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

The staff file for Staff person #1 was observed to contain fire safety trainings that were conducted more than 12 months apart; those fire safety trainings are dated 8/31/24 and 9/5/25.

Corrected Corrected by Nov 20, 2025

Category: recordkeeping. Marked corrected in the state record.

3270.32(a)/3270.192(4) · The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL.

The file for Staff person #2 (See IS Code Sheet), who has resided out of state within the previous five years, was observed to have a Child Abuse and Neglect check from New York dated 3/3/25 and Sex Offender check from New York dated 3/12/25 both of which were obtained seven months after their start date working with children. The staff file for Staff person #3 lacked a valid disclosure statement; the disclosure statement in the file was from prior previous employment with the legal entity.

Corrected Corrected by Nov 20, 2025

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

3270.51 · TIERED LIS: 1.) 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. This portion of the plan shall have an immediate correction date. 2.) The facility will compose a specific policy for maintaining staff: child ratio, including for when staff need to leave a childcare space both with and without children. The policy should detail step-by-step actions staff need to take prior to leaving the childcare space. The policy should indicate acceptable vs. unacceptable reasons for staff leaving a childcare space. The policy will be submitted to the Regional Office for review. Once the policy is finalized, the staff handbook shall be updated. Currently employed staff will sign off that they have read and understand the policy. The facility may seek technical assistance for creation of the policy, if desired. The correction date for this part of the plan shall be within one month of acceptance of this plan of correction. 3.) Director will develop an assessment tool with which Director and/ or other YMCA Leadership staff will conduct a minimum of one weekly, unannounced check to document staff:child ratios The tool should be submitted to the Regional Office prior to use. The tool should collect names of staff, first names of children, ages of children, time and dates of the check, number of children each staff was responsible at the time of the check and the name of the person who conducted the check. The checks should be completed at different times of the program day. This tool can be combined with the tool used for supervision checks. Upon approval of the plans of correction, the completed tool will be submitted to the Regional office within 2 business days after the checks have occurred, for a period of four months. The facility may seek technical assistance from the ELRC #5 for creation of the tool, if desired. The correction date for this portion of the plan shall be at minimum four months from the date the WRO reviews the checklist.

At approximately 9:35am Staff person #1 was observed coming out of the classroom and towards another empty classroom and approximately 3 seconds later Staff person #2 was observed walking out of the classroom and down the hallway while on the phone. After seeing this certification rep., Staff person #1 alerted Staff person #2 who then turned around and walked back into the classroom. This certification rep entered the classroom and observed Staff person #2 and Staff person #3 with 22 young school age children inside the room. Staff person #1 never returned to the classroom. When Staff person #2 was observed outside the hallway, Staff person #3 was left in the room with 22 young school age children inside the room therefore staff: child ratio was 1:22 young school age children.

Corrected Corrected by May 8, 2026

Category: supervision. Marked corrected in the state record.

3270.113(a)(1) · 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.) All staff, including the director(s) will attend onsite, in-person Active Supervision training to be conducted by the ELRC #5. This training will emphasize specific supervision challenges that arise with school-age in a school building facilities. This training can be counted towards annual training requirements, as long as proper documentation is obtained. The operator shall provide a date for when this training will be completed. 3.) Director will develop an assessment tool with which Director and/ or other YMCA Leadership staff will conduct a minimum of one weekly, unannounced check to ensure that staff can name all children for who they are responsible. The tool should be submitted to the Regional Office prior to use. The tool should collect names of staff, first names of children, ages of children, time and dates of the check, number of children each staff was responsible at the time of the check and the name of the person who conducted the check. The checks should be completed at different times of the program day. This tool can be combined with the tool used for ratio checks. Upon approval of the plans of correction, the completed tool will be submitted to the Regional office within 2 business days after the checks have occurred, for a period of four months. The facility may seek technical assistance from the ELRC #5 for creation of the tool, if desired. The correction date for this portion of the plan shall be at minimum four months from the date the WRO reviews the checklist.

At approximately 9:35am Staff person #1 was observed coming out of the classroom and towards another empty classroom and approximately 3 seconds later Staff person #2 was observed walking out of the classroom and down the hallway while on the phone. After seeing this certification rep., Staff person #1 alerted Staff person #2 who then turned around and walked back into the classroom. This certification rep then entered the classroom and observed Staff person #2 and Staff person #3 with 22 young school age children inside the room. During the onset of supervision and ratio, when staff were asked to identify and name the children whom they were responsible for, Staff person #3 identified and named 12 young school age children, Staff person #2 identified and named 10 young school age children. Staff person #1 never returned to the classroom. When asked, Staff person #2 admitted that they were still the one responsible for their assigned group of children when Staff person #2 stepped out of the classroom on the phone. Therefore, it was determined that Staff person #2 was not physically present with their assigned group of children.

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 child file for Child #1 contained a current financial agreement and emergency contact form that were not reviewed and signed by the parent every 6 months; the two most recent reviews of the financial agreement and the emergency contact form were dated 9/11/25 and 2/11/25. The child file for Child #2 contained a current financial agreement and emergency contact form that were not reviewed and signed by the parent every 6 months; the two most recent reviews of the financial agreement were dated 9/6/25 and 2/18/25 and the emergency contact form dated 9/11/25 and 2/18/25.

Corrected Corrected by Dec 16, 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 annual emergency drill documentation for 2024, which has been previously viewed by the certification representative was observed to not be in the file at the of inspection. Therefore, it cannot be determined if this year's annual emergency drill dated 8/21/25 was done timely.

Corrected Corrected by Dec 16, 2025

Category: recordkeeping. 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 9:30am Staff person #1 was observed walking down the hallway, away from the classroom, and Staff person #2 was observed in the hallway at that same time assisting one child at their locker. After seeing this certification rep., Staff person #1 turned around to walk back towards the classroom. Staff person #1 and this certification rep entered the classroom together and observed Staff person #3 with 21 young school age children inside the room therefore staff: child ratio was 1:21 young school age children.

Corrected Corrected by Jun 20, 2025

Category: ratio. 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 9:30am Staff person #1 and this certification rep entered the classroom together and observed Staff person #3 with 21 young school age inside the room. Staff person #2, and the child they were assisting out in the hallway, also returned to the room shortly thereafter. During the onset of supervision and ratio, when staff were asked to identify and name the children whom they were responsible for, Staff person #3 identified and named 11 young school age children, Staff person #2 identified and named 11 young school age children, and Staff person #1 did not claim a supervisory group. Therefore, it was determined that Staff person #2 was not physically present with all of the children in their assigned group during the time Staff person #2 was in the hallway assisting another child at their locker.

Corrected Corrected by Jun 20, 2025

Category: supervision. Marked corrected in the state record.

3270.133(6) · A parent shall provide written consent for administration of medication or a special diet.

Child #1 lacked signed parental consent for administration of an Auvi-Q EpiPen.

Corrected Corrected by Jun 20, 2025

Category: ratio. Marked corrected in the state record.

3270.94(a)(9) · The Director or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that a written record is maintained on file at the facility indicating the specific time of day of the drill, the hypothetical location of the fire, the evacuation time, and the names of the facility persons and the number of children who participate in the fire drill.

Upon arrival at the facility, and throughout the duration of the unannounced inspection, none of the staff present at the facility were able to produce or obtain the fire drill log.

Corrected Corrected by Jun 20, 2025

Category: ratio. Marked corrected in the state record.

3270.20(a)(1) · The operator shall immediately notify a child's parent and shall telephone notice to the appropriate regional office within 24 hours if a child in care at the facility is hospitalized or receives emergency room treatment.

During an incident investigation conducted on 3/28/25 it was determined that on 3/4/25 Child #1 received a laceration while outside on the playground, was taken to the emergency room for treatment, and the facility did not notify the western region office of the incident within 24 hours.

Corrected Corrected by Apr 15, 2025

Category: ratio. Marked corrected in the state record.

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

The child file for Child #1 was observed to contain a current financial agreement form that lacked the departure time.

Corrected Corrected by Dec 16, 2024

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.

In the Cafeteria, one trash receptacle specifically used by the school age program to discard trash that has been contaminated by human secretions was observed to not have a lid.

Corrected Corrected by Dec 12, 2024

Category: ratio. 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 staff file for Staff person #3 lacked emergency plan training within 90 days of hire.

Corrected Corrected by Dec 11, 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.

Staff person #1 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Pediatric First Aid/CPR and Health and Safety Training. Staff person #1 has since completed pediatric first aid/CPR training on 11/30/23 and Health and Safety training on 8/24/24. Staff person #4 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Pediatric First Aid/CPR. Staff person #4 has completed the training on 11/30/23.

Corrected Corrected by Dec 12, 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.

The staff file for Staff person #5 was observed to not have a completed National Sex Offender Registry (NSOR) on file until 10/3/24 (SEE IS CODE SHEET). The staff file for Staff person #6 was observed to not have a completed National Sex Offender Registry (NSOR) on file until 10/1/24 (SEE IS CODE SHEET).

Corrected Corrected by Dec 12, 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 staff file for Staff person #1 contained current staff evaluation dated 8/15/24 which was not completed at least one every 12 months from the previous staff evaluation on file dated 5/18/23. The staff file for Staff person #2 contained current staff evaluation dated 6/14/24 which was not completed at least one every 12 months from the previous staff evaluation on file dated 5/24/23.

Corrected Corrected by Dec 12, 2024

Category: recordkeeping. Marked corrected in the state record.

3270.37(b)(1)/3270.192(2)(ii) · An aide shall have a high school diploma or a general educational development certificate. A facility person's record shall include verification of child care experience, education and training prior to service at the facility.

The staff file for Staff person #6, who is functioning as an Aide, lacked proof of a high school diploma.

Corrected Corrected by Dec 12, 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 child file for Child #1 through Child #4, who have been in attendance for more than 60 days, was observed to lack an initial health report.

Corrected Corrected by Dec 16, 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.

In the cafeteria, at approximately 7:45am, 1 staff and 13 young school age children were observed. During the assessment of supervision and ratio Staff person #1 identified and named responsibility for 13 young school age children resulting in the staff:child ratio being 1:13.

Corrected Corrected by Dec 19, 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.

In the cafeteria, at approximately 7:45am, 1 staff and 13 young school age children were observed. During the assessment of supervision and ratio Staff person #1 identified and named responsibility for 13 young school age children. Staff person #2 and Staff person #3 were observed returning to the cafeteria and were asked to identify and name the children whom they were responsible for. Staff person #2 identified and named responsibility for 5 young school age children, Staff person #3 was not responsible for any children, and Staff person #1 identified and named responsibility for 7 children thus leaving 1 unaccounted for. When staff were asked again to identify and name the children they were responsible the same 1 child was unaccounted for. On the third attempt all children were identified and accounted for.

Corrected Corrected by Dec 19, 2023

Category: supervision. Marked corrected in the state record.

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

The staff file for Staff person #1 contained current staff evaluation dated 5/15/23 which was not completed at least one every 12 months from the previous staff evaluation on file dated 4/21/22.

Corrected Corrected by Dec 18, 2023

Category: recordkeeping. Marked corrected in the state record.

3270.131(c) · A health report must be written and signed by a physician, physician's assistant or a CRNP. The signature must include the individual's professional title.

The child file for Child #1 contained an initial health report dated 11/11/22 that lacked the physician's signature.

Corrected Corrected by Dec 14, 2022

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.

The staff file for Staff person #2 lacked emergency plan training at time of hire (See IS CODE SHEET); Staff person #2 received emergency plan training on 8/22/22.

Corrected Corrected by Dec 5, 2022

Category: recordkeeping. Marked corrected in the state record.

3270.31(b) · A staff person shall be 18 years of age or older.

The staff file for Staff person #2, who was hired on 4/30/22 as an aide and has a date of birth of 9/2/2004, was not 18 years of age at time of hire.

Corrected Corrected by Sep 2, 2022

Category: recordkeeping. 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 staff file for Staff person #3 contained current first-aid/CPR training dated 10/13/22 which was not renewed on or before the expiration of the previous training certificate on file dated 8/26/20.

Corrected Corrected by Oct 13, 2022

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 #4 and Staff person #5 had not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Pediatric First Aid/CPR; Staff person #4 and Staff person #5 did not obtain Pediatric First Aid/CPR by 6/17/21 as required for all staff hired prior to 12/19/20.

Corrected Corrected by Oct 22, 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 staff person #2 was observed not to contain documentation of application for a National Sex Offender Registry (NSOR) prior to date of hire (See IS CODE SHEET) required under the Child Protective Service Law (CPSL).

Corrected Corrected by Sep 2, 2022

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

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

The child file for Child #2, and Child #4 [See IS CODE SHEET] lacked a copy of their immunization record.

Corrected Corrected by Nov 18, 2022

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 child file for Child #1 contained a financial agreement and an emergency contact information form that were not reviewed and updated by the parent at least once in a 6-month period; the dates of the most recent updates were 3/9/22 for the financial agreement and 3/21/22 for the emergency contact information form. The child file for Child #2 contained a financial agreement and an emergency contact information form that were not reviewed and updated by the parent with in a 6-month period; the dates of the most two most recent reviews for the financial agreement and the emergency contact information form were 3/23/22 and 10/4/22. The child file for Child #3 contained a financial agreement and an emergency contact information form that were not reviewed and updated by the parent at least once in a 6-month period; the dates of the most recent updates were for the financial agreement and the emergency contact information form was 2/22/22. The child file for Child #4 contained a financial agreement and an emergency contact information form that were not reviewed and updated by the parent with in a 6-month period; the dates of the most two most recent reviews for the financial agreement and the emergency contact information form were 2/23/22 and 10/4/22.

Corrected Corrected by Nov 18, 2022

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 child file for Child #2, Child #3, and Child #4 [See IS CODE SHEET] lacked an initial health report.

Corrected Corrected by Nov 18, 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. Staff Person #1 may not work in a child care position at the facility.

The file for staff person #1, with a start date of 10-25-21, had an FBI clearance dated 5-18-18 that indicated a record and lacked the corresponding rap sheet.

Corrected Corrected by Dec 8, 2021

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

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

The files for child #1 and #2 had an agreement that lacked the child's admission date.

Corrected Corrected by Nov 19, 2021

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 file for child #2 had an emergency contact form that lacked the health insurance policy number.

Corrected Corrected by Nov 19, 2021

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