Mar 8, 2026

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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 file for child #1 contained documentation of a health report dated 9/5/25 but was not within 60 days following the first day of attendance at the facility.

Corrected by Mar 8, 2026

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

Facility's files did not contain documentation of notifying local traffic safety authorities in writing of the location of the facility and the program's use of pedestrian and vehicular routes around the child care facility.

Corrected by Mar 8, 2026

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

A fire drill has not been conducted within the last 60 days. The most recent documented fire drill conducted was on 9/16/25.

Corrected by Dec 19, 2025

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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.

The facility's documentation of testing the fire detection system exceeded 30 days between testing from 1/20/25 to 2/20/25, 4/3/25 to 5/5/25, 5/5/25 to 6/9/25, and 8/16/25 to 9/16/25.

Corrected by Dec 19, 2025

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

A written plan of daily activities was not posted in Room 2-YT.

Corrected by Sep 30, 2025

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3270.21 · Conditions at the facility may not pose a threat to the health or safety of the children.

According to staff interviews, written statements, and facility video, on 6/6/2025 at ~ 7:40am child #1 sustained 2nd degree burns on their arm when they pulled a cup of hot coffee off of a table onto their chest and arm. Staff person #1 who had placed the cup of coffee on the table and was assigned supervision of child #1 had their back turned to the child and was not able to supervise the child. Neither staff person #1 nor staff person #2 contacted the child's parent until ~ 3:50pm that afternoon.

Corrected by Jun 9, 2025

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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.

According to staff interviews, written statements, and facility video, on 6/6/2025 at ~ 7:40am child #1 sustained 2nd degree burns on their arm when they pulled a cup of hot coffee off of a table onto their chest and arm. Staff person #1 who had placed the cup of coffee on the table and was assigned supervision of child #1 had their back turned to the child and was not able to supervise the child. Neither staff person #1 nor staff person #2 contacted the child's parent until ~ 3:50pm that afternoon.

Corrected by Jun 9, 2025

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3270.113(a)(1) · Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises.

According to staff interviews, written statements, and facility video, on 6/6/2025 at ~ 7:40am child #1 sustained 2nd degree burns on their arm when they pulled a cup of hot coffee off of a table onto their chest and arm. Staff person #1 who had placed the cup of coffee on the table and was assigned supervision of child #1 had their back turned to the child and was not able to supervise the child. Neither staff person #1 nor staff person #2 contacted the child's parent until ~ 3:50pm that afternoon.

Corrected by Jun 9, 2025

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3270.132(a) · If emergency medical care is needed for a child, the parent shall be contacted as soon as practical in the best interest of the child. If the parent cannot be reached, the operator shall record in writing the reason emergency care was required and the attempts made to inform the parent. TIERED LIS: 1. If emergency medical care is needed for a child, the parent shall be contacted as soon as practical in the best interest of the child. If the parent cannot be reached, the operator shall record in writing the reason emergency care was required and the attempts made to inform the parent. (This portion of the plan will have an immediate correction date.) 2. The legal entity will ensure that all facility persons complete the PA Required Health and Safety for Centers-Group Child Care Part 1 and PA Required Health and Safety for Centers-Group Child Care Part 2 trainings found on Penn State Better Kid Care website within 21 calendar days of the acceptance of this plan of correction. All facility persons who have already completed PA Required Health and Safety for Centers-Group Child Care Part 1 and PA Required Health and Safety for Centers-Group Child Care Part 2 trainings will be required to take the trainings again and provide documentation of completion after the date of the acceptance of this plan of correction. Once all facility persons have completed these required trainings, the legal entity will submit the training certificates for all facility persons to the Western Regional Office within 5 business days of the last date of completion. (The operator will provide a date for when this training will be completed.) 3. Once the requirement in Tier #2 is met, the legal entity will ensure that all facility persons complete the 1 hour training entitled 911-Responding to Medical Emergencies found on Penn State Better Kid Care website within 21 calendar days. Once all facility persons have completed the required training, the legal entity will submit the training certificates for all facility persons to the Western Regional Office within 5 business days of the last date of completion. (The operator will provide a date for when this training will be completed.) 4. Once the requirement in Tier #3 is met, the legal entity will ensure that the facility director and other legal entity representatives in a leadership role participate in technical assistance for a minimum of 3 hours with the PA Key and ECELS (The Early Childhood Linkage System at the PA Chapter of the American Academy of Pediatrics) to develop a plan that includes but is not limited to training staff to recognize when a child may need emergency medical care, how staff should recognize and respond to child injuries, how staff should respond when a child receives a burn, and how the administration can support staff in implementing the plan. The legal entity will submit the plan to the Regional Office within 5 business days of completion. (The operator will provide a date for when the plan will be completed.) 5. Once the requirement in Tier #4 is met, the legal entity will ensure that all facility persons participate in a minimum of 2 hours of training conducted by the PA Key and ECELS. The training will include but will not be limited to the plan that was developed in Tier #4. All facility persons will be required to complete an assessment after the training to assess their knowledge of the information given in the training. All facility persons will be required to obtain at least a 90% score on the assessment. The legal entity will submit the training sign in sheet and assessment for all facility persons to the Regional Office within 5 business days of completion. (The operator will provide a date for when this training will be completed.) 6. Once the requirement in Tier #5 is met, the legal entity will ensure that all facility persons participate in a monthly staff meeting for 3 consecutive months. The staff meeting agenda will include discussion and debriefing on how the plan written in Tier #3 is being implemented as well as a review of the citations that were issued since January 2025. The meeting agenda and sign in sheet will be submitted to the Regional Office for review within 5 business days after the completion of the meeting. (The operator will provide a date for when the staff meetings will be completed.)

According to staff interviews, written statements, and facility video, on 6/6/2025 at ~ 7:40am child #1 sustained 2nd degree burns on their arm when they pulled a cup of hot coffee off of a table onto their chest and arm. Staff person #1 who had placed the cup of coffee on the table and was assigned supervision of child #1 had their back turned to the child and was not able to supervise the child. Neither staff person #1 nor staff person #2 contacted the child's parent until ~ 3:50pm that afternoon.

Corrected by Feb 26, 2026

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3270.21 · Conditions at the facility may not pose a threat to the health or safety of the children.

In Room 5, the following was observed: A staff person's electric hand drill was observed on the counter next to the sink posing a safety hazard to children in care. Two staff person's belongings that contained the medications of Prilosec and Pepto-Bismol tablets that state "Keep Out of Reach of Children" were observed in an unlocked cabinet below the sink accessible to children in care.

Corrected by Mar 31, 2025

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

In Room 5, large wooden shelves were observed stacked up against the wall in the corner of the room posing a visible toppling hazard.

Corrected by Apr 2, 2025

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

SECOND VIOLATION: Room 5 was observed to have peeling paint and damaged plaster throughout the walls in the room. Previously cited on SIN-00261556 on 2/28/25. Room 6 and Room 11 are now in compliance.

Corrected by Apr 2, 2025

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

The file for staff person #1 did not include documentation of emergency plan training at initial employment (See IS Code Sheet).

Corrected by Feb 28, 2025

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3270.32(a)/3270.192(4) · The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Facility Person #2 may not work in a child care position at the facility.

The file for staff person #2, identified as the Director, lacked child abuse and neglect clearance results for the state of New York where the staff person resided in the five years prior to employment as required under the CPSL. The file for staff person #2 had documentation of State Sex Offender Registry check clearance results for the state of New York dated 1/10/25, which was after the staff person's date of hire (See IS Code Sheet).

Corrected by Mar 1, 2025

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

In Room 5, a bottle of disinfectant spray that says "keep out of reach of children" was observed underneath the sink in an unlocked cabinet and was accessible to children in care.

Corrected by Feb 28, 2025

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

In Room 5, several bottles of disinfectant spray were observed to be stored next to and above children's food. In Room 6, a bottle of disinfectant spray was observed on the counter next to the children's breakfast foods/drinks.

Corrected by Feb 28, 2025

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

Room 5, Room 6, and Room 11 was observed to have peeling paint and damaged plaster throughout the walls in each room.

Corrected by Mar 14, 2025

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

The refrigerator in the Infant Room did not have an operable thermometer as the thermometer in the refrigerator read 10° F.

Corrected by Mar 14, 2025

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

In Room 6 at approximately 10:05am, a bottle of milk was observed on the counter, and per staff the milk was provided by the facility for the children's breakfast that ended at 9:30am.

Corrected by Mar 14, 2025

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

The Director has not conducted a fire drill within the last 60 days. The most recent fire drill conducted on file at the facility at the time of inspection was dated 12/9/24.

Corrected by Mar 14, 2025

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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.

The facility's fire detection system has not been tested within the last 30 days. The most recent testing on file at the time of inspection was on 12/20/24.

Corrected by Mar 14, 2025

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

The file for staff person #2 had documentation of Pediatric First Aid/CPR training that was not renewed before the expiration date of the most current certification: 7/20/22 and 8/4/24.

Corrected by Aug 4, 2024

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

The two most recent fire safety trainings in the files for staff persons #2 and #3 are dated more than one year apart. Staff person #2: 7/20/22 and 8/30/24. Staff person #3: 4/10/23 and 8/29/24.

Corrected by Aug 30, 2024

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3270.32(a)/3270.192(4) · The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Facility Person #1 may not work in a child care position at the facility.

The file for staff person #1 had documentation of NSOR application dated 11/15/23 but did not contain the NSOR clearance results within 45 days of hire (See IS CODE SHEET).

Corrected by Sep 10, 2024

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

The first aid kit in Room 5 did not contain scissors.

Corrected by Sep 10, 2024

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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 information was not present for children who were observed receiving care in the Indoor Gym.

Corrected by Sep 10, 2024

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

The file for Staff Person #2 did not contain documentation of fire safety training conducted within the past 12 months.

Corrected by Dec 21, 2023

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3270.32(a)/3270.192(4) · The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). 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 #3 may not work at the facility.

The file for Staff Person #1, who has been working for more than 45 days, did not include an FBI Clearance. The file for Staff Person #3, who has been working for more than 45 days, did not include a Child Abuse Clearance from New York, where the staff person had resided in the past five years. (See LIS Code Sheet)

Corrected by Dec 18, 2023

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

The file for Staff Person #2, who has been working at the facility for more than one year, did not include an annual written evaluation. (See LIS Code Sheet).

Corrected by Dec 20, 2023

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

Observed flaking plaster at the end of the first floor hallway where repairs had been made to the wall and a hole in the wall near the bathroom in Room #2.

Corrected by Dec 14, 2023

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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 file for Child #2, an Infant, did not include an updated health report conducted within the past six months. Health report was received by parent. Parents will be given 30 days notice to health report expiring to prevent things from happening.

Corrected by Dec 15, 2023

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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 file for Child #1, an Older Toddler, did not contain an updated health report conducted within the past 12 months.

Corrected by Dec 18, 2023

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3270.131(d)(5)/3270.131(e)(3) · A health report shall include a review of the child's immunized status according to recommendations of the ACIP. The facility shall implement dismissal policies in accordance with the Department of Health regulation in 28 Pa. Code § 27.77 (relating to immunization requirements for children in child care group settings). Child #3 must be dismissed from care by close of business 12/14/23 and may only return to care when the immunization record is updated or when a parent provides a written, signed exemption letter.

The most recent immunization record in the file for Child #3 did not include documentation of a flu shot administered within the past year or a letter of exemption from the parent or physician.

Corrected by Dec 14, 2023

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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 most recent parental updates for the fee agreement and emergency contact form in the file for Child #3 exceeded six months between updates. The fee agreement and emergency contact form in the file for Child #2 have not been updated within the past six months.

Corrected by Dec 14, 2023

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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.

On the day of the inspection, 9/15/23, a fire system test had not been conducted since 7/17/23, which exceeds mandatory testing every 30 days.

Corrected by Sep 18, 2023

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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).

Per staff statements, on 6/21/23, Staff #1 was responsible for 5 children in the play space. Staff #1 took the 5 children inside the facility to use the bathroom located on the lower level. Child #1 remained upstairs near the main floor bathroom. Child #1 was unsupervised for several minutes, until another staff discovered the child alone in the hallway.

Corrected by Jun 21, 2023

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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.

Per staff statements, on 6/21/23, Staff #1 was responsible for 5 children in the play space. Staff #1 took the 5 children inside the facility to use the bathroom located on the lower level. Child #1 remained upstairs near the main floor bathroom. Child #1 was unsupervised for several minutes, until another staff discovered the child alone in the hallway.

Corrected by Jun 21, 2023

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3270.113(a)(1) · Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises.

Per staff statements, on 6/21/23, Staff #1 was responsible for 5 children in the play space. Staff #1 took the 5 children inside the facility to use the bathroom located on the lower level. Child #1 remained upstairs near the main floor bathroom. Child #1 was unsupervised for several minutes, until another staff discovered the child alone in the hallway.

Corrected by Jun 21, 2023

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3270.113(b) · A facility person may not use any form of physical punishment, including spanking a child.

Per staff statements, on 6/8/23, Child #1 stepped on the shoes of Staff #2. Staff #2 responded by striking the child in the stomach with the back of staff #2's hand.

Corrected by Aug 18, 2023

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

The one-hour Health and Safety Update in the file for Staff Person #1 was conducted after the prescribed timeframe of 12/30/22.

Corrected by Jan 30, 2023

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

The most recent fire safety trainings in the file for Staff Person #1 exceeded 12 months in between trainings: 11/20/21-1/19/23.

Corrected by Jan 19, 2023

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3270.32(a)/3270.192(4) · The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). 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 at the facility.

The file for Staff Person #3, who has been working at the facility for more than 45 days (See LIS Code Sheet), lacked an FBI Clearance.

Corrected by Jun 12, 2023

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3270.37(c) · An aide or a combination of aides shall be supervised at all times by a staff person qualified at minimum as an assistant group supervisor.

During lunchtime on 6/8/23, Staff Person #2, who qualifies as an Aide, was observed supervising two Preschool children alone in the hallway for bathroom break.

Corrected by Jun 8, 2023

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3270.102(a) · Toys, play equipment and other indoor and outdoor equipment used by the children shall be clean, in good repair and free from rough edges, sharp corners, pinch and crush points, splinters and exposed bolts.

The dramatic play toy shelf in the Preschool Room was wobbly, which creates a potential toppling hazard. Observed dirt and debris under the mats of the diaper changing tables in Room #1, #2 and #3.

Corrected by Jun 8, 2023

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3270.106(a) · Individual, clean, age-appropriate rest equipment shall be provided for preschool, toddler and infant children as agreed between the child's parent and the operator. The rest equipment shall be labeled for the use of a specific child and used only by the specified child.

The cots for use by the children at the facility were not properly labeled. The cot lists on the walls did not match the names and numbers of the children in care.

Corrected by Jun 8, 2023

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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 in Room #6 for Child #2 and #3 or in Room #1 for Child #4 who were receiving care in these rooms.

Corrected by Jun 8, 2023

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3270.131(d)(5)/3270.131(e)(3) · A health report shall include a review of the child's immunized status according to recommendations of the ACIP. The facility shall implement dismissal policies in accordance with the Department of Health regulation in 28 Pa. Code § 27.77 (relating to immunization requirements for children in child care group settings). Child # 1 must be dismissed from care by close of business (6/8/23) and may only return to care when the immunization record is updated or when a parent provides a written, signed exemption letter.

The most recent immunization record in the file for Child #1 did not contain documentation of a flu shot administered within the past year or a letter of exemption from the parent or physician.

Corrected by Jun 8, 2023

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

Observed on 6/8/23 at approximately 10:00 am in Room #2: Staff Person #4 changed three children's diapers and did not have the children wash their hands until the third child's diaper had been changed.

Corrected by Jun 8, 2023

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3270.51 · **The director will conduct classroom checks in each classroom at least three times a week to ensure that all staff persons are physically present with the children to whom they are assigned and to ensure that all children are assigned to a staff person. The checks need to be done for a period of three months and must be documented in writing on a form that is approved by the Department prior to its use.

**During the self-reported noncompliance investigation on 5/15/23 a video of an incident was viewed by the certification representative and staff interviews were held. Staff person #1 and staff person #2 brought 4 toddlers inside after playing on the outdoor playground. Staff person #1 and staff person #2 walked into classroom #2 while child #1 and child #2 walked into classroom #1 and were left alone in classroom #1 from 5:04pm until 5:09pm. At 5:09pm staff person #2 walked into classroom #1 and brought child #1 and child #2 back into classroom #2.

Corrected by Oct 27, 2023

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3270.51 · *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.

*During the self-reported noncompliance investigation on 5/15/23 a video of an incident was viewed by the certification representative and staff interviews were held. Staff person #1 and staff person #2 brought 4 toddlers inside after playing on the outdoor playground. Staff person #1 and staff person #2 walked into classroom #2 while child #1 and child #2 walked into classroom #1 and were left alone in classroom #1 from 5:04pm until 5:09pm. At 5:09pm staff person #2 walked into classroom #1 and brought child #1 and child #2 back into classroom #2.

Corrected by May 15, 2023

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3270.113(a) · ***The legal entity will develop a policy that addresses supervision of children in order to maintain compliance with the regulations regarding supervision of children. The legal entity will ensure that all staff persons will read and sign off on the policy. The legal entity will ensure that all substitute staff persons read the policy and sign off on it prior to working with the children. Proof that each staff person and substitute staff person have read the policy must be retained in that person's record.

***During the self-reported noncompliance investigation on 5/15/23 a video of an incident was viewed by the certification representative and staff interviews were held. Staff person #1 and staff person #2 brought 4 toddlers inside after playing on the outdoor playground. Staff person #1 and staff person #2 walked into classroom #2 while child #1 and child #2 walked into classroom #1 and were left alone in classroom #1 from 5:04pm until 5:09pm. At 5:09pm staff person #2 walked into classroom #1 and brought child #1 and child #2 back into classroom #2.

Corrected by Oct 9, 2023

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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.

*During the self-reported noncompliance investigation on 5/15/23 a video of an incident was viewed by the certification representative and staff interviews were held. Staff person #1 and staff person #2 brought 4 toddlers inside after playing on the outdoor playground. Staff person #1 and staff person #2 walked into classroom #2 while child #1 and child #2 walked into classroom #1 and were left alone in classroom #1 from 5:04pm until 5:09pm. At 5:09pm staff person #2 walked into classroom #1 and brought child #1 and child #2 back into classroom #2.

Corrected by Aug 8, 2023

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3270.113(a) · **In person supervision training presented by the ELRC 5 will be completed by all staff. Confirmation of the completed training by all staff must be submitted to the Department within 5 working days of the completion of the training.

**During the self-reported noncompliance investigation on 5/15/23 a video of an incident was viewed by the certification representative and staff interviews were held. Staff person #1 and staff person #2 brought 4 toddlers inside after playing on the outdoor playground. Staff person #1 and staff person #2 walked into classroom #2 while child #1 and child #2 walked into classroom #1 and were left alone in classroom #1 from 5:04pm until 5:09pm. At 5:09pm staff person #2 walked into classroom #1 and brought child #1 and child #2 back into classroom #2.

Corrected by Oct 30, 2023

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3270.113(a)(1) · *Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises.

*During the self-reported noncompliance investigation on 5/15/23 a video of an incident was viewed by the certification representative and staff interviews were held. Staff person #1 and staff person #2 brought 4 toddlers inside after playing on the outdoor playground. Staff person #1 and staff person #2 walked into classroom #2 while child #1 and child #2 walked into classroom #1 and were left alone in classroom #1 from 5:04pm until 5:09pm. At 5:09pm staff person #2 walked into classroom #1 and brought child #1 and child #2 back into classroom #2.

Corrected by May 15, 2023

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3270.113(a)(1) · **The director/LE will hold monthly staff meetings in which all staff will attend for a period of 3 months. The agenda will be required to include but is not limited to a review of all citations issued within the past 24 months as well as direction on how to utilize the identification tags appropriately to ensure that all children are assigned to a specific staff person and that the children are physically present with their assigned staff person. The agenda and staff sign in sheet for each meeting must be submitted to the Department within 5 business days of the meeting being held.

**During the self-reported noncompliance investigation on 5/15/23 a video of an incident was viewed by the certification representative and staff interviews were held. Staff person #1 and staff person #2 brought 4 toddlers inside after playing on the outdoor playground. Staff person #1 and staff person #2 walked into classroom #2 while child #1 and child #2 walked into classroom #1 and were left alone in classroom #1 from 5:04pm until 5:09pm. At 5:09pm staff person #2 walked into classroom #1 and brought child #1 and child #2 back into classroom #2.

Corrected by Nov 30, 2023

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

The file for staff #1 lacked the one hour health and safety training which was to completed by 12/30/22. There is now training on file and dated 1/17/23.

Corrected by Jan 17, 2023

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

The files of facility persons #1 through 5, who completed the "Get Started with Center-Based Care: Building Blocks for Quality" through Better Kid Care prior to 10/4/2022, did not contain documentation of completion of the additional 1 hour training, "Get Started with Center-Based Care-Revised 2022" on or before 12/30/2022.

Corrected by Feb 3, 2023

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3270.51 · 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.

At approximately 8:55 am, the toddler classroom was transitioning to their classroom with staff person #1 when child #1 wandered from the group and went to the stairwell creating a staff to child ratio of 0:1.

Corrected by Jan 19, 2023

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3270.113(a) · The Legal Entity will create a policy and procedure for the transitioning of children to another location when leaving a classroom. All current staff, all substitute staff and all future staff will be trained on the policy and it will be posted in each classroom.

**At approximately 8:55 am, the toddler classroom was transitioning to their classroom with staff person #1 when child #1 wandered from the group and went to the stairwell creating a staff to child ratio of 0:1, leaving the child unsupervised by a staff person.

Corrected by Jan 26, 2023

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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. Verification of implementation will be accomplished by more than one visit by the Department.

At approximately 8:55 am, the toddler classroom was transitioning to their classroom with staff person #1 when child #1 wandered from the group and went to the stairwell creating a staff to child ratio of 0:1, leaving the child unsupervised by a staff person.

Corrected by Jan 19, 2023

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3270.113(a)(1) · The Legal Entity will schedule and conduct a staff meeting. The agenda will include effective transitioning children from one child care space to another space at the facility to ensure the children are accounted for prior to, in transit and at arrival of the destination. Signage will be created and posted at the door of each classroom to remind staff to stop and count their children before leaving a classroom and at the arrival to the destination.

**At approximately 8:55 am, the toddler classroom was transitioning to their classroom with staff person #1 when child #1 wandered from the group and went to the stairwell creating a staff to child ratio of 0:1, leaving the child unsupervised by a staff person.

Corrected by Jan 26, 2023

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3270.113(a)(1) · Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises.

At approximately 8:55 am, the toddler classroom was transitioning to their classroom with staff person #1 when child #1 wandered from the group and went to the stairwell creating a staff to child ratio of 0:1, leaving the child unsupervised by a staff person.

Corrected by Jan 19, 2023

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3270.51 · 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.

Staff #1 failed to walk Child #1 all the way to the school-age classroom. The child continued to the classroom without adult supervision and ended up entering an empty classroom. The child then left the empty classroom and proceeded to the classroom where the teacher and children were present, after 46 minutes.

Corrected by Oct 7, 2022

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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.

Staff #1 failed to walk Child #1 all the way to the school-age classroom. The child continued to the classroom without adult supervision and ended up entering an empty classroom. The child then left the empty classroom and proceeded to the classroom where the teacher and children were present, after 46 minutes.

Corrected by Oct 7, 2022

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3270.113(a) · The legal entity must submit a plan to DHS proving that the facility procedure for assigning individual responsibility for supervision of children is followed at all times e.g., a card or tag system. The legal entity will confirm continuing compliance by implementing this procedure for a minimum of three months after DHS approves the supervision system. All Staff will be trained on the supervision system once it is approved.

Staff #1 failed to walk Child #1 all the way to the school-age classroom. The child continued to the classroom without adult supervision and ended up entering an empty classroom. The child then left the empty classroom and proceeded to the classroom where the teacher and children were present, after 46 minutes.

Corrected by Oct 7, 2022

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3270.113(a) · The legal entity must arrange for all facility staff to receive a minimum of two hours of training regarding supervision of children. The legal entity must receive DHS approval of the training content prior to scheduling the training. Proof of the training will be submitted to the department upon completion.

Staff #1 failed to walk Child #1 all the way to the school-age classroom. The child continued to the classroom without adult supervision and ended up entering an empty classroom. The child then left the empty classroom and proceeded to the classroom where the teacher and children were present, after 46 minutes.

Corrected by Oct 7, 2022

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3270.113(a)(1) · Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises.

Staff #1 failed to walk Child #1 all the way to the school-age classroom. The child continued to the classroom without adult supervision and ended up entering an empty classroom. The child then left the empty classroom and proceeded to the classroom where the teacher and children were present, after 46 minutes.

Corrected by Oct 7, 2022

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

The file for staff person #1 completed emergency plan training on 2/24/22, which is not at initial hire. (SEE LIS FOR HIRE DATE)

Corrected by Feb 24, 2022

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

The file for staff person #3 completed fire safety training on 8/26/20 and 3/15/22, which is not annually.

Corrected by May 19, 2022

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3270.32(a)/3270.192(4) · The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). LACKING REQUIRED HIRING DOCUMENTS: Facility Person #1, #4 -- may not work 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 #1, #4--- may not work at the facility.

The file for staff person #1 lacked a dated disclosure statement and contained a FBI finger print clearance dated for after the hire date. The file for staff person #4 lacked a signed and dated disclosure statement.

Corrected by May 19, 2022

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

The file for staff person #2 had an evaluation completed on 11/30/20 and 12/2/21, which is not every 12 months.

Corrected by Dec 21, 2021

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

In room 9 it was observed that the first-aid kit lacked nonporous gloves.

Corrected by May 18, 2022

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

The gym lacked a daily activities schedule posted.

Corrected by May 18, 2022

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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 form for child #3 lacked the health insurance coverage provider.

Corrected by May 20, 2022

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3270.131(d)(5) · A health report shall include a review of the child's immunized status according to recommendations of the ACIP.

The immunization record for child #1, child #2, child #3, and child #4 lacked an influenza vaccination in accordance with the ACIP.

Corrected by Jun 30, 2022

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

Facility conducted an emergency drill on 2/9/22, which was not annually from when the regulations took effect on 12/19/2020.

Corrected by May 19, 2022

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

It was observed on the fire drill log that the facility had allowed more than 60 days to pass between the fire drill on 9/10/21 and 12/2/21. Fire drill log was up to date during the renewal inspection.

Corrected by May 18, 2022

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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.

Facility lacked a current letter of operability of the inter-connected smoke alarms or documentation of testing them every 30 days.

Corrected by May 18, 2022

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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 file for child #1, child #2, child #4, child #5, and child #6 lacked an initial health assessment within 60 days following the first day of attendance at the facility, all now have a current health assessment on file.

Corrected by May 18, 2022

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

There were exposed sharp points on the fence in the outdoor playspace, which poses a hazard.

Corrected by Nov 24, 2021

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