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. TIERED LIS: 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. This portion of the plan shall have an immediate correction date. 2. The legal entity will require all childcare leadership staff, to participate with the ELRC 5 Leadership Development Strategist to identify the roles and expectations of each childcare leadership staff. The legal entity will complete a minimum of 3, in-person meetings with the ELRC 5 Leadership Development Strategist. The meetings must be completed within 3 months of the approval of this plan of correction. Upon completion of the visits, documentation including the meeting dates and meeting participants will be provided to the OCDEL-DHS representative by email. The operator shall provide a date for when this training will be complete. 3. The legal entity will require all childcare staff persons at the facility to complete an Active Supervision Training including a review of using a tangible system to identify what children are assigned each staff. The training must be offered by ELRC 5, in-person and a minimum of 2 hours. The training must be completed within 2 months of the approval of this plan of correction. The training must be approved by the Department prior to implementation. Upon completion of the training, staff training documentation will be provided to the OCDEL-DHS representative by email. The training may count towards the mandatory 12 training hours required by the Department. The operator shall provide a date for when this training will be complete. 4. The legal entity will require all childcare staff to participate in technical assistance visits provided by the ELRC regarding classroom supervision and the utilization of the selected system to identify what children are assigned each staff. The legal entity will complete a minimum of 3, in-person technical assistance visits provided by ELRC 5. The technical assistance visits must be completed within 3 months of the approval of this plan of correction. Upon completion of the visits, documentation will be provided to the OCDEL-DHS representative by email. The operator shall provide a date for when this training will be complete.

Continued Non-Compliance: On 10/28/25 at approximately 10:05am in the Red Room, Staff #1 identified 4 of the 5 children in their supervision group; When prompted, Staff #1 utilized their ID Tags and correctly identified the 5th child in their supervision group. On 10/28/25 at approximately 10:10am, in the Blue Room, Staff #2 identified 8 of the 9 children in their supervision group; Staff #2 had 8 ID Tags and a sticky note for the 9th child. On 10/28/25, at approximately 10:30am, Staff #3, #4, and #5 were each supervising 4YT in the outdoor play area; Staff #3, #4, and #5 left the ID Tags in the classroom. On 10/28/25, at approximately 10:35am, Staff #6 was observed to be supervising 3 children at the restroom; Staff #6 had 6 ID Tags. 5 of the ID Tags were for children being supervised by other staff in the outside play area at that time. On 11/13/25 at approximately 2:55pm in the Yellow Room, Staff #7 reported that they did not have ID Tags for the 6 OT they were supervising; Staff #8 had 6 ID Tags but only 5 OT were present in their supervision group. On 11/13/25, at approximately 3:00pm, Staff #9 identified 6 of the 7 children in their supervision group; When prompted, Staff #9 utilized their ID Tags and correctly identified the 7th child in their supervision group. Previously Cited on 5/6/25

Corrected Corrected by Mar 1, 2026

Category: supervision. Marked corrected in the state record.

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

The files for Staff #5, #9, #10, #11, and #12 lacked documentation of emergency plan training at initial time of hire. The file for Staff #7 contained emergency plan training dated 7/31/24, more than 12 months ago.

Corrected Corrected by Oct 16, 2025

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 (f)1-10. Until such time as the required pre- service trainings are completed, staff #9 and #12 must be supervised, when interacting with children at a minimum by, an AGS who has completed all preservice trainings and has all qualifications to care for children unsupervised. If there are no staff person(s) available to supervise staff #9 and #12, staff #9 and #12 may not work in a child-care position at the facility.

Staff person #2 did not complete following required pre-service training within 90 days of their date of hire (see LIS code sheet): PA Required Health and Safety for Centers-Group Child Care Part 1 and Part 2 dated 4/21/25. Staff person #3 did not complete following required pre-service training within 90 days of their date of hire (see LIS code sheet): PA Required Health and Safety for Centers-Group Child Care Part 1, dated 6/8/25, and Part 2, dated 9/17/25. Staff person #4 did not complete following required pre-service training within 90 days of their date of hire (see LIS code sheet): Pediatric first aid and CPR training dated 10/12/24. Staff person #9 has not completed the following required pre- service training within 90 days of their date of hire (see LIS code sheet): Health and Safety training 3270.31(f)(1-9). Staff #12 has completed Pediatric first aid and CPR training, however the training was completed through a trainer that has not provided documentation that they are PQAS-certified in that training curriculum.

Corrected Corrected by Oct 17, 2025

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. Facility Person #12, #15, and #16 may not work in a child care position at the facility.

The file for Staff #8 contained a PA Child Abuse clearance dated 9/14/25 which was obtained after starting in a child care position (See LIS Code Sheet). The file for Staff #12 contained an FBI Clearance dated 5/28/25 and NSOR Certificate dated 5/30/25 which were obtained after starting in a child care position (See LIS Code Sheet). The file for Staff #12 lacked the required out of state clearances. The file for Staff #16 lacked the required out of state clearances. The file for Staff #15 lacked an FBI clearance.

Corrected Corrected by Oct 17, 2025

Category: background checks. 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 Staff Person #1 contained a mandated reporter training dated 5/28/25 which was obtained more than 60 months from the previous mandated reporter training dated 2/25/20.

Corrected Corrected by Oct 17, 2025

Category: recordkeeping. 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 files for Staff #9 and #10, identified as GS, lacked documentation of staff qualifications for the position in which they were performing. The file for Staff #16, serving as an aide, lacked documentation of qualifications for the position in which they were performing.

Corrected Corrected by Oct 17, 2025

Category: recordkeeping. Marked corrected in the state record.

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

At approximately 3:00pm, CR observed 2 infants sleeping in cribs in the Rainbow Room that lacked at least 2 feet of free space on three sides.

Corrected Corrected by Oct 17, 2025

Category: physical safety. 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 assessment on file for Staff #9, dated 8/25/25, was obtained after starting work in a child care position. There is no health assessment on file for Staff #11. The health assessment on file for Staff #14, dated 12/12/24, was obtained after starting work in a child care position.

Corrected Corrected by Oct 17, 2025

Category: ratio. Marked corrected in the state record.

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 #13 lacked a disclosure statement.

Corrected Corrected by Oct 17, 2025

Category: background checks. 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 #5 lacked one written, nonfamily reference from individuals attesting to the person's suitability to serve as a facility person. The files for Staff #6, #8, #9, and #10 lacked two written nonfamily references from individuals attesting to the person's suitability to serve as a facility person.

Corrected Corrected by Oct 17, 2025

Category: recordkeeping. Marked corrected in the state record.

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

Documentation of the fire alarm system test shows more than 30 days between testing. (5/7/25 and 6/9/25; 8/14/25 and 9/23/25)

Corrected Corrected by Oct 17, 2025

Category: recordkeeping. Marked corrected in the state record.

3270.162(c) · Food may not be withheld from a child for purposes of discipline.

Based staff interviews, it was verified that Staff Person #1 and #2 withheld a popsicle from Child #1 on 6/2/25 because the child had refused to take a nap.

Corrected Corrected by Oct 10, 2025

Category: nutrition. 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.

4/16/26 between 9:30-10:50AM staff #1 was responsible for the supervision of 11 PS children on 3 occasions. Sixteen children were present. Staff #2 exited the room with 5 children two separate times while Staff #1 remained in the room with the other 11 children. Later, staff #1 exited the room to go to the playground with 11 PS children. Staff #2 remained in the room with 5 children.

Corrected Corrected by Aug 7, 2025

Category: supervision. Marked corrected in the state record.

3270.31(f) · Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10.. Until such time as the required training has been completed, staff person #5 must be supervised, when interacting with children at a minimum by, an AGS who has completed all preservice trainings and has all qualifications to care for children unsupervised. If there are no staff person(s) available to supervise staff person #5, then staff person #5- may not work in a child-care position at the facility.

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 Pediatric First Aid.

Corrected Corrected by Aug 7, 2025

Category: supervision. Marked corrected in the state record.

3270.32(a) · The operator shall comply with the CPSL and with Chapter 3490 (relating to Child Protective Services). Until such time as the required training has been completed, staff persons #6-8- must be supervised, when interacting with children at a minimum by, an AGS who has completed all preservice trainings and has all qualifications to care for children unsupervised. If there are no staff person(s) available to supervise staff persons #6-8-, staff persons #6-8 may not work in a child-care position at the facility.

Staff persons #6, #7, and #8 have not completed mandated reporter training within the last 60 months. This is evidenced by the previously documented mandated reporter training on file being dated 4/24/20 for staff #6, 1/27/20 for staff #7, and 2/21/20 for staff #8.

Corrected Corrected by Aug 8, 2025

Category: supervision. Marked corrected in the state record.

3270.113(a)(1) · 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. This portion of the plan shall have an immediate correction date. 2. For a period of 3 months, the facility is required to maintain its hands-free method for identifying the specific children for which each staff person is responsible. It will include, minimally, the name and a picture of the child and staff will utilize the identification method at all times while on duty at the facility. When a new child enrolls at the facility, a supervision card will be present at the facility before the child's first day of attendance. The correction date for this portion of the plan shall be 3 months from the date of approval by the Regional Office. 3. For a period of 3 months, the director or designated staff person will conduct random assessments of each classroom at least once daily. During the assessment, the director will ask each staff person in each classroom to identify the children that are in their group, and are therefore, responsible for. The director will document all assessments in a log, including the date, time, staff persons, number and ages of children. The log will be made available to OCDEL-DHS representatives upon request. The correction date for this portion of the plan shall be 3 months from the date of approval by the Regional Office.

At approximately 11:05AM Staff #1 and Staff #2 were observed with 12 children (2 PS and 10 OT) in room 105. When asked to identify the children they were responsible for supervising, staff #1 and staff #2 named the same two children during multiple attempts to identify their assigned groups. This left two children unidentified as assigned to a care group. In the gym, staff #3 and staff #4 were observed with 10 YTs. When asked, staff #4 was unable to identify which children she was assigned to supervise. Staff #4 named 2 children already identified as part of staff #3's assigned care group.

Corrected Corrected by Nov 8, 2025

Category: supervision. Marked corrected in the state record.

3270.119 · Infants shall be placed in the sleeping position recommended by the American Academy of Pediatrics unless there is a medical reason an infant should not sleep in this position. The medical reason shall be documented in a statement signed by a physician, physician's assistant or CRNP and placed in the child's record at the facility.

At approximately 10:55AM child #1 and child #2, both infants, were observed sleeping in inclined seats in the Rainbow Room.

Corrected Corrected by Aug 8, 2025

Category: health medication. 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, a drill has not been conducted in over 60 days. The last documented drill occurred 1/28/25.

Corrected Corrected by Aug 8, 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 policy for Shaken Baby Syndrome/Abusive Head Trauma lacked prevention and identification of child maltreatment as per Announcement C-22-03.

Corrected Corrected by Feb 18, 2025

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.

The file for Staff Person #1 lacked the one hour Health and Safety Update as per Announcement C-22-06.

Corrected Corrected by Feb 7, 2025

Category: ratio. Marked corrected in the state record.

3270.27(a)(4) · 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's emergency plan lacked a method for facility persons to inform parents that the emergency has ended and instructions as to how parents can safely be reunited with their children as per Announcement C-22-04.

Corrected Corrected by Jan 31, 2025

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

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

The parent letter lacked information explaining the emergency procedures for lockdown situation and accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions.

Corrected Corrected by Jan 31, 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.

Staff Person #7 completed pediatric first aid and CPR training on 10/12/24, more than 24 months from the previous training on 8/11/22. Staff Person #14 completed pediatric first aid and CPR on 5/24/24 more than 24 months from the previous training on 3/8/22.

Corrected Corrected by Jan 31, 2025

Category: ratio. Marked corrected in the state record.

3270.32(a)/3270.192(4) · The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A 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 Persons #4, 5, 10, 11, 12, and 25 may not work in a child care position at the facility.

The file for Staff Person #4 lacked a current FBI clearance; the FBI clearance in the file for Staff Person #4 was dated 8/22/19. The file for Staff Person #5 contained a Volunteer PA Criminal Clearance. The file for Staff Person #10 lacked a current FBI clearance; the FBI clearance in the file for Staff Person #10 was dated 5/24/19. The file for Staff Person #11 contained an NSOR dated 11/6/19 which was obtained more than 60 months ago. The file for Staff Person #11 contained an FBI clearance dated 12/2/24, more than 60 months from the previous clearance dated 10/17/19. The file for Staff Person #12 lacked an NSOR clearance as well as a DHS FBI clearance. The file for Staff Person #12 contained a Criminal Justice FBI clearance dated 8/28/24. The file for Staff Person #13 contained a PA Child Abuse clearance dated 11/23/24 which was obtained after starting in a child care position (See LIS Code Sheet). The file for Staff Person #25 lacked a Texas Criminal History Check and the Texas Sex Offender Registry Check.

Corrected Corrected by Jan 30, 2025

Category: background checks. 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 Staff Person #11 contained a mandated reported training dated 8/26/19 which was obtained more than 60 months ago.

Corrected Corrected by Jan 10, 2025

Category: recordkeeping. 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 Person #1 lacked a copy of their High School Diploma and years of experience working with children. The file for Staff Person #12 lacked documentation of education and years of experience working with children. The file for Staff Person #16 lacked documentation of experience working with children. The file for Staff Person # 21 lacked documentation of education and years of experience working with children. The file for Staff Person #22 lacked documentation of education and years of experience working with children. The file for Staff Person #23 lacked documentation of education and years of experience working with children. The file for Staff Person #24 lacked documentation of education and years of experience working with children.

Corrected Corrected by Jan 17, 2025

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 file for Staff Person #7 contained a staff evaluation completed in October 2024 more than 12 months after the previous staff evaluation dated June 2022; The file for Staff Person #19 contained a staff evaluation completed in October 2024 more than 12 months after the previous staff evaluation dated May 2022.

Corrected Corrected by Feb 21, 2025

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.

There was a hot water tank accessible to the children in an unlocked cabinet under the sink in the bathroom connected to the Blue room.

Corrected Corrected by Jul 17, 2025

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

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

There is peeling paint in the Red room under the mirror. There is peeling paint in the Orange room around the far left window and around the stars along the window wall.

Corrected Corrected by Feb 14, 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.

The toilet in the bathroom off the Violet room lacked a handwashing sign. The sink in the bathroom off the Red room lacked a handwashing sign.

Corrected Corrected by Jan 17, 2025

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

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

The bathroom off the Blue room lacked a lidded waste receptacle.

Corrected Corrected by Jan 17, 2025

Category: health medication. 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.

The play couch in the Orange room has a ripped vinyl covering on the corner, exposing foam padding to children still placing objects in their mouths. The changing pad in the Silver room has a hole in the final covering.

Corrected Corrected by Jan 17, 2025

Category: physical safety. 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.

The cribs in the Rainbow Room lacked 2 feet of space around them while in use. An infant was sleeping in a crib in the corner next to the rocking chair and there was a bouncy seat on the other side of the crib impeding access. Another child was observed sleeping in a crib next to two other empty cribs on either side less than 2 feet apart.

Corrected Corrected by Jan 21, 2025

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 form for Child # 1 lacked the signature of the operator.

Corrected Corrected by Jan 17, 2025

Category: recordkeeping. Marked corrected in the state record.

3270.123(a)(3) · The services to be provided to the family and the child, including the Department's approved form to provide information to the family about the child's growth and development in the context of the services being provided. The operator shall complete and update the form and provide a copy to the family in accordance with the updates regarding emergency contact information in § 3270.124(f) (relating to emergency contact information).

The files for child #4, #5, #6, #9 & #10 contained child growth and development forms dated more than 6 months ago. The file for Child #4 contained a child growth and development form dated 9/24/23. The file for Child #5 contained a child growth and development form dated 10/13/23. The file for Child #6 contained a child growth and development form dated 10/25/23. The file for Child #9 contained a child growth and development form dated for the Fall of 2023. The file for Child #10 contained a child growth and development form dated October 2023.

Corrected Corrected by Feb 17, 2025

Category: recordkeeping. Marked corrected in the state record.

3270.123(b)/3270.182(8) · A parent shall receive the original agreement. The facility shall retain a copy of the agreement. A child's record shall contain a copy of the initial agreement and subsequent written agreements between the parent and the operator. The parent receives the original agreement.

The file for Child #1, Child #2, Child #3, Child #4, Child #5, Child #6, Child #7, Child #8, Child #9, and Child #10 contained the original fee agreement form signed by the parent.

Corrected Corrected by Jan 17, 2025

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 #7 lacked the name of the physician or source of medical care.

Corrected Corrected by Jan 24, 2025

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

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

The emergency contact form for Child #1, Child #4, Child #5, Child #6, Child #8 and Child #10 lacked the enrolling parent's work address and work phone number; The emergency contact form for Child #3 lacked the enrolling parent's home address, work address, and work phone number.

Corrected Corrected by Feb 17, 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 #1 lacked the release person's address and phone number; The emergency contact forms for Child #3, Child #8, Child #9, and Child #10 lacked the release person's address.

Corrected Corrected by Feb 17, 2025

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.

The Pink room lacked a copy of the emergency transportation plan displayed conspicuously in the child care space.

Corrected Corrected by Jan 17, 2025

Category: transportation. 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 financial agreement for Child #4 was last updated on 7/25/23, more than 6 months ago. The emergency contact form for Child #10 was updated on 9/6/24 more than 6 months after the previous review dated 9/18/23. The financial agreement for Child #10 was updated on 11/12/24 more than 6 months after the previous review dated 12/5/22.

Corrected Corrected by Feb 14, 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 health report on file for Child #5, a toddler (See LIS Code Sheet), was dated 7/29/24 more than 6 months after the previous health report dated 7/31/23. The health report for Child #6, a toddler (See LIS Code Sheet) was dated 11/4/24 more than 6 months after the previous health report dated 4/20/24.

Corrected Corrected by Feb 14, 2025

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

3270.131(e) · The facility may not accept or retain an infant 2 months of age or older, a toddler or a preschool child at the facility for more than 60 days following the first day of attendance at the facility unless the parent provides written verification from a physician, physician's assistant, CRNP, the Department of Health or a local health department of the dates (month, day and year) the child was administered immunizations in accordance with the recommendations of the ACIP. Child #7 will be dismissed from care by close of business 12/13/24 until either the immunization record is updated or a parent provides a written, signed exemption letter.

The file for Child #7, enrolled more than 60 days, lacked verification of vaccinations in accordance with the ACIP.

Corrected Corrected by Feb 14, 2025

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 Person #15 (See LIS Code Sheet) contained a health assessment dated 8/14/23, and TB screening results dated 8/21/23 which were more than 12 months old when hired. The file for Staff Person #18 (See LIS Code Sheet) contained a health assessment dated 1/8/24 which was more than 24 months from the previous health assessment dated 12/29/21. The file for Staff Person #12 (See LIS Code Sheet) lacked a health assessment. The file for Staff Person #24 (See LIS Code Sheet) lacked a health assessment.

Corrected Corrected by Feb 4, 2025

Category: ratio. Marked corrected in the state record.

3270.151(c)(3) · An adult health assessment must include an examination for communicable diseases and the results of that examination.

The health assessment on file for Staff Person #4 (See LIS Code Sheet) lacks assessment results for communicable diseases.

Corrected Corrected by Jan 31, 2025

Category: health medication. 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 files for Staff Person #16, Staff Person #20, and Staff Person #21 lacked one written, nonfamily reference from individuals attesting to the person's suitability to serve as a facility person. The files for Staff Person #1, Staff Person #5, Staff Person #12, Staff Person #13, Staff Person #15, Staff Person #22, Staff Person #24, and Staff Person #25 lacked two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person.

Corrected Corrected by Feb 14, 2025

Category: recordkeeping. 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 a current annual emergency drill. The most recent emergency drill was recorded on 11/16/23, more than 12 months ago.

Corrected Corrected by Jan 1, 2025

Category: recordkeeping. Marked corrected in the state record.

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

The files for Staff Person #3, Staff Person #8, and Staff Person #9 completed professional development in pediatric first aid and pediatric CPR on 5/24/2024, more than 90 days following their date of hire (See LIS Code Sheet). The file for Staff Person #4 lacked a pediatric first aid and pediatric CPR training provided by a certified PQAS instructor more than 90 days following their date of hire (See LIS Code Sheet). The pediatric first aid and pediatric CPR on file for Staff Person #4 completed on 4/14/24 was not provided by a certified PQAS instructor. The files for Staff Person #5 completed professional development in pediatric first aid and pediatric CPR on 12/10/2024, more than 90 days following their date of hire (See LIS Code Sheet). The files for Staff Person #6 completed professional development in pediatric first aid and pediatric CPR on 12/10/2024, more than 90 days following their date of hire (See LIS Code Sheet).

Corrected Corrected by Feb 14, 2025

Category: health medication. 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)).

Documentation of the fire alarm system test shows more than 30 days between testing. (11/1/24 and 12/6/24; 8/5/24 and 9/9/24; 3/7/24 and 4/8/24)

Corrected Corrected by Feb 14, 2025

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

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

The file for Staff Person #2 contained 3 of the 12 required annual training hours for the most recent review period, June 2023 and June 2024.

Corrected Corrected by Feb 17, 2025

Category: recordkeeping. Marked corrected in the state record.

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

Staff #1 and staff #2 were supervising a group of 9 younger toddlers in the facility's outdoor play space. As staff #1 and staff #2 were transitioning the children from the building to the area designated for younger children in the outdoor play space, child #1 stopped midway between the two points while the staff and children continued to move ahead. Child #1 was left alone and unsupervised until staff #3 entered the outdoor play space and discovered the child had been left behind.

Corrected Corrected by Jun 26, 2024

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.

Staff #1 and staff #2 were supervising a group of 9 younger toddlers in the facility's outdoor play space. As staff #1 and staff #2 were transitioning the children from the building to the area designated for younger children in the outdoor play space, child #1 stopped midway between the two points while the staff and children continued to move ahead. Child #1 was left alone and unsupervised until staff #3 entered the outdoor play space and discovered the child had been left behind.

Corrected Corrected by Jun 26, 2024

Category: supervision. Marked corrected in the state record.

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

The bathroom in room 104 was equipped with a waste receptacle that was not lidded.

Corrected Corrected by Jan 5, 2024

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

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

The written plan of daily activities was not posted in room 111.

Corrected Corrected by Jan 26, 2024

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.

A handwashing sign was not posted at the sink in room 105.

Corrected Corrected by Jan 4, 2024

Category: health medication. 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 operator's policy and procedure to identify the prevention of shaken baby syndrome, abusive head trauma, and child maltreatment did not address the prevention and identification of child maltreatment, as per Announcement C-22-03. Staff Person #5, #7, #8, #9, #13, #14 and #19 completed the Pennsylvania Health and Safety Update 2022 following the prescribed timeframe of December 30, 2022, as required by OCDEL per Announcement C-22-06.

Corrected Corrected by Jan 5, 2024

Category: ratio. Marked corrected in the state record.

3270.20(e)/3270.182(7) · Copies of reports of injury, death or fire shall be kept in a file at the facility. 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.

Reports of accidents, injuries and illnesses involving children in care at the facility were not retained at the facility in an accident file.

Corrected Corrected by Jan 5, 2024

Category: health medication. 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.

Garbage bags were being stored in an unlocked cabinet under the diaper changing table in room 101, accessible and posing a suffocation hazard to children in care.

Corrected Corrected by Jan 5, 2024

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

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

Staff Person #2, #3, #5, #7, #8 and #9 did not receive training regarding the emergency plan on an annual basis during the period of time between the dates of their current and previous trainings. Staff Person #6, #10 and #15 received training regarding the emergency plan more than 90 days following their date of hire. (See LIS Code Sheet)

Corrected Corrected by Jan 5, 2024

Category: recordkeeping. Marked corrected in the state record.

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

The operator did not provide to the parent of each enrolled child a letter explaining the emergency procedures.

Corrected Corrected by Jan 5, 2024

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 current Pediatric First Aid/CPR certification for Staff Person #18 was completed following the expiration of their previous certification.

Corrected Corrected by Jan 5, 2024

Category: ratio. Marked corrected in the state record.

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

Staff Person #2, #5, #7, #8 and #9 did not participate in fire safety training, at least annually, during the period of time between their current and previous training.

Corrected Corrected by Jan 5, 2024

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 (f)1-10 within 90 days of hire. Staff person #1 will have until 1/21/2023 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, staff person #1 may not work in a child-care position at the facility.

Staff Person #1 did not complete the following required pre-service training within 90 days of their date of hire: CCDBG Health and Safety training. (see LIS code sheet)

Corrected Corrected by Jan 9, 2024

Category: supervision. Marked corrected in the state record.

3270.31(f) · Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10.

Staff Person #6, #15, #16 and #19 completed the CCDBG Health and Safety training more than 90 days following their date of hire. (See LIS Code Sheet)

Corrected Corrected by Jan 5, 2024

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

3270.32(a)/3270.192(4) · The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Facility Person #21 may not work in child care position.

The record for Staff Person #7 included a current State Police Clearance dated more than 60 months following the date of their previous clearance. The record for Staff Person #10 and #11 included a current State Police Clearance dated more than 45 days following their first day working at the facility. The record for Staff Person #11 included a current NSOR Verification Certificate dated more than 45 days following their first day working at the facility. The disclosure statement in the record for Staff Person #10, #12 and #20 were not dated. The record for Staff Person #17 did not include a disclosure statement. The record for Staff Person #21, who has resided out of state within the past five years, did not include the required out of state clearances.

Corrected Corrected by Jan 5, 2024

Category: background checks. 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 director did not complete a written evaluation for Staff Person #8 within the past year.

Corrected Corrected by Feb 5, 2024

Category: recordkeeping. Marked corrected in the state record.

3270.36(b)(5)/3270.192(2)(ii) · An assistant group supervisor shall have a high school diploma or a general educational development certificate and 2 years experience with children. A facility person's record shall include verification of child care experience, education and training prior to service at the facility.

The record for Staff Person #1 lacked verification of the required education and child care experience for them to be qualified to work as an assistant group supervisor.

Corrected Corrected by Jan 31, 2024

Category: supervision. 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.

There was sunscreen being stored in an unlocked cabinet under the diaper changing table in room 101.

Corrected Corrected by Jan 5, 2024

Category: health medication. 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.

There was no door or other barrier being used to prevent children from entering the kitchen area from the hallway, which made the kitchen stove and warming equipment, sources of heat exceeding 110°, accessible to children in care.

Corrected Corrected by Jan 5, 2024

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

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

The agreement for child #1 did not specify the amount of the fee to be charged per day or per week.

Corrected Corrected by Jan 23, 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 agreement for child #2 did not specify the persons designated by a parent to whom the child may be released.

Corrected Corrected by Jan 23, 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 information for child #4 did not include the name, address and telephone number of the child's physician or source of medical care.

Corrected Corrected by Jan 31, 2024

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

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

The emergency contact information for child #4 did not include the written consent signed by a parent for emergency medical care.

Corrected Corrected by Jan 31, 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 information for child #4 did not include health insurance coverage and policy number for a child under a family policy or Medical Assistance benefits, if applicable.

Corrected Corrected by Jan 24, 2024

Category: health medication. 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.

An emergency contact form was not present in room G1 for child #10 who was receiving care in the space.

Corrected Corrected by Jan 5, 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 and staffing provisions in the event of an emergency was not displayed in room G1 and room 201.

Corrected Corrected by Jan 4, 2024

Category: transportation. Marked corrected in the state record.

3270.131(b)(2)/3270.182(1) · The operator shall require the parent to provide an updated health report at least every 12 months for an older toddler or preschool child. A child's record shall contain initial and subsequent health reports.

The record for child #6 lacked a current health report.

Corrected Corrected by Jan 26, 2024

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

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.

There was no means for children to dry their hands after handwashing at the sink in room G4..

Corrected Corrected by Jan 4, 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 TB results for Staff Person #4 were read after the staff person's start date. The file for Staff Person #5 did not include an updated health assessment conducted within the past 24 months. The date of the initial health assessment for Staff Person #6, #11 and #15 was after their start date. (See LIS Code Sheets). The current health assessment for Staff Person #7, #8, #9 and #13 was dated more than 24 months following the date of their previous health assessment. The initial health assessment for Staff Person #12 was conducted more than one year prior to the staff person's start date and is not valid.

Corrected Corrected by Jan 5, 2024

Category: ratio. Marked corrected in the state record.

3270.166(1) · A written statement giving the formula and feeding schedule for an infant shall be obtained from the parent.

A written statement giving the formula and feeding schedule was not obtained from the parents of child #8 and #9, who are both infants.

Corrected Corrected by Jan 31, 2024

Category: nutrition. Marked corrected in the state record.

3270.171(c) · Written notification of safe routes shall be posted by the operator at a conspicuous location in the child care facility.

Written notification of safe routes were not posted in the child care facility.

Corrected Corrected by Jan 31, 2024

Marked corrected in the state record.

3270.182(5) · A child's record shall contain signed parental consent for administration of minor first-aid procedures by facility staff. Written consent is required prior to admission.

The record for child #3 and #7 did not contain signed parental consent for administration of minor first-aid procedures by facility staff.

Corrected Corrected by Jan 23, 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 record for staff #1 and #10 lacked two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person.

Corrected Corrected by Jan 23, 2024

Category: recordkeeping. Marked corrected in the state record.

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

The Pediatric First Aid/CPR Certification in the record for Staff Person #16 was completed more than 90 days following their date of hire. (See LIS Code Sheet)

Corrected Corrected by Jan 5, 2024

Category: health medication. 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.

A fire drill was not conducted at least once every 60 days during the period from 10/20/2023 to 1/3/2024.

Corrected Corrected by Jan 24, 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.

Testing of fire detection system every 30 days was not documented.

Corrected Corrected by Jan 24, 2024

Category: recordkeeping. Marked corrected in the state record.

3270.131(a)/3270.182(1) · 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. A child's record shall contain initial and subsequent health reports.

The record for child #2, #4 and #5 lacked an initial health report more than 60 days following their first day of attendance. The record for child #7 contained an initial health report dated more than 60 days following their first day of attendance.

Corrected Corrected by Jan 26, 2024

Category: health medication. 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.

The operator did not 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.

Corrected Corrected by Jan 31, 2024

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 emergency plan on file at the facility lacked continuity of operations in the aftermath of a disaster as required by Federal Regulation.

Corrected Corrected by Jan 13, 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)1-9.

The health and safety training on file for Facility Person #8 was not completed within 90 days of starting at the facility. The health and safety training was completed 98 days after starting.

Corrected Corrected by Dec 14, 2022

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

3270.32(a)/3270.192(4) · The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). 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 Facility Person #1 lacked a request for an NSOR Certificate prior to starting at the facility. The NSOR certificate on file was dated 14 days after starting at the facility.

Corrected Corrected by Dec 14, 2022

Category: background checks. 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 file for Facility Person, a Staff Person, #3 lacked a Child Abuse Clearance that had been completed for employment purposes. The Child Abuse Clearance on file was a Volunteer Clearance. The files for Facility Person's #6 and #9 lacked a signed disclosure statement prior to starting at the Facility. The disclosure statements were completed 14 days after starting for both Facility Persons. The mandated reporter training on file for Facility Person #8 was not completed within 90 days of starting at the facility. The training was completed 97 days after starting at the Facility.

Corrected Corrected by Dec 14, 2022

Category: background checks. 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 written staff evaluations on file for Facility Person #2 were dated 8.23.21 and 10.18.22. The written staff evaluations for Facility Person #4 were dated 8.10.21 and 9.12.22. The written staff evaluations for Facility Person #5 were dated 8.21.21 and 10.4.22. Written evaluations are to be completed at least once every 12 months.

Corrected Corrected by Dec 20, 2022

Category: recordkeeping. Marked corrected in the state record.

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

The first aid kit in Classroom #102 was observed in an unlocked backpack on a low chair that could be accessible to children receiving care in the space.

Corrected Corrected by Dec 13, 2022

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

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

A lidded can was missing from a sink in Classroom 203.

Corrected Corrected by Dec 13, 2022

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

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

A cracked bin with a potential pinch point was observed in Classrooms 201 and 203. In Classroom #104 a torn cushion was observed on a couch intended for children receiving care in the space.

Corrected Corrected by Dec 13, 2022

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

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

The file for Child #5, an infant, lacked an updated health report that had been completed within the last 6 months. The last assessment on file was dated 1.4.22.

Corrected Corrected by Feb 6, 2023

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

3270.131(d)(7)/3270.131(d)(8) · A health report shall include a statement that the child is able to participate in child care and appears to be free from contagious or communicable disease. A health report shall include a statement that age-appropriate screenings recommended by the American Academy of Pediatrics were conducted since the time of the previous health report required by this section.

The current health report on file for Child #2 lacked information to include a statement that the child is able to participate in child care and appears to be free from contagious or communicable disease. The assessment also lacked a statement that they had received age-appropriate screenings recommended by the AAP since the time of the previous health report.

Corrected Corrected by Jan 6, 2023

Category: health medication. 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 immunization record on file for Child #3 lacked verification that they had received their 6-month DTAP, HIB and Pneumococcal immunizations. The immunization record on file for Child #4 lacked verification that the child has received an annual influenza vaccination. Written exemptions were not on file for children.

Corrected Corrected by Mar 20, 2023

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

3270.133(4) · Medication shall be stored in a locked area of the facility or in an area that is out of the reach of children.

An Auvi Q medication was observed in an unlocked backpack on a low chair in Classroom #102. The unlocked backpack could be accessible to children receiving care in the space.

Corrected Corrected by Dec 13, 2022

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

3270.151(c)(3) · An adult health assessment must include an examination for communicable diseases and the results of that examination.

The current health assessment on file for Facility Person #5 lacked the results of an examination for communicable diseases.

Corrected Corrected by Jan 13, 2023

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

3270.151(c)(5) · An adult health assessment must include the physician's or CRNP's assessment of the person's suitability to provide child care.

The health assessment on file for Facility Person #10 lacked information related to the physician's assessment of their suitability to provide child care.

Corrected Corrected by Jan 23, 2023

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

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

The updates to the emergency contact forms and financial agreements on file for Children #2, #4 and #6 exceeded 6 months between updates. The emergency contact forms on file for Child #2 were dated 8.11.21 and 5.13.22 and the agreement was dated 8.26.21. The emergency contact forms on file for Child #4 were dated 3.31.22 and 12.4.22 and the agreement on file is dated 4.5.22. The emergency contact forms on file for Child #6 were dated 2.9.22 and 11.13.22 and the agreement forms were dated 2.27.22 and 12.7.22.

Corrected Corrected by Jan 20, 2023

Category: recordkeeping. Marked corrected in the state record.

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

The file for Facility Person #7 lacked two written, nonfamily references attesting to their suitability to serve as a facility person.

Corrected Corrected by Dec 15, 2022

Category: recordkeeping. Marked corrected in the state record.

3270.27(a)(5) · The facility shall have an emergency plan that provides for accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions.

The emergency plan on file lacked information related to accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions.

Corrected Corrected by Mar 20, 2023

Category: recordkeeping. Marked corrected in the state record.

3270.131(a) · The operator shall require the parent of an enrolled child, including a child, a foster child and a relative of an operator or a facility person, to provide an initial health report no later than 60 days following the first day of attendance at the facility.

The file for Child #1, an older toddler, lacked an initial health assessment and the child has exceeded 60 days in care at this time (refer to LIS code sheet).

Corrected Corrected by Jan 13, 2023

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

3270.18(a) · The legal entity shall have comprehensive general liability insurance to cover the persons who are on the premises. A current copy of the insurance policy shall be on file at the facility.

The facility has general liability insurance, but a copy of the current policy was not on file at the facility.

Corrected Corrected by Mar 4, 2022

Category: recordkeeping. Marked corrected in the state record.

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

The emergency plan training in the file for staff person #11 was dated after their initial employment. Facility person #15 had emergency plan training, but the training was not documented.

Corrected Corrected by Mar 4, 2022

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 last 2 Mandated Reporter trainings in the file for staff person #20 were dated more than 60 months apart. The file for facility person #21, employed more than 90 days, did not include Mandated Reporter training.

Corrected Corrected by Mar 4, 2022

Category: recordkeeping. Marked corrected in the state record.

3270.32(a)/3270.192(4) · The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). 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 disclosure statement in the file for staff person #9 and #13 were not able to be verified timely as neither document was dated. Based on review of the file for staff person #11 and on conversation with the individual, they had resided in Nevada in the previous 5 years and their file did not include any of Nevada's clearances. The FBI clearance and NSOR Certificate in the file for staff person #11 was dated after they began working with children. Based on review of the file for staff person #14 and on conversation with the individual, they had resided in DC in the previous 5 years and their file did not include any of DC's clearances. The FBI clearance and NSOR Certificate in the file for staff person #14 was dated after they began working with children. The state police clearance in the file for staff person #14 was missing a disposition when the individual began working with children and they continued to work without the disposition for approximately 2 months. The child abuse, FBI and NSOR certificate in the file for individual #15 were dated after the individual began working as a facility person. The facility did not have a provisional hire waiver at the time of the inspection. The last 2 SP, CA and FBI for #20 were dated more than 60 months apart and the individual continued to work with children with expired clearances.

Corrected Corrected by Mar 4, 2022

Category: background checks. 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 initial evaluation in the file for staff person #17 was dated more than 12 months after the individual began working with children. There was no evaluation in the file for staff person #23, employed more than 12 months. The last two evaluations in the file for the following staff were dated more than 12 months apart: 1, 3, 18, 20, 22, 26, 27, 28 and 30.

Corrected Corrected by Mar 4, 2022

Category: recordkeeping. Marked corrected in the state record.

3270.35(b) · A group supervisor shall have attained one of the qualification levels specified at §3270.35(b)(1)-(4).

Based on review of the file for staff person #2 and #7, both holding the title of group supervisor, they did not have the qualifications to be a group supervisor because they did not have an associates degree. Based on review of the file for staff person #8, holding the title of group supervisor, they did not have qualifications to be a group supervisor as their bachelor's degree was in an unrelated field and did not include 30 credits in a related field.

Corrected Corrected by Feb 1, 2022

Category: supervision. Marked corrected in the state record.

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

In the large indoor gym, observed a large loft. On the first landing of the loft, observed carpet which was starting to come loose and was fraying. This causes a tripping hazard to the children in care.

Corrected Corrected by Feb 1, 2022

Category: physical safety. 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.

At approximately 10:45 am, staff persons #3, #4 and #5 were in the Gold room with 4 infants. Staff person #4 was sitting in a rocking chair holding child #2 in their arms. When asked to identify the children for whom they were responsible, staff person #4 identified child #1, a 2 month old, who was asleep in a crib on the back wall of the room. With the lights dimmed in the room, based on the position of the crib, the direction the child was laying and where staff person #4 was sitting, the staff person could not see the child's face or assess the child at that time.

Corrected Corrected by Dec 22, 2021

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.

At approximately 10:30 am, in the orange room, staff person #1 and #2 were present with 8 older toddlers. Staff person #1, who was sitting on the carpeted floor with a group of children, identified 2 children that were in the classroom bathroom, which they could not see, hear, direct or assess from where they were sitting.

Corrected Corrected by Dec 22, 2021

Category: supervision. Marked corrected in the state record.

3270.123(b) · A parent shall receive the original agreement. The facility shall retain a copy of the agreement.

The agreement forms in the file for child #2, #4, #5, #6 and #7 included two different colors of ink and the director confirmed that those forms were the originals.

Corrected Corrected by Mar 4, 2022

Category: recordkeeping. Marked corrected in the state record.

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

The emergency contact information in the file for child #7 did not include dad's work address.

Corrected Corrected by Mar 4, 2022

Category: recordkeeping. Marked corrected in the state record.

3270.124(f) · 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

The last update in writing by a parent on the agreement form in the file for child #6 was dated more than 6 months ago.

Corrected Corrected by Mar 4, 2022

Category: recordkeeping. Marked corrected in the state record.

3270.131(e)(2)(i) · Exemption from immunization for religious belief or strong personal objection equated to a religious belief shall be documented by a written, signed and dated statement from the child's parent or guardian. The statement shall be kept in the child's record.

The most recent list of immunizations in the file for child #3, a 2 year-old, was missing 1 of 4 Pneumococcal vaccines. The last flu shot in the file for child #5, a 2 year-old, and child #8, a 4 year-year old, was in 2020. The most recent list of immunizations in the file for child #6, a 5 year-old was missing the following vaccinations: 2 of 3 Hep B, 2 of 4 DTAP, 3 of 4 HIB, 3 of 4 pneumococcal, 2 of 3 polio and 1 of 2 Hep A. None of the files included a written statement of exemption by a parent.

Corrected Corrected by Mar 4, 2022

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

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

The health assessment in the file for staff person #5, #8, #9, #10 and #11 was dated after they began working with children. The health assessment in the file for staff person #12 was more dated more than 12 months before the individual began working with children. The last 2 health assessments in the file for #19 were dated more than 24 months apart.

Corrected Corrected by Mar 4, 2022

Category: ratio. Marked corrected in the state record.

3270.151(c)(2) · An adult health assessment must include tuberculosis screening by the Mantoux method at initial employment. Subsequent tuberculosis screening is not required unless directed by a physician, physician's assistant, CRNP, the Department of Health or a local health department.

The TB screening in the file for staff person #5, #8, #10 and #11was dated after they began working with children. There was no evidence of a TB screening in the file for staff person #2.

Corrected Corrected by Mar 4, 2022

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

3270.171(c) · Written notification of safe routes shall be posted by the operator at a conspicuous location in the child care facility.

There was not written notification of safe pick-up and drop-off routes posted at a conspicuous location at the facility.

Corrected Corrected by Mar 4, 2022

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 person #8 and facility person #21did not include any letters of reference. The file for staff person #14 and #15 included only 1 letter of reference.

Corrected Corrected by Mar 4, 2022

Category: recordkeeping. Marked corrected in the state record.

3270.31(h) · All staff persons shall complete the professional development under subsection (f).

There was no health and safety training in the file for staff person #24, employed more than 90 days.

Corrected Corrected by Mar 4, 2022

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 facility did not have proof of purchase of their fire detection system, which is interconnected.

Corrected Corrected by Feb 1, 2022

Category: recordkeeping. Marked corrected in the state record.