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 log contained documented dates 8/13/25-9/30/25, more than 30 days apart.

Corrected Corrected by Oct 29, 2025

Category: recordkeeping. 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.

The file for Staff #1, an assistant group supervisor, included documentation of 2 years' experience with children, but lacked documentation of education.

Corrected Corrected by Sep 12, 1925

Category: supervision. Marked corrected in the state record.

3270.31(f) · Staff #1 must complete PA Required Health and Safety for Centers-Group Child Care Part 1 and Part 2.

Staff #1, hired for more than 90 days, did not obtain training in the 10 required health and safety training topics.

Corrected Corrected by Sep 30, 2025

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

3270.32(a) · The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). LACKING REQUIRED HIRING DOCUMENTS: Staff #2 -- may not work in a childcare position at the facility.

The file for Staff #2 contained a volunteer child abuse clearance, making it invalid.

Corrected Corrected by Sep 17, 2025

Category: background checks. 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.

In the upstairs bathroom near the office, Lysol wipes, labeled "keep out of the reach of children," were observed in an unlocked cabinet under the sink and accessible to children.

Corrected Corrected by Sep 10, 2025

Marked corrected in the state record.

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

The file for Staff #2 and Staff #3 lacked two written, nonfamily references.

Corrected Corrected by Sep 12, 2025

Category: recordkeeping. Marked corrected in the state record.

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

The facility's fire detection log documented dates 7/2/25-8/13/25, with more than 30 days in between.

Corrected Corrected by Sep 10, 2025

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

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

The file for Staff #2 includes a First Aid/CPR certificate dated 1/26/25, after the expiration date of 9/2024.

Corrected Corrected by Jan 26, 2025

Category: ratio. Marked corrected in the state record.

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

The two most recent FBI (11/15/19 & 11/20/24), child abuse (11/14/19 & 11/19/24), and state police (11/13/19 & 11/19/24) clearances on file for Staff #1 were dated more than 60 months apart. (SEE LIS CODE SHEET)

Corrected Corrected by Nov 19, 2024

Category: background checks. 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.

A window in the first-floor older toddler room was observed to be higher than the ground level, unlocked, and not modified to limit the opening to 6 inches or fewer.

Corrected Corrected by Feb 21, 2025

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

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

The carpet in the back of the indoor playroom was observed to be ripped and not in good repair.

Corrected Corrected by Feb 12, 2025

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.

In the second-floor older toddler room, the diapering area lacked a handwashing sign.

Corrected Corrected by Feb 11, 2025

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

3270.123(a) · An agreement shall be signed by the operator and the parent.

The agreement form for Child #1 was not signed by the operator.

Corrected Corrected by Feb 12, 2025

Category: recordkeeping. Marked corrected in the state record.

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

The agreement form for Child #1 lacked the child's date of admission.

Corrected Corrected by Feb 12, 2025

Category: recordkeeping. Marked corrected in the state record.

3270.124(b)(4)/3270.182(3) · Emergency contact information must include the written consent signed by a parent for emergency medical care. A child's record shall contain signed parental consent for emergency medical care for the child. Written consent is required prior to admission.

The emergency contact form for Child #2 lacked signed parental consent for emergency medical care.

Corrected Corrected by Feb 13, 2025

Category: recordkeeping. Marked corrected in the state record.

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

The emergency contact form for Child #2 lacked a complete address for the release persons.

Corrected Corrected by Feb 13, 2025

Category: recordkeeping. Marked corrected in the state record.

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

The two most recent health reports on file for Child #3 (a young toddler) are dated 7/9/24 and 2/5/25, more than 6 months apart. (SEE LIS CODE SHEET)

Corrected Corrected by Feb 11, 2025

Category: health medication. 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.

The fire alarm testing log contains the following dates 2/13/24-4/9/24, 4/9/24-5/15/24, 5/15/24-7/5/24, 7/5/24-8/29/24, 8/29/24- present, which is more than 30 days apart.

Corrected Corrected by Jan 3, 2025

Category: recordkeeping. Marked corrected in the state record.

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

The facility's emergency plan did not include details regarding continuity of operations as required by Announcement C-22-04.

Corrected Corrected by Apr 19, 2024

Category: ratio. Marked corrected in the state record.

3270.27(a)(4)/3270.27(a)(5) · The facility shall have an emergency plan that provides for a method for facility persons to inform parents that the emergency has ended and to provide instruction as to how parents can safely be reunited with their children. The facility shall have an emergency plan that provides for accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions.

When asked, the operator stated communication with families during and after an emergency would occur through Brightwheel and via phone, however the facility's emergency plan did not include that information.

Corrected Corrected by Apr 19, 2024

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

3270.27(b) · The operator shall review the emergency plan at least annually and update the plan as needed. The operator shall document in writing each review and update of the emergency plan and kept on file at the facility.

Documentation of an annual review of the emergency plan dated January 2024 was observed. Documentation of previous annual reviews were not on file, therefore compliance could not be determined,

Corrected Corrected by Feb 26, 2024

Category: recordkeeping. Marked corrected in the state record.

3270.27(c)/3270.192(2)(iii) · 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. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

The following staff files lacked documentation of completing emergency plan training on an annual basis; #2,#4, #5, #6, #7, #8, #11, #12, #15, #16 and Facility person #14. Current training for all listed staff is now on file.

Corrected Corrected by Feb 26, 2024

Category: recordkeeping. Marked corrected in the state record.

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

When asked, the operator stated communication with families during and after an emergency would occur through Brightwheel and via phone, however the facility's letter to parents explaining the emergency procedures did not include that information.

Corrected Corrected by Apr 19, 2024

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

3270.31(e)(4)(ii)/3270.192(2)(iii) · 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. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

The file for staff #5 contained fire safety training completed more than 12 months after their first day in a child care position. The file for staff #15 contained consecutive fire safety training documentation dated more than 12 months apart; 10/10/22 and 1/18/24. Current training is now on file for both staff #5 and #15.

Corrected Corrected by Feb 26, 2024

Category: recordkeeping. Marked corrected in the state record.

3270.32(a)/3270.192(2)(iii) · The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

The file for facility person #14 did not contain documentation of completing mandated reporter training.

Corrected Corrected by Apr 19, 2024

Category: recordkeeping. Marked corrected in the state record.

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

The facility lacked means of preventing access to a functional stove in the kitchen on the second floor. The kitchen does not have a door and a gate was not in use.

Corrected Corrected by Feb 29, 2024

Category: physical safety. 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 #13- may not work in a child care position at the facility.

The file for staff #2 did not contain a valid state police clearance. The file contained an unacceptable certificate from criminalbackgroundrecords.com. The file for staff #13 contained a state police clearance dated 1/06/22 and an FBI clearance dated 1/07/22 which indicated a record. The attachments were not on file with the clearances.

Corrected Corrected by Feb 27, 2024

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

3270.33(a)/3270.192(2)(ii) · A staff person or a substitute staff person shall meet one of the applicable staff qualifications for the position in which the person is performing. A facility person's record shall include verification of child care experience, education and training prior to service at the facility.

The file for staff #1, designated as the director on the staff data worksheet, did not contain verified experience in childcare. The files for staff #3 and #13, designated as AGS on the staff data sheet, did not contain documentation of the qualifications required for the position. The file for staff #9, designated as an AGS on the staff data sheet, contained documentation of previous job experience that did not include childcare related duties.

Corrected Corrected by Apr 19, 2024

Category: recordkeeping. Marked corrected in the state record.

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

The following staff files did not contain written evaluations conducted in the last 12 months: #4, #5, #6, #7, #8, #11, #12, #15, #16. The file for staff #2 contained an evaluation conducted more than 12 months after their start.

Corrected Corrected by Apr 19, 2024

Category: recordkeeping. 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.

The following accessible toxics were observed; Lysol wipes under the sink in an unlocked cabinet in the 2nd floor restroom near the PS office, Lysol wipes and multipurpose cleaner under the sink in an unlocked cabinet in the 2nd floor restroom near the kitchen. Though this restroom is designated for staff, the door was open. Liquid White Out was accessible to children in the OT room in a small white plastic drawered storage box sitting on the radiator guard.

Corrected Corrected by Feb 26, 2024

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

3270.68(b) · Ashes and cigarette or cigar butts are prohibited in a child care space, a play space or a food preparation area.

A cigarette butt was observed on the playground near the bench on the far-right side.

Corrected Corrected by Feb 26, 2024

Category: ratio. Marked corrected in the state record.

3270.75(b) · A first-aid kit must be inaccessible to children.

A first aid kit was accessible to children under the sink in an unlocked cabinet of the second-floor restroom near the PS office.

Corrected Corrected by Feb 26, 2024

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.

The following surface hazards were observed; a metal heater guard in the kitchen where children eat meals, was not secured to the wall, 4 low cabinets in the kitchen were missing doorknobs and/or drawer pulls leaving protruding screws exposed, a metal carpet trim piece in the rear hall behind the rec room was missing a tack on one end causing a tripping hazard, a protruding nail head was observed on the bench on the playground near the sandbox, an access panel in the restroom near the PS office on the second floor was not attached to the wall leaving a sharp screw exposed and allowing open access to the pipes in the wall behind the panel. A broken brochure holder with sharp edges was accessible under the bench in the first floor hall.

Corrected Corrected by Feb 29, 2024

Category: nutrition. Marked corrected in the state record.

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

Peeling paint was observed on two of the wooden fire escape stairs leading to the playground.

Corrected Corrected by Apr 19, 2024

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

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

A toilet in a second-floor restroom near the kitchen was loose and not fully secured to the floor.

Corrected Corrected by Feb 29, 2024

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

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 rear exit from the facility, from the hall at the back of the rec room, was observed to be blocked by 2 snow shovels, a lid for an outdoor cabinet, and a trash can.

Corrected Corrected by Apr 19, 2024

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

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

A broken handle and a cracked plastic door were observed on the play kitchen equipment in the PS room on the second floor.

Corrected Corrected by Feb 27, 2024

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

3270.102(a)/3270.103 · 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. Toys and objects with a diameter of less than 1 inch, objects with removable parts that have a diameter of less than 1 inch, plastic bags and styrofoam objects may not be accessible to children who are still placing objects in their mouths.

A split seam, which exposed the inner foam padding, was observed on the changing pad in the OT restroom,

Corrected Corrected by Mar 20, 2024

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

3270.103 · Toys and objects with a diameter of less than 1 inch, objects with removable parts that have a diameter of less than 1 inch, plastic bags and styrofoam objects may not be accessible to children who are still placing objects in their mouths.

The following accessible small items were observed in the OT room; 5 lollipops accessible in a red plastic bin sitting on the radiator guard, dried beans in the sensory bin, bingo chips and small stampers on a storage shelf with art supplies, batteries, pushpins, and staples in a small white plastic set of storage drawers sitting on a radiator guard. A sponge and loose grocery bags were observed to be accessible in the YT room in an unlocked drawer in the kitchen area where children were observed eating breakfast.

Corrected Corrected by Feb 26, 2024

Marked corrected in the state record.

3270.106(f) · At least 2 feet of space is required on three sides of a bed, cot, crib or other rest equipment while the equipment is in use.

At approximately 2PM, two toddlers were observed sleeping on cots between the cribs in the infant nap room. The cots did not have the required 2 feet of space on 3 sides.

Corrected Corrected by Feb 26, 2024

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

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

A written daily schedule was not posted in the carpeted PS room on the second floor.

Corrected Corrected by Feb 26, 2024

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

3270.123(a) · An agreement shall be signed by the operator and the parent.

The agreement for child #2 was not signed by the parent or operator. The agreements for child #1 and #3 were dated after their documented first day in care.

Corrected Corrected by Feb 27, 2024

Category: recordkeeping. Marked corrected in the state record.

3270.123(a)(4) · An agreement shall specify the child's arrival and departure times.

The agreement for child #5 did not specify the child's arrival and departure times.

Corrected Corrected by Feb 26, 2024

Category: recordkeeping. Marked corrected in the state record.

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

The agreements for child #2 and child #5 did not specify the persons designated by a parent to whom the child may be released.

Corrected Corrected by Feb 27, 2024

Category: recordkeeping. Marked corrected in the state record.

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

The emergency contact form for child #3 did not include the phone number of the child's physician or source of medical care.

Corrected Corrected by Feb 27, 2024

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

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

The emergency contact form for child #1 did not include the enrolling parent's work address or phone number.

Corrected Corrected by Feb 27, 2024

Category: recordkeeping. Marked corrected in the state record.

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

The emergency contact form for child #5 did not include the health insurance policy number.

Corrected Corrected by Feb 27, 2024

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

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

The emergency contact forms for child #1, #3, and #5 did not include complete addresses and telephone numbers of the individuals designated by the parent to whom the child may be released.

Corrected Corrected by Feb 29, 2024

Category: recordkeeping. Marked corrected in the state record.

3270.124(c) · When children are in the facility, emergency contact information shall be present in a child care space for children receiving care in the space.

Emergency contact information was not present in the carpeted 1st floor PS room for the children observed receiving care in the room.

Corrected Corrected by Feb 26, 2024

Category: recordkeeping. Marked corrected in the state record.

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

A written plan identifying the means of transporting a child to emergency care was not posted in the PS Support room or the carpeted PS room on the second floor.

Corrected Corrected by Apr 19, 2024

Category: transportation. Marked corrected in the state record.

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).

The file for child #3, 17 months old, contained an immunization record which lacked documentation of receiving the first doses of MMR and Varicella vaccines. A written exemption was not on file.

Corrected Corrected by Apr 19, 2024

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

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

Psoriasis Relief cream, which was not labeled for a specific child, was observed the OT medication bag. Grape Pain & Fever medication, which was not labeled for a specific child, was observed in the YT medication bag. The label of a prescription medication in the YT room was illegible.

Corrected Corrected by Feb 26, 2024

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

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

The file for staff #13 contained an invalid health assessment. The health assessment is dated more than 12 months prior to their first day in a child care position. The files for staff #2 and #10 contained initial health assessments dated after their first day of initial service in a child care setting. The file for facility person #14, whose duties include food preparation contained health assessments dated more than 12 months apart. The most recent health assessments on file for facility person #14 and staff #2 and #10 are now current.

Corrected Corrected by Feb 27, 2024

Category: ratio. Marked corrected in the state record.

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

The file for facility person #14 did not contain written references.

Corrected Corrected by Apr 19, 2024

Category: recordkeeping. Marked corrected in the state record.

3270.15(b) · The legal entity shall maintain ongoing compliance with the applicable requirements prescribed by the Department of Labor and Industry in 34 Pa. Code § 403.23 and under section 1016(c) of the act at all times following issuance of any certificate of compliance issued by the Department under this chapter.

The facility's certificate of occupancy, dated 4/11/95, indicates the certificate is for 205 Orchard Pl. The facility is located at 201 Orchard Pl.

Corrected Corrected by Apr 19, 2024

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.

The facility lacked documentation of an emergency drill conducted in the past 12 months.

Corrected Corrected by Apr 19, 2024

Category: recordkeeping. Marked corrected in the state record.

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

Proof of purchase for the interconnected fire alarm system was not available for review during the inspection.

Corrected Corrected by Feb 27, 2024

Category: recordkeeping. Marked corrected in the state record.

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

Documentation of submitting the emergency plan to the local and county EMA was not on file.

Corrected Corrected by Apr 19, 2024

Category: recordkeeping. Marked corrected in the state record.

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.

Documentation of writing and submitting an annual letter to local traffic safety authorities was not on file.

Corrected Corrected by Apr 19, 2024

Category: recordkeeping. Marked corrected in the state record.

3270.182(7) · A child's record shall contain reports of accidents, injuries and illnesses involving a child in care at the facility. The original report shall be given to the parent on the day of the incident. The second copy of the report shall be retained at the facility in an accident file. The third copy of the report shall be retained at the facility in the child's file.

The facility lacked documentation of providing an incident report to the parent of child #1 after an incident on 8/14/23 after which the child displayed signs of a possible injury to the arm.. The incident report on file was not signed by the parent.

Corrected Corrected by Feb 19, 2024

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

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 10:40AM, the certification representative came down the stairs to the open door of the infant room. Staff #1 was observed near the windows of the infant room and staff #2 was observed sitting on the couch with 3 infants on the floor nearby. Upon seeing the certification representative, staff #1 walked into the infant nap room which connects to the infant room. The certification then observed 2 sleeping infants in cribs in the infant nap room. No other staff were present in these two rooms. The position of the two cribs in use was such that the infants could not been seen from where the two staff were positioned. Previously cited on SIN-00224326.

Corrected Corrected by Oct 11, 2023

Category: ratio. Marked corrected in the state record.

3270.51 · *The legal entity will conduct mandatory staff meetings at least once per month for a period of 3 months following the approval of this plan of correction. At each staff meeting, time will be set aside to review and discuss the facility's previous regulatory non-compliance items documented on inspection summaries issued in the last year, as well as, the Department of Human Services' regulations related to staff:child ratios and supervision of children. An agenda will be prepared for each staff meeting and a log identifying the date, time and persons attending each meeting will be maintained. The staff meeting agendas and logs will be made available to OCDEL-DHS representatives upon request

*At approximately 10:40AM, the certification representative came down the stairs to the open door of the infant room. Staff #1 was observed near the windows of the infant room and staff #2 was observed sitting on the couch with 3 infants on the floor nearby. Upon seeing the certification representative, staff #1 walked into the infant nap room which connects to the infant room. The certification then observed 2 sleeping infants in cribs in the infant nap room. No other staff were present in these two rooms. The position of the two cribs in use was such that the infants could not been seen from where the two staff were positioned. Previously cited on SIN-00224326.

Corrected Corrected by Dec 31, 2023

Category: supervision. Marked corrected in the state record.

3270.113(a)/3270.113(a)(1) · Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Outdoor play space used by the facility is considered part of the facility premises. 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 10:40AM, the certification representative came down the stairs to the open door of the infant room. Staff #1 was observed near the windows of the infant room and staff #2 was observed sitting on the couch with 3 infants on the floor nearby. Upon seeing the certification representative, staff #1 walked into the infant nap room which connects to the infant room. The certification then observed 2 sleeping infants in cribs in the infant nap room. No other staff were present in these two rooms. The position of the two cribs in use was such that the infants could not been seen from where the two staff were positioned. Previously cited on SIN-00223479.

Corrected Corrected by Oct 10, 2023

Category: supervision. Marked corrected in the state record.

3270.113(a) · **All staff persons at the facility will be required to attend an OCDEL-approved training regarding supervision of children presented by the ELRC within 3 months of the approval of this plan of correction. The training will count towards the mandatory 12 training hours required by the Department.

**At approximately 10:40AM, the certification representative came down the stairs to the open door of the infant room. Staff #1 was observed near the windows of the infant room and staff #2 was observed sitting on the couch with 3 infants on the floor nearby. Upon seeing the certification representative, staff #1 walked into the infant nap room which connects to the infant room. The certification then observed 2 sleeping infants in cribs in the infant nap room. No other staff were present in these two rooms. The position of the two cribs in use was such that the infants could not been seen from where the two staff were positioned. Previously cited on SIN-00223479.

Corrected Corrected by Oct 12, 2023

Category: supervision. Marked corrected in the state record.

3270.113(a)(1) · ***The legal entity will post the appropriate ratios for each age group and the definition of supervision in each child care space and outdoor space, along with the instructions for contacting the OCDEL office. The posting shall address the requirement for staff being physically present n the room with the children they are supervising. The posting will be in a conspicuous location and will be easily visible to parents and staff. The posting will be submitted to OCDEL for approval.

***At approximately 10:40AM, the certification representative came down the stairs to the open door of the infant room. Staff #1 was observed near the windows of the infant room and staff #2 was observed sitting on the couch with 3 infants on the floor nearby. Upon seeing the certification representative, staff #1 walked into the infant nap room which connects to the infant room. The certification then observed 2 sleeping infants in cribs in the infant nap room. No other staff were present in these two rooms. The position of the two cribs in use was such that the infants could not been seen from where the two staff were positioned. Previously cited on SIN-00223479.

Corrected Corrected by Oct 10, 2023

Category: supervision. Marked corrected in the state record.

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

The following exits were blocked at the time of the inspection; 2 exits from the OT room, 1 exit from the YT room, 1 exit from the infant room, 1 exit from the infant nap room, 1 exit from the tiled side of PS1, 2 exits from the carpeted side of PS1, 2 exits from the carpeted side of PS2, 2 exits from the PS Support Room, and 1 exit from the facility at the rear of the Rec Room.

Corrected Corrected by Oct 6, 2023

Marked corrected in the state record.

3270.113(a) · Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Outdoor play space used by the facility is considered part of the facility premises.

Based on statements made by staff, child #1 was left unsupervised by staff in the carpeted room of PS2.

Corrected Corrected by May 10, 2023

Category: supervision. Marked corrected in the state record.

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.

Based on statements made by staff, child #1 was left in the carpeted room of PS2 without a staff person physically present in the room.

Corrected Corrected by May 10, 2023

Category: supervision. Marked corrected in the state record.

3270.113(e) · A facility person may not restrain a child by using bonds, ties or straps to restrict a child's movement or by enclosing the child in a confined space, closet or locked room. The prohibition against restraining a child does not apply to the use of adaptive equipment prescribed for a child with special needs.

Based on statements made by staff, on 4/26/23 staff #1 restrained child #2 by placing their arms and 1 leg across the child to prevent the child from leaving the nap mat he was laying on and by placing their arms and legs around the child while sitting on the floor behind him to prevent the child from striking other children.

Corrected Corrected by May 15, 2023

Category: recordkeeping. Marked corrected in the state record.

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

Staff person #2 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Health and Safety topics 1-9 PREVIOUSLY CITED ON SIN-00221658

Corrected Corrected by Jun 30, 2023

Category: ratio. Marked corrected in the state record.

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

Staff #4 has not yet completed the 1 hour training titled Pennsylvania Health and Safety Update 2022 as required by Announcement C-22-06.

Corrected Corrected by Jun 1, 2023

Category: ratio. Marked corrected in the state record.

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

Approximately 3 inches of standing water was observed in the sandbox in the outdoor play space while children were using the space. A tarp covering the sandbox had collected the water and it was not removed prior to allowing the children on the play ground.

Corrected Corrected by May 10, 2023

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

3270.32(a)/3270.192(4) · The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Staff #1 and facility person #3 may not be present at the facility.

The file for staff #1 did not include documentation of applying for the correct FBI clearance. The FBI clearance on file was from the Department of Education, making it invalid. Based on statements made by staff, staff #1 has had direct contact with children on two separate days while observing classrooms. The file for facility person #3 contained three expired clearances. The clearances on file were dated as follows; state police 5/17/16, child abuse 5/19/16, and FBI 5/28/16.

Corrected Corrected by Jun 30, 2023

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

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.

Based on statements made by staff, child #1 was left in PS2 for approximately 5-10 minutes with facility person #3, an individual who is not a staff person.

Corrected Corrected by May 10, 2023

Category: ratio. 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.

Two electrical outlets on a power strip on the floor of the older toddler room and two wall outlets in the Rec Room lacked protective covers. The outlets are accessible to children 5 years of age or younger. The outlets in the Rec Room have a built-in safety feature that was not functioning correctly at the time of the inspection.

Corrected Corrected by May 10, 2023

Marked corrected in the state record.

3270.75(b) · A first-aid kit must be inaccessible to children.

A bag containing a first aid kit was accessible to children. The bag was observed on the ground in the outdoor play space while children were present in the space.

Corrected Corrected by May 10, 2023

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

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

A tear approximately 4-5 inches long was observed on the seat a blue child size couch in PS2.

Corrected Corrected by May 10, 2023

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

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

Staff #2 and #3 have not completed the one-hour course titled Pennsylvania Health and Safety Update 2022. As stated in Announcement C-22-06, staff were required to complete the training by 12/30/22.

Corrected Corrected by Mar 21, 2023

Category: ratio. Marked corrected in the state record.

3270.31(f) · Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10.Staff person #1 will have until 4/11/23 to complete the required training. Until such time as the required training has been completed, staff person #1 must be supervised, when interacting with children, by an AGS who has completed the required training related to this citation. If there are no staff available to supervise staff person #1, then staff person #1 may not work in a child-care position at the facility.

Staff person #1 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Health and Safety topics 1-9 and pediatric CPR/First Aid.

Corrected Corrected by Apr 3, 2023

Category: supervision. 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 #1 may not work in a child care position at the facility.

The file for staff #1 lacked current state police, child abuse, and FBI clearances. The dates of the expired clearances are as follows; state police 10/30/15, child abuse 11/03/15, and FBI 11/17/16.

Corrected Corrected by Mar 31, 2023

Category: background checks. 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.

Two windows on the second floor, in PS 2, were not restricted to open 6 or fewer inches.

Corrected Corrected by Mar 28, 2023

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

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

Splintering wood was observed on a broken section of baseboard behind the water table in PS 1.

Corrected Corrected by Mar 28, 2023

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

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

Based on the facility's fire drill log, drills are not being conducted at least every 60 days. The last documented drill occurred 10/12/22.

Corrected Corrected by Mar 31, 2023

Category: recordkeeping. Marked corrected in the state record.

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

The facility's proof of purchase for the fire alarm system was not available for review at the time of the inspection.

Corrected Corrected by Apr 4, 2023

Category: recordkeeping. Marked corrected in the state record.

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

Standing water was observed in the sensory table bins and in two toy bins in the fenced playground while children were present in the space.

Corrected Corrected by Oct 24, 2022

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

3270.31(e)(4)(ii)/3270.192(2)(iii) · 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. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

The file for staff #7 contained documentation of fire safety training completed more than 12 months apart; 10/11/21 and 11/03/22.

Corrected Corrected by Oct 24, 2022

Category: recordkeeping. Marked corrected in the state record.

3270.31(f) · Staff persons shall complete professional development within 90 days of hire as listed in subsections 3270.31(f)1-10. Staff person #3 must do one of the following: provide documentation that the trainer has become PQAS-certified or at least is on the waiting list, request the instructor provide documentation, such as their Pediatric First-Aid/CPR Instructor Card from the PQAS-approved organization or the approved curriculum organization, that the instructor is approved to offer Pediatric First-Aid/CPR training on behalf of their organization, or receive pediatric first-aid/CPR training in an approved curriculum by a PQAS-certified trainer. Staff person #5 will have15 days from the date of the plan is requested to complete the required training. Until such time as the required training has been completed, staff person #5 must be supervised, when interacting with children, by an AGS who has completed the required training related to this citation. If there are no staff available to supervise staff person #5, staff person #5 may not work in a child-care position at the facility.

Staff person #2 did not complete the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Health and safety topics 1-9. Current training is now on file. Staff person #3 has acceptable pediatric first aid/CPR training in an approved curriculum; however, the trainer has not provided documentation that they are PQAS-certified in that training topic. Staff person #5 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Pediatric CPR and First Aid.

Corrected Corrected by Feb 23, 2023

Category: supervision. Marked corrected in the state record.

3270.32(a) · The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services).Facility #8 will have until 12/01/22 to complete the mandated reporter training. Until such time as the required training has been completed, facility person #8 must be supervised, when interacting with children, by an AGS who has completed the required training related to this citation. If there are no staff person(s) available to supervise facility person #8, facility person #8 may not work in a child-care position at the facility.

Facility person #8 has not completed the mandated reporter training from an approved source within 90 days of their date of hire (see LIS code sheet).

Corrected Corrected by Nov 15, 2022

Category: supervision. Marked corrected in the state record.

3270.32(a)/3270.192(4) · A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL.

The file for staff #1 contained an NSOR certificate and application dated after their first day in a child care position. The application was dated 9/15/22. The completed certificate was dated 9/21/22 (SEE LIS CODE SHEET). The file for staff #4 contained an NSOR certificate dated 5/11/22 which is more than 45 days after their start date . The application on file was dated 3/10/21 (SEE LIS CODE SHEET). No record of suspension was on file.

Corrected Corrected by Nov 15, 2022

Category: background checks. 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.

Three guards covering heat sources were not fully secured to the walls creating pinch points and a tipping hazard. Two of the loose guards are located in the older toddler room and one in the hall outside the kitchen.

Corrected Corrected by Dec 3, 2022

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

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

Peeling paint was observed in the older toddler room near the window by the stereo and in the restroom of the young PS room on the wall facing the toilet.

Corrected Corrected by Nov 24, 2022

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

3270.102(a)/3270.103 · 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. Toys and objects with a diameter of less than 1 inch, objects with removable parts that have a diameter of less than 1 inch, plastic bags and styrofoam objects may not be accessible to children who are still placing objects in their mouths.

Tears were observed on three blue child size couches which left the inner foam filling accessible to children; 1 couch was located in the young toddler room, 2 were located in the older PS room. Accessible foam batting was observed on the back cover of a bouncy seat on the infant porch.

Corrected Corrected by Oct 24, 2022

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

3270.104(a) · Furniture must be durable, safe, easily cleaned and appropriate for the child's size, age and special needs.

A white storage cabinet in the crib area of the infant room was not anchored to the wall and presented a tipping hazard.

Corrected Corrected by Nov 3, 2022

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

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

The files for children #1 and #1 contained agreements which did not specify the date of the child's admission.

Corrected Corrected by Oct 24, 2022

Category: recordkeeping. Marked corrected in the state record.

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

The file for child #2 contained emergency contact information and an agreement which were updated by the parent more than 6 months apart; 12/07/21 and 8/07/22. The documents are now current.

Corrected Corrected by Oct 24, 2022

Category: recordkeeping. Marked corrected in the state record.

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

The file for child #1 contained an immunization record which did not include documentation of receiving the influenza vaccine in 2021 or 2022 in accordance with the schedule recommended by the ACIP. A written exemption was not on file.

Corrected Corrected by Oct 27, 2022

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

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

The health assessments on file for staff #6, #7 and #9 dated in 2022, were determined to be invalid. The files for staff #6, #7, and #9 lacked health assessments completed within the past 24 months.

Corrected Corrected by Nov 22, 2022

Category: ratio. Marked corrected in the state record.

20.71(a)(7) · The Department may deny, refuse to renew or revoke a certificate of compliance for fraud or deceit in obtaining or attempting to obtain a certificate of compliance.

The file for staff #6 contained a health assessment dated 7/18/22. The file for staff #7 contained a health assessment dated 9/17/22. The file for staff #9 contained a health assessment dated 3/10/22. The three physicians whose signatures were on the health assessments for staff #6, #7, and #9 have verified the individuals were not seen in their offices on those dates.

Corrected Corrected by Nov 1, 2022

Category: health medication. 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.

The staff file for Staff person #1 contained fire safety training that was not completed annually; the dates of the last two fire safety trainings were 1/7/20 and 10/11/21.

Corrected Corrected by Nov 1, 2021

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.

The staff file for Facility person #2 who has a start date working in child care of 7/18/19 and Staff person #3 who has a start date working in child care of 9/24/14 contained a National Sex Offender Registry (NSOR) certificate dated 7/8/20 which was not obtained by 7/1/20 as required by the Child Protective Service Law (CPSL).

Corrected Corrected by Nov 1, 2021

Category: background checks. 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.

The first-aid kits used in the to-go bags in the Young Preschool Art Room and Young Toddler Room lacked soap.

Corrected Corrected by Nov 1, 2021

Marked corrected in the state record.

3270.151(a) · A facility person providing direct care who comes into contact with the children or who works with food preparation shall have a health assessment conducted within 12 months prior to providing initial service in a child care setting and every 24 months thereafter. A health assessment is valid for 24 months following the date of signature, if the person does not contract a communicable disease or develop a medical problem.

The staff file for Facility person #2 contained a current health assessment dated 2/10/21 which was updated more than 24 months from the previously dated 1/28/19 health assessment. The staff file for Staff person #3 contained a current health assessment dated 7/27/21 which was updated more than 24 months from the previously dated 6/21/19 health assessment.

Corrected Corrected by Nov 1, 2021

Category: ratio. Marked corrected in the state record.

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

On day of renewal inspection director tested the interconnected smoke detection system and the audible alarm could not be heard in the infant room with the door closed.

Corrected Corrected by Nov 8, 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.

As of 12/19/20 the facility emergency plan lacked a lock-down procedure.

Corrected Corrected by Nov 1, 2021

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