Joy Garden Creative Center

Regulation: 3270.111(b)

Description: Posted in group space

Noncompliance Area: A renewal inspection was conducted on 9/11/2025. At that time, daily activities were not posted in the office (room 3), which is measured child care space.

Correction Required: The written plan of daily activities shall be posted in the group space.

Regulation: 3270.124(b)(3)

Description: Parent home/work address, phone

Noncompliance Area: A renewal inspection was conducted on 9/11/2025. At that time, a sample of children's files were reviewed. The following information was missing from emergency contact forms: Child #2: Both parents' work addresses and work telephone numbers. Child #3: Both parents' work addresses and work telephone numbers. Child #4: Both parents' work telephone numbers.

Correction Required: Emergency contact information must include the home and work addresses and telephone numbers of the enrolling parent.

Regulation: 3270.124(c)

Description: Each child care space

Noncompliance Area: A renewal inspection was conducted on 9/11/2025. At that time, emergency contact form for child #3 was not present in the Sunflower Room, where child was receiving care.

Correction Required: When children are in the facility, emergency contact information shall be present in a child care space for children receiving care in the space.

Regulation: 3270.131(d)(7)

Description: Free from contagious/communicable disease

Noncompliance Area: A renewal inspection was conducted on 9/11/2025. At that time, a sample of children's files were reviewed. Health assessment dated 7/2/2025 on file for child #1 does not include a statement that the child is able to participate in child care and appears to be free from contagious or communicable disease.

Correction Required: 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.

Regulation: 3270.151(a)/3270.151(c)(2)

Description: 12 months prior to service and every 24 months thereafter/Mantoux TB

Noncompliance Area: A renewal inspection was conducted on 9/11/2025. At that time, staff files were reviewed. Initial health assessment and TB testing on file for staff person #4 are dated 4/29/2025, which is after their start date (see LIS code sheet for start date).

Correction Required: 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. 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.

Regulation: 3270.171(c)

Description: Safe routes posted

Noncompliance Area: A renewal inspection was conducted on 9/11/2025. During that time, pick-up and drop-off procedures were not posted in a conspicuous location in the child care facility.

Correction Required: Written notification of safe routes shall be posted by the operator at a conspicuous location in the child care facility.

Regulation: 3270.192(5)

Description: Two written references

Noncompliance Area: A renewal inspection was conducted on 9/11/2025. At that time, staff files were reviewed. Staff person #1's file contained a reference written by their sister.

Correction Required: 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.

Regulation: 3270.27(a)(5)

Description: Emergency plan

Noncompliance Area: A renewal inspection was conducted on 9/11/2025. At that time, the facility's letter explaining the emergency plan did not include accommodations for infants, toddlers, children with disabilities, or children with chronic medical conditions.

Correction Required: The facility shall have an emergency plan that provides for accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions.

Regulation: 3270.27(a)(6)

Description: Emergency plan

Noncompliance Area: A renewal inspection was conducted on 9/11/2025. During that time, last emergency drill log on file at the facility was dated 9/7/2023.

Correction Required: Emergency drills shall be conducted annually. Annual emergency drills shall be documented and on file at the facility.

Regulation: 3270.31(f)(10)

Description: Health and Safety Training - Pediatric First Aid and CPR

Noncompliance Area: A renewal inspection was conducted on 9/11/2025. At that time, staff files were reviewed. Certificate for pediatric first-aid/CPR training on file for staff person #4 is dated 8/12/2025, which is more than 90 days after hire date (see LIS code sheet for hire date).

Correction Required: Staff persons shall complete professional development in the topic of pediatric first aid and pediatric cardiopulmonary resuscitation within 90 days of hire.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: A renewal inspection was conducted on 9/11/2025. At that time, staff files were reviewed. Staff person #3's file had NSOR clearance dated 4/30/2025 which was after their start date. Staff person #4's file had NSOR clearance dated 3/5/2025 which was after their start date. Staff person #4 also had a DHS FBI clearance on file dated 3/12/2025. There was no copy of request on file stating when fingerprints were completed for DHS FBI clearance (see LIS code sheet for start dates).

Correction Required: 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.

Regulation: 3270.35(b)

Description: Group sup qualifications

Noncompliance Area: A renewal inspection was conducted on 9/11/2025. At that time, staff files were reviewed. Staff person #1 and staff person #2 were listed as Group Supervisors. A review of their qualifications determined that they qualify as Assistant Group Supervisors.

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

Regulation: 3270.65

Description: Protective Outlet Covers 5 yrs. or less

Noncompliance Area: A renewal inspection was conducted on 9/11/2025. At that time, an uncovered outlet was observed in the Lily Room near the refrigerator. Outlet was accessible to preschool-aged children.

Correction Required: Protective receptacle covers shall be placed in electrical outlets accessible to children 5 years of age or younger.

Regulation: 3270.66(a)

Description: Locked or inaccessible

Noncompliance Area: A renewal inspection was conducted on 9/11/2025. At that time, several cleaning materials labeled "keep out of reach of children" were observed in a closet off of Room 4. Closet door was open and had a plastic gate propped against the doorframe. The gate was not secured and could easily be moved. Additionally, Mr. Clean floor cleaner and Goo Gone, both labeled "keep out of reach of children" were observed in the cabinet under the sink in the Lily Room. The cabinet was not locked and therefore accessible to children.

Correction Required: Cleaning materials and other toxic materials shall be kept in an area or container that is locked or made inaccessible to children.

Regulation: 3270.17(a)

Description: Accommodate a child with special needs

Noncompliance Area: During a complaint investigation it was discovered that therapists were not being allowed into facility to work with children.

Correction Required: The operator shall make reasonable accommodation to include a child with special needs in accordance with applicable Federal and State laws.

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: During unannounced monitoring conducted on 11/19/2024, Staff person #2 and staff person #3 were observed to be caring for children unsupervised. Staff person #2 has not completed the following pre-service training required prior to caring for children unsupervised: CCDBG Health and Safety training. Staff person #3 has not completed the following pre-service training required prior to caring for children unsupervised: CCDBG Health and Safety training or mandated reporter training. An acceptable plan of correction was received with a correction date of 11/20/2024. When certification representative returned for unannounced monitoring on 1/7/2025, Staff person #1, staff person #4, and staff person #5 were observed to be caring for children unsupervised. Staff person #1, staff person #4, and staff person #5 have not completed the following pre-service training required prior to caring for children unsupervised: Pediatric first-aid/CPR from PQAS instructor.

Correction Required: 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. Until such time as the required pre-service trainings are completed, staff person #1, staff person #4, and staff person #5 must be supervised, when interacting with children, by an AGS who has completed the required training related to this citation. If there are no staff person(s) available to supervise staff person #1, staff person #4, and staff person #5, staff person #1, staff person #4, and staff person #5 may not work in a child-care position at the facility.

Regulation: 3270.113(a)/3270.113(a)(1)

Description: Supervised at all times /Staff assigned to specific children

Noncompliance Area: During renewal inspection conducted 10/3/2024, staff person #1 and staff person #2 were in the Sunflower Room during naptime. Both staff persons stated that there were 14 children total in the room, ranging from young to older toddler. Staff person #1 and staff person #2 each identified 5 children as being assigned to their individual groups, totaling 10 children. When asked about this, staff stated that the other staff member in the room assigned to the remaining 4 children is on break. Rep advised that all children must be accounted for. Staff understood and each took 2 additional children. Staff person #1 and staff person #2 were able to correctly identify all children in the room and each had a total of 7 children in their individual groups prior to rep departing room. An acceptable plan of correction was received with a correction date of 10/3/2024. When certification representative returned for unannounced monitoring on 11/19/2024, there were 13 children total in the Sunflower Room, ranging from young to older toddler. Staff person #2 identified 3 young toddlers as being in their group and staff person #3 first identified 3 young toddlers in their group. Staff person #3 was reminded that they were assigned an additional child and then identified that child as being in their group. Staff person #4 identified 6 older toddlers as being in their group. Prior to visiting the Sunflower Room, certification representative was verifying corrections from previous inspection summary and staff person #4 was accompanying certification representative throughout the facility without their assigned group, leaving staff person #2 and staff person #3 to supervise the 13 children. An acceptable plan of correction was received with a correction date of 11/19/2024. When certification representative returned to facility on 12/10/2024 for a complaint investigation, it was verified that on 12/5/2024, a representative from an outside agency observed the Lily Room to have 13 preschool-aged children and one staff member. Staff person #4 was informed that she needed to be in the Lily Room until another staff person arrived. Staff person #4 was observed to leave the classroom for 2 minutes and the other staff member leave the classrooms for 2 to 3 minutes. The legal entity is in the process of arranging for all staff to receive a minimum of three (3) hours of training regarding Supervision/Ratios. The training will be PQAS approved, in-person, and outside of childcare hours.

Correction Required: Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Outdoor play space used by the facility is considered part of the facility premises. Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises.

Regulation: 3270.51/3270.52

Description: Similar Age Level/Mixed Age Level

Noncompliance Area: During unannounced monitoring conducted 11/19/2024, staff person #6 was alone in the Lily Room with 12 preschool-aged children. Additionally, there were 13 children total in the Sunflower Room, ranging from young to older toddler. Staff person #2 identified 3 young toddlers as being in their group and staff person #3 first identified 3 young toddlers in their group. Staff person #3 was reminded that they were assigned an additional child and then identified that child as being in their group. Staff person #4 identified 6 older toddlers as being in their group. Prior to visiting the Sunflower Room, certification representative was verifying corrections from previous inspection summary and staff person #4 was accompanying certification representative throughout the facility without their assigned group, leaving staff person #2 and staff person #3 to supervise the 13 children. An acceptable plan of correction was received with a correction date of 11/19/2024. When certification representative returned to facility on 12/10/2024 for a complaint investigation, it was verified that on 12/5/2024, a representative from an outside agency observed the Lily Room to have 13 preschool-aged children and one staff member. Staff person #4 was informed that she needed to be in the Lily Room until another staff person arrived. Staff person #4 was observed to leave the classroom for 2 minutes and the other staff member leave the classrooms for 2 to 3 minutes.

Correction Required: When children are grouped in similar age levels, the following maximum child group sizes and ratios of staff persons apply: Infants 1:4 with a maximum group size of 8; Young toddlers 1:5 with a maximum group size of 10; Older toddlers 1:6 with a maximum group size of 12; Preschool children 1:10 with a maximum group size of 20; Young school-age children 1:12 with a maximum group size of 24; Older school-age children 1:15 with a maximum group size of 30. When children are grouped in mixed age levels, the age of the youngest child in the group determines the staff:child ratio and maximum group size in accordance with the requirements in § 3270.51 (relating to similar age level).

Regulation: 3270.51/3270.52

Description: Similar Age Level/Mixed Age Level

Noncompliance Area: During unannounced monitoring conducted 11/19/2024, staff person #6 was alone in the Lily Room with 12 preschool-aged children. Additionally, there were 13 children total in the Sunflower Room, ranging from young to older toddler. Staff person #2 identified 3 young toddlers as being in their group and staff person #3 first identified 3 young toddlers in their group. Staff person #3 was reminded that they were assigned an additional child and then identified that child as being in their group. Staff person #4 identified 6 older toddlers as being in their group. Prior to visiting the Sunflower Room, certification representative was verifying corrections from previous inspection summary and staff person #4 was accompanying certification representative throughout the facility without their assigned group, leaving staff person #2 and staff person #3 to supervise the 13 children. An acceptable plan of correction was received with a correction date of 11/19/2024. When certification representative returned to facility on 12/10/2024 for a complaint investigation, it was verified that on 12/5/2024, a representative from an outside agency observed the Lily Room to have 13 preschool-aged children and one staff member. Staff person #4 was informed that she needed to be in the Lily Room until another staff person arrived. Staff person #4 was observed to leave the classroom for 2 minutes and the other staff member leave the classrooms for 2 to 3 minutes.

Correction Required: When children are grouped in similar age levels, the following maximum child group sizes and ratios of staff persons apply: Infants 1:4 with a maximum group size of 8; Young toddlers 1:5 with a maximum group size of 10; Older toddlers 1:6 with a maximum group size of 12; Preschool children 1:10 with a maximum group size of 20; Young school-age children 1:12 with a maximum group size of 24; Older school-age children 1:15 with a maximum group size of 30. When children are grouped in mixed age levels, the age of the youngest child in the group determines the staff:child ratio and maximum group size in accordance with the requirements in § 3270.51 (relating to similar age level). The Legal Entity/Director must post similar, mixed age, and napping ratios in each room of the facility. Ratios should be reviewed with staff members.

Regulation: 3270.113(a)/3270.113(a)(1)

Description: Supervised at all times /Staff assigned to specific children

Noncompliance Area: During renewal inspection conducted 10/3/2024, staff person #1 and staff person #2 were in the Sunflower Room during naptime. Both staff persons stated that there were 14 children total in the room, ranging from young to older toddler. Staff person #1 and staff person #2 each identified 5 children as being assigned to their individual groups, totaling 10 children. When asked about this, staff stated that the other staff member in the room assigned to the remaining 4 children is on break. Rep advised that all children must be accounted for. Staff understood and each took 2 additional children. Staff person #1 and staff person #2 were able to correctly identify all children in the room and each had a total of 7 children in their individual groups prior to rep departing room. An acceptable plan of correction was received with a correction date of 10/3/2024. When certification representative returned for unannounced monitoring on 11/19/2024, there were 13 children total in the Sunflower Room, ranging from young to older toddler. Staff person #2 identified 3 young toddlers as being in their group and staff person #3 first identified 3 young toddlers in their group. Staff person #3 was reminded that they were assigned an additional child and then identified that child as being in their group. Staff person #4 identified 6 older toddlers as being in their group. Prior to visiting the Sunflower Room, certification representative was verifying corrections from previous inspection summary and staff person #4 was accompanying certification representative throughout the facility without their assigned group, leaving staff person #2 and staff person #3 to supervise the 13 children.

Correction Required: Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Outdoor play space used by the facility is considered part of the facility premises. Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises.

Regulation: 3270.113(a)/3270.113(a)(1)

Description: Supervised at all times /Staff assigned to specific children

Noncompliance Area: During renewal inspection conducted 10/3/2024, staff person #1 and staff person #2 were in the Sunflower Room during naptime. Both staff persons stated that there were 14 children total in the room, ranging from young to older toddler. Staff person #1 and staff person #2 each identified 5 children as being assigned to their individual groups, totaling 10 children. When asked about this, staff stated that the other staff member in the room assigned to the remaining 4 children is on break. Rep advised that all children must be accounted for. Staff understood and each took 2 additional children. Staff person #1 and staff person #2 were able to correctly identify all children in the room and each had a total of 7 children in their individual groups prior to rep departing room. An acceptable plan of correction was received with a correction date of 10/3/2024. When certification representative returned for unannounced monitoring on 11/19/2024, there were 13 children total in the Sunflower Room, ranging from young to older toddler. Staff person #2 identified 3 young toddlers as being in their group and staff person #3 first identified 3 young toddlers in their group. Staff person #3 was reminded that they were assigned an additional child and then identified that child as being in their group. Staff person #4 identified 6 older toddlers as being in their group. Prior to visiting the Sunflower Room, certification representative was verifying corrections from previous inspection summary and staff person #4 was accompanying certification representative throughout the facility without their assigned group, leaving staff person #2 and staff person #3 to supervise the 13 children.

Correction Required: Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Outdoor play space used by the facility is considered part of the facility premises. Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises. The legal entity must arrange for all staff to receive a minimum of three (3) hours of training regarding Supervision/Ratios. The training must be PQAS approved, in-person, and outside of childcare hours. The legal entity must receive DHS approval of the training content prior to scheduling the training.

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: During unannounced monitoring conducted on 11/19/2024, Staff person #2 and staff person #3 were observed to be caring for children unsupervised. Staff person #2 has not completed the following pre-service training required prior to caring for children unsupervised: CCDBG Health and Safety training. Staff person #3 has not completed the following pre-service training required prior to caring for children unsupervised: CCDBG Health and Safety training or mandated reporter training.

Correction Required: 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. Until such time as the required pre-service trainings are completed, staff person #2 and staff person #3 must be supervised, when interacting with children, by an AGS who has completed the required training related to this citation. If there are no staff person(s) available to supervise staff person #2 and staff person #3, staff person #2 and staff person #3 may not work in a child-care position at the facility.

Regulation: 3270.151(a)/3270.151(c)(2)

Description: 12 months prior to service and every 24 months thereafter/Mantoux TB

Noncompliance Area: During renewal inspection conducted on 10/3/2024, there was no initial health assessment or TB test results on file for staff person #2 or staff person #5. An acceptable plan of correction was received with a correction date of 10/16/2024. When certification representative returned for unannounced monitoring on 11/19/2024, there was no initial health assessment or TB test results on file for staff person #3.

Correction Required: 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. 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.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: During unannounced monitoring conducted 11/19/2024, disclosure statements on file for staff person #3 and staff person #6 were not dated.

Correction Required: 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 #3 and staff person #6 may not work in a child care position at the facility until disclosure statements on file are dated.

Regulation: 3270.51/3270.52

Description: Similar Age Level/Mixed Age Level

Noncompliance Area: During unannounced monitoring conducted 11/19/2024, staff person #6 was alone in the Lily Room with 12 preschool-aged children. Additionally, there were 13 children total in the Sunflower Room, ranging from young to older toddler. Staff person #2 identified 3 young toddlers as being in their group and staff person #3 first identified 3 young toddlers in their group. Staff person #3 was reminded that they were assigned an additional child and then identified that child as being in their group. Staff person #4 identified 6 older toddlers as being in their group. Prior to visiting the Sunflower Room, certification representative was verifying corrections from previous inspection summary and staff person #4 was accompanying certification representative throughout the facility without their assigned group, leaving staff person #2 and staff person #3 to supervise the 13 children.

Correction Required: When children are grouped in similar age levels, the following maximum child group sizes and ratios of staff persons apply: Infants 1:4 with a maximum group size of 8; Young toddlers 1:5 with a maximum group size of 10; Older toddlers 1:6 with a maximum group size of 12; Preschool children 1:10 with a maximum group size of 20; Young school-age children 1:12 with a maximum group size of 24; Older school-age children 1:15 with a maximum group size of 30. When children are grouped in mixed age levels, the age of the youngest child in the group determines the staff:child ratio and maximum group size in accordance with the requirements in § 3270.51 (relating to similar age level).

Regulation: 3270.75(c)

Description: Has all items

Noncompliance Area: During unannounced monitoring conducted 11/19/2024, first-aid kit in Room 4 (entryway) did not contain scissors or soap.

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

Regulation: 3270.113(a)/3270.113(a)(1)

Description: Supervised at all times /Staff assigned to specific children

Noncompliance Area: During renewal inspection conducted 10/3/2024, staff person #1 and staff person #2 were in the Sunflower Room during naptime. Both staff persons stated that there were 14 children total in the room, ranging from young to older toddler. Staff person #1 and staff person #2 each identified 5 children as being assigned to their individual groups, totaling 10 children. When asked about this, staff stated that the other staff member in the room assigned to the remaining 4 children is on break. Rep advised that all children must be accounted for. Staff understood and each took 2 additional children. Staff person #1 and staff person #2 were able to correctly identify all children in the room and each had a total of 7 children in their individual groups prior to rep departing room.

Correction Required: Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Outdoor play space used by the facility is considered part of the facility premises. Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises.

Regulation: 3270.113(a)/3270.113(a)(1)

Description: Supervised at all times /Staff assigned to specific children

Noncompliance Area: During renewal inspection conducted 10/3/2024, staff person #1 and staff person #2 were in the Sunflower Room during naptime. Both staff persons stated that there were 14 children total in the room, ranging from young to older toddler. Staff person #1 and staff person #2 each identified 5 children as being assigned to their individual groups, totaling 10 children. When asked about this, staff stated that the other staff member in the room assigned to the remaining 4 children is on break. Rep advised that all children must be accounted for. Staff understood and each took 2 additional children. Staff person #1 and staff person #2 were able to correctly identify all children in the room and each had a total of 7 children in their individual groups prior to rep departing room.

Correction Required: Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Outdoor play space used by the facility is considered part of the facility premises. Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises. The legal entity must create a policy in order to maintain proper supervision. This policy will ensure that all children are properly assigned to a staff person and supervised at all times. This policy must address supervision during transition times, such as visiting the bathroom, supervision on the playground, and naptime when staff members may be on break. The legal entity must receive approval of the policy from the Regional Office. Once approved by the Regional Office, the legal entity must review policy with all staff and have staff sign off that the understand and will follow the supervision policy.

Regulation: 3270.123(a)(3)/3270.123(a)(5)

Description: Services proceeded/Designated release persons

Noncompliance Area: During renewal inspection conducted 10/3/2024, the following information was missing from children's files: Child #1: Release person(s) on fee agreement. Last child service report (CSR) on file is dated 2/8/2024, which is past 6 months. Child #2: Last child service report (CSR) on file is dated 1/16/2024, which is past 6 months. Child #3: Last child service report (CSR) on file is dated 1/31/2024, which is past 6 months. Child #4: Last child service report (CSR) on file is dated 1/29/2024, which is past 6 months..

Correction Required: 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). An agreement shall specify the persons designated by a parent to whom the child may be released.

Regulation: 3270.124(b)(3)/3270.124(b)(7)

Description: Parent home/work address, phone/Name/address/phone release person

Noncompliance Area: During renewal inspection conducted 10/3/2024, the following information was missing from children's emergency contact forms: Child #2: father's address, who is also listed as a release person. Child #5: release person's address and phone number.

Correction Required: Emergency contact information must include the home and work addresses and telephone numbers of the enrolling parent. 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.

Regulation: 3270.131(b)(2)

Description: Toddler/preschool: updated health report every 12 months

Noncompliance Area: During renewal inspection conducted 10/3/2024, last health assessment on file for child #3 is dated 9/19/2023, which is past 12 months.

Correction Required: The operator shall require the parent to provide an updated health report at least every 12 months for an older toddler or preschool child.

Regulation: 3270.131(d)(5)/3270.131(e)(3)

Description: Immunization record/Dismissal policy

Noncompliance Area: During renewal inspection conducted 10/3/2024, immunization summary on file for child #5 does not indicate that child is immunized according to the recommendations. Child #5 has received 3 of 4 doses of DTAP vaccine and 1 of 2 doses of Hep A vaccine. Child #5 is a young toddler (see LIS code sheet). There is no exemption on file.

Correction Required: A health report shall include a review of the child's immunized status according to recommendations of the ACIP. The facility shall implement dismissal policies in accordance with the Department of Health regulation in 28 Pa. Code § 27.77 (relating to immunization requirements for children in child care group settings). Child #5 must be dismissed from care by close of business 10/3/2024 and may only return to care when the immunization record is updated or when a parent provides a written, signed exemption letter.

Regulation: 3270.151(a)/3270.151(c)(2)

Description: 12 months prior to service and every 24 months thereafter/Mantoux TB

Noncompliance Area: During renewal inspection conducted on 10/3/2024, there was no initial health assessment or TB test results on file for staff person #2 or staff person #5.

Correction Required: 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. 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.

Regulation: 3270.182(3)/3270.182(5)

Description: Consent for emergency medical care required prior to admission/Consent for administration of minor first-aid required prior to admission

Noncompliance Area: During renewal inspection conducted 10/3/2024, emergency contact form for child #1 does not contain signed parental consents for minor first-aid or emergency medical care.

Correction Required: A child's record shall contain signed parental consent for emergency medical care for the child. Written consent is required prior to admission. 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.

Regulation: 3270.192(2)(ii)

Description: Exp, educ., training prior to facility

Noncompliance Area: During renewal inspection conducted 10/3/2024, there was no verification of education on file for staff person #2.

Correction Required: A facility person's record shall include verification of child care experience, education and training prior to service at the facility.

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: During renewal inspection conducted 10/3/2024, staff person #3 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 from PQAS instructor.

Correction Required: Staff person(s) shall complete professional development in the topics of 3270.31(f)(1 -- 10) within 90 days of hire. Staff person #3 will have until October 19, 2024 to complete the required training. Until such time as the required training has been completed, staff person #3 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 #3, staff person #3 may not work in a child-care position at the facility.

Regulation: 3270.36(b)(5)

Description: HS/GED + 2 yrs

Noncompliance Area: During renewal inspection conducted 10/3/2024, staff person #3 and staff person #5 are both listed as AGS on staff data sheet, which was completed by director. File for staff person #3 contains proof of completing 11th grade and 3.5 years of childcare experience, which qualifies them as an Aide. File for staff person #5 contains a HS diploma and proof of 8 months childcare experience, qualifying them as an Aide.

Correction Required: An assistant group supervisor shall have a high school diploma or a general educational development certificate and 2 years experience with children.

Regulation: 3270.75(a)

Description: In child care spaces

Noncompliance Area: During renewal inspection conducted 10/3/2024, there was no first-aid kit in Room 4 (entryway) which is measured childcare space.

Correction Required: A first-aid kit shall be in a child care space.

Regulation: 3270.95(a)/3270.95(b)

Description: Devices must be compliant/Director or designated staff person ensure compliance

Noncompliance Area: During renewal inspection conducted 10/3/2024, fire detection testing log indicated that smoke alarms were tested past 30 days on the following occasions: 12/8/2023-1/8/2024 and 3/4/2024-4/4/2024.

Correction Required: 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.

Regulation: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: It was observed that a rest mat used by a child in the toddler room was ripped and not in good repair.

Correction Required: 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.

Regulation: 3270.111(b)

Description: Posted in group space

Noncompliance Area: It was observed that although the preschool room had a schedule posted, that posted schedule did not include the plan of daily activities for the entire day. It was stated that the room opened at 6:30am, but the posted schedule of activities did not start until 8am.

Correction Required: The written plan of daily activities shall be posted in the group space.

Regulation: 3270.123(a)(5)/3270.124(a)

Description: Designated release persons/Each child emergency contact person

Noncompliance Area: File for child #2 did not contain a completed emergency contact form or any of the required emergency contact information. Agreement for child #2 did not specify designated release persons; this section was left blank.

Correction Required: An agreement shall specify the persons designated by a parent to whom the child may be released. Emergency contact information is required for each enrolled child. Emergency contact information must reference who shall be contacted in an emergency.

Regulation: 3270.124(b)(2)/3270.124(b)(3)

Description: Physician name, address, phone/Parent home/work address, phone

Noncompliance Area: Emergency contact form for child #4 did not contain the address of the child's physician or source of medical care, and did not contain the work address or work telephone number of the enrolling parent.

Correction Required: Emergency contact information must include the name, address and telephone number of the child's physician or source of medical care. Emergency contact information must include the home and work addresses and telephone numbers of the enrolling parent.

Regulation: 3270.124(b)(6)

Description: Insurance coverage information

Noncompliance Area: Emergency contact form for child #3 did not contain the child's health insurance coverage name or policy number.

Correction Required: Emergency contact information must include health insurance coverage and policy number for a child under a family policy or Medical Assistance benefits, if applicable.

Regulation: 3270.124(b)(7)

Description: Name/address/phone release person

Noncompliance Area: Emergency contact forms for child #3 and #4 did not contain the release person's address.

Correction Required: 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.

Regulation: 3270.124(c)

Description: Each child care space

Noncompliance Area: It was observed that the emergency contact forms for children in the toddler and preschool rooms were not present for those children receiving care in those spaces.

Correction Required: When children are in the facility, emergency contact information shall be present in a child care space for children receiving care in the space.

Regulation: 3270.131(d)(5)/3270.131(e)(3)

Description: Immunization record/Dismissal policy

Noncompliance Area: File for child #1 did not contain documentation regarding the status of all immunizations recommended by the ACIP; child #1 did not have any documentation regarding the influenza vaccine.

Correction Required: A health report shall include a review of the child's immunized status according to recommendations of the ACIP. The facility shall implement dismissal policies in accordance with the Department of Health regulation in 28 Pa. Code § 27.77 (relating to immunization requirements for children in child care group settings).

Regulation: 3270.166(6)

Description: Infant/toddler - no bottle in mouth to sleep

Noncompliance Area: It was observed during rest time that a toddler had fallen asleep with a bottle.

Correction Required: Neither an infant nor a toddler is permitted to sleep with a bottle in his mouth.

Regulation: 3270.27(e)

Description: Letter to parents

Noncompliance Area: It was observed that the facility did not provide to parents a letter explaining all of the facility's emergency plan procedures. The letter provided to the families did not include information regarding the facility's lockdown procedures or accommodations for toddlers, those with special needs or chronic medical conditions.

Correction Required: 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.

Regulation: 3270.27(f)

Description: Emergency plan

Noncompliance Area: It was observed that the facility did not have on file documentation to verify that the facility's emergency plan was sent to both the local municipality and to the county emergency management agency.

Correction Required: The operator shall send a copy of the emergency plan and subsequent plan updates to the local municipality and to the county emergency management agency.

Regulation: 3270.31(b)/3270.33(a)

Description: Staff person - 18 yrs./Each staff person meets quals

Noncompliance Area: Files for staff person #1 and #2, both employed as aides, verified that neither of these staff persons are 18 years of age or older and neither had on file documentation to meet one of the applicable qualifications to be employed as an aide.

Correction Required: A staff person shall be 18 years of age or older. 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.

Regulation: 3270.61(h)(2)(i)/3270.61(h)(2)(ii)

Description: No more than two 1/2 hour time periods daily/Designated on facility schedule

Noncompliance Area: It was stated during inspection by facility staff that up to 12 preschoolers and 13 school agers could be present in the preschool classroom after school between 3:45p-4:15p on certain days, and the preschool classroom is only measured for a total capacity of 17 children. In addition, the classroom schedule does not show the room being over capacity at any point of the day, and there is nothing specifying the program activity that the children are involved in during that time that the room is over capacity.

Correction Required: The capacity established for an indoor space may be exceeded for no more than two separate 1/2 hour time periods daily when older toddler, preschool or school-age children are participating in a program activity. When the number of older toddler, preschool or school-age children participating in a program activity exceeds the capacity of the child care space each time period shall be designated on the facility's schedule of daily activities.

Regulation: 3270.66(b)

Description: Original container

Noncompliance Area: It was observed that cleaning materials in both the toddler and preschool rooms were in spray bottles that were left unlabeled and did not specify the contents.

Correction Required: Cleaning materials and other toxic materials shall be stored in an original labeled container or in a container that specifies the content. Toxics shall be stored away from food, food preparation areas and child care spaces.

Regulation: 3270.74

Description: Emergency Numbers Posted

Noncompliance Area: It was observed that the facility used portable phones which were moved about the facility, and neither the toddler or preschool rooms contained posted emergency telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center.

Correction Required: The telephone number of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted by each telephone in the facility.

Regulation: 3270.95(b)

Description: Director or designated staff person ensure compliance

Noncompliance Area: It was observed on the facility's fire alarm test log that an alarm test was completed on 3/3/23 and the subsequent test was completed on 4/21/23. These dates show that the testing of the alarms was not completed and logged every 30 days as required.

Correction Required: The Director or designated staff person who is responsible for compliance with this chapter shall ensure the requirements under subsection (a) are met.

Regulation: 3270.123(a)(6)

Description: Admission date

Noncompliance Area: Agreement for child #1 did not specify the child's admission date.

Correction Required: An agreement shall specify the date of the child's admission.

Regulation: 3270.124(c)

Description: Each child care space

Noncompliance Area: It was observed that the facility did not have emergency contact information present in the child care spaces where children were receiving care that day.

Correction Required: When children are in the facility, emergency contact information shall be present in a child care space for children receiving care in the space.

Regulation: 3270.131(a)(2)

Description: Initial health report for young toddler no more than 6 months

Noncompliance Area: Health report on file for child #1 did not contain a date.

Correction Required: The initial health report for a young toddler must be dated no more than 6 months prior to the first day of attendance at the facility.

Regulation: 3270.171(a)

Description: Pick-up and drop-off points

Noncompliance Area: It was observed and stated that the facility did not send an annual traffic letter to the local traffic authorities.

Correction Required: 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.

Regulation: 3270.27(a)(6)

Description: Emergency plan

Noncompliance Area: It was observed that written document of an annual emergency drill conducted by the facility within the last 12 months was not found on file.

Correction Required: Emergency drills shall be conducted annually. Annual emergency drills shall be documented and on file at the facility.

Regulation: 3270.31(e)

Description: Age and Training

Noncompliance Area: It was observed that staff person #1 did not have written verification on file of completing 12 clock hours of annual child care training.

Correction Required: A staff person shall obtain an annual minimum of 12 clock hours of child care training.

Regulation: 3270.31(e)(4)(ii)

Description: Fire safety - 1 yr.

Noncompliance Area: Staff person #1, see code sheet for date of hire, did not complete annual fire safety training and has been employed at the facility for more than 1 year.

Correction Required: 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.

Regulation: 3270.36(b)(5)/3270.192(2)(iv)

Description: HS/GED + 2 yrs/Transcript, diploma and letters

Noncompliance Area: File for staff person #2, who is currently employed as an assistance group supervisor, did not contain adequate or acceptable documentation verifying their education level.

Correction Required: 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 acceptable verification of experience, education or training is a transcript or a diploma or a letter signed by a representative of the experiential, educational or training entity.

Regulation: 3270.51

Description: Similar Age Level

Noncompliance Area: It was observed that staff person #2 was in room 2 with 7 toddlers. It was stated that the youngest child present in room 2 with staff person #2 at that time was a young toddler.

Correction Required: 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. The required staff:child ratios must be maintained at all times.

Regulation: 3270.76

Description: Building Surfaces

Noncompliance Area: It was observed that an extension cord was run from the right side of room 3, across the floor in front of an emergency exit, and was plugged into the wall on the left side of room 3, causing a tripping hazard.

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

Regulation: 3270.135(a)(3)

Description: Disposable diapers

Noncompliance Area: It was observed that a soiled diaper was left in a plastic grocery bag at the foot of the changing table in Room 2 instead of being immediately discarded into a plastic-lined, hands-free covered garbage can.

Correction Required: If disposable diapers are provided by a parent or by a facility, a soiled diaper shall be discarded by immediately placing the diaper into a plastic-lined, hands-free covered can.

Regulation: 3270.21/3270.76

Description: General Health and Safety/Building Surfaces

Noncompliance Area: On 7/26/22, it was observed that the facility had sustained extensive damage to the outdoor play space fence, and the front left corner of the building. It was observed that a sign was posted on the door indicating that as of 7/21/22 at 10:30am, the building code official condemned the facility writing, "Section 116(A) 116.1 Structure unfit for human habitation due to a vehicle in the structure." It was confirmed by local authorities that on 7/21/22 at approximately 9:30am a vehicle crashed through the outdoor play space and into the side of the facility causing structural damage. It was observed that no one was present in the building on 7/26/22.

Correction Required: Conditions at the facility may not pose a threat to the health or safety of the children.Floors, walls, ceilings and other surfaces, including the facility's outdoor play space surfaces shall be kept clean, in good repair and free from visible hazards. Facility must remain closed, that is without children in care, until such time as code enforcement provides, in writing, notification that the facility is structurally sound and safe for human habitation. Facility may not reopen for child care without scheduling with the NE Regional Office to have a physical site inspection completed for the purposes of reopening the childcare facility.

Regulation: 3270.21/3270.76

Description: General Health and Safety/Building Surfaces

Noncompliance Area: On 7/26/22, it was observed that the facility had sustained extensive damage to the outdoor play space fence, and the front left corner of the building. It was observed that a sign was posted on the door indicating that as of 7/21/22 at 10:30am, the building code official condemned the facility writing, "Section 116(A) 116.1 Structure unfit for human habitation due to a vehicle in the structure." It was confirmed by local authorities that on 7/21/22 at approximately 9:30am a vehicle crashed through the outdoor play space and into the side of the facility causing structural damage. It was observed that no one was present in the building on 7/26/22.

Correction Required: Conditions at the facility may not pose a threat to the health or safety of the children. Floors, walls, ceilings and other surfaces, including the facility's outdoor play space surfaces shall be kept clean, in good repair and free from visible hazards.

Regulation: 3270.62(a)/3270.63

Description: Large muscle space provided/Unsafe Areas in Outdoor Space

Noncompliance Area: It was observed on 7/26/22, that the facility's out door play space fence, which restricts the children from the busy highway in front of the facility, was knocked over and broken, and a wall of crumbling brick from the side of the building was falling down in that play space. It was observed that this single out door play space containing the broken fence and crumbling brick is the facility's only indoor or outdoor space used for large muscle activity.

Correction Required: A facility shall provide outdoor or indoor play space to be used for large muscle activity which includes running, jumping, climbing and riding. If unsafe areas or conditions are in or near an outdoor play space, fencing or natural barriers are required to restrict children from those unsafe areas or conditions.

Regulation: 3270.27(a)(5)

Description: Emergency plan

Noncompliance Area: On 11/18/21, it was observed that the facility did not follow their previously accepted plan of correction requested on 10/15/21; the facility did not have in their emergency plan accommodations for toddlers, and toddlers were observed in care at the time of the inspection.

Correction Required: The facility shall have an emergency plan that provides for accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions.

Regulation: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: It was observed in the outdoor play space that the wall of the climber was weathered and had a large open crack leaving it not in good repair.

Correction Required: 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.

Regulation: 3270.111(b)/3270.124(e)

Description: Posted in group space/Written emergency plan posted

Noncompliance Area: It was observed in Room 3 and Room 4 that neither a daily schedule nor the facility's emergency transportation plan were posted.

Correction Required: The written plan of daily activities shall be posted in the group space. 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.

Regulation: 3270.123(a)(6)

Description: Admission date

Noncompliance Area: Agreement for child #2 did not specify the child's admission date.

Correction Required: An agreement shall specify the date of the child's admission.

Regulation: 3270.124(b)(6)

Description: Insurance coverage information

Noncompliance Area: Emergency contact forms for child #1 and #2 did not contain the child's health insurance coverage and policy number or Medical Assistance benefits information.

Correction Required: Emergency contact information must include health insurance coverage and policy number for a child under a family policy or Medical Assistance benefits, if applicable.

Regulation: 3270.124(b)(7)

Description: Name/address/phone release person

Noncompliance Area: Emergency contact form for child #3 did not contain the release person's address.

Correction Required: 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.

Regulation: 3270.27(a)(1)/3270.27(a)(5)

Description: Emergency plan/Emergency plan

Noncompliance Area: It was observed that the facility did not have in their emergency plan, a lock-down procedure or accommodations for toddlers, and toddlers were observed in care at the time of the inspection. A lock-down procedure was added to the facility emergency plan and verified as implemented on 11/18/21.

Correction Required: The facility shall have an emergency plan that provides for accommodations for shelter of children during an emergency including lock-down, shelter in place at the facility and shelter at locations away from the facility premises. The facility shall have an emergency plan that provides for accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions.

Regulation: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: File for staff person #1, hired in 2011, contained a PA state police clearance dated 4/11/16 and 9/14/21, a child abuse clearance dated 4/14/16 and 9/20/21, and a FBI clearance dated 4/13/16 and 9/19/21. These clearances on file were obtained more than 60 months apart. File for staff person #2, hired in 2011, contained a PA state police clearance dated 4/11/16 and 9/14/21, a child abuse clearance dated 4/19/16 and 9/16/21, a FBI clearance dated 4/13/16 and 9/18/21, and a mandated reporter training certificate dated 11/29/15. These clearances on file were obtained more than 60 months apart. The mandated reporter training on file for staff person #2 is more than 60 months old and no updated training was observed on file. File for staff person #3, hired on 08/18/21, contained a NSOR verification certificate dated 09/21/21. Due to the start date of the staff person and the date of their NSOR verification certificate, this staff person would have been hired provisionally, but the facility does not currently have a provisional hire waiver on file.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services).

Regulation: 3270.52

Description: Mixed Age Level

Noncompliance Area: It was observed upon arrival at the facility that staff person #1 and #3 were outside in the outdoor play space with eight toddler-aged children. Staff person #1 left the outdoor play space to go find staff person #2 leaving staff person #3 outside with all eight children, the youngest being child #4 who is a one-year-old. It was observed in Room 1, from approximately 10:30am until noon, staff person #4 was alone in the room and had 12 preschool aged children present.

Correction Required: When children are grouped in mixed age levels, the age of the youngest child in the group determines the staff:child ratio and maximum group size in accordance with the requirements in § 3270.51 (relating to similar age level).

Regulation: 3270.74

Description: Emergency Numbers Posted

Noncompliance Area: A telephone was observed in Room 1 but the emergency telephone numbers were not posted by this phone as required. It was observed that the emergency telephone numbers posted by the telephone in Room 3 did not include the phone number to the nearest hospital.

Correction Required: The telephone number of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted by each telephone in the facility.

Regulation: 3270.76

Description: Building Surfaces

Noncompliance Area: It was observed in Room 1 that the roll shades, which were pulled down and used during rest time, contained frayed sides on three of the windows and a large hole at the bottom of one of them leaving these not in good repair.

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

Regulation: 3270.95(a)/3270.95(b)

Description: Devices must be compliant/Director or designated staff person ensure compliance

Noncompliance Area: It was observed that the facility did not have on file documentation of proof of purchase for their fire alarm system. It was observed that the facility maintains a fire alarm system but does not have on file a functional annual fire alarm inspection report, so in place of this, the facility logs testing of their fire alarms. The log shows that the alarms were tested on 3/23/21, 5/17/21, 7/1/21, 8/19/21, and 9/21/21. These fire alarm tests were not being completed and logged every 30 days as required. It was observed that the facility pulled the fire alarm to test and sound the system during the inspection. Although multiple alarms throughout the facility did sound, it was observed that the alarm in Room 1, as part of the system as a whole, did not sound during the inspection.

Correction Required: 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.