Berwick Area Ymca Day Care

Regulation: 3270.133(6)/3270.182(4)

Description: Written consent/Consent for administration of medications or special dietary needs

Noncompliance Area: Staff #9 stated that summer camp began on 6/8/26 and since that date child #1 had been allowed to carry their insulin and related equipment on their person, while in care, and self-administer medication as needed and in childcare space with peers present. Staff #9 stated that they nor their staff observed child #1 administer their medication. Staff #9 stated that they did not have a medication log or permission from child #1 parent(s) for administration of the medication. Staff #9 admitted to allowing child #1 to house the unsecured medication in the refrigerator, accessible by children in care.

Correction Required: A parent shall provide written consent for administration of medication or a special diet. A child's record shall contain signed parental consent for administration of medications or special dietary needs.

Regulation: 3270.133(7)

Description: Medication log

Noncompliance Area: Staff #9 stated that summer camp began on 6/8/26 and since that date child #1 had been allowed to carry their insulin and related equipment on their person, while in care, and self-administer medication as needed and in childcare space with peers present. Staff #9 stated that they nor their staff observed child #1 administer their medication. Staff #9 stated that they did not have a medication log or permission from child #1 parent(s) for administration of the medication. Staff #9 admitted to allowing child #1 to house the unsecured medication in the refrigerator, accessible by children in care.

Correction Required: An operator is responsible to establish and maintain a medication log if prescription or nonprescription medication is administered.

Regulation: 3270.66(a)/3270.133(4)

Description: Locked or inaccessible/Locked

Noncompliance Area: Staff #9 stated that summer camp began on 6/8/26 and since that date child #1 had been allowed to carry their insulin and related equipment on their person, while in care, and self-administer medication as needed and in childcare space with peers present. Staff #9 stated that they nor their staff observed child #1 administer their medication. Staff #9 stated that they did not have a medication log or permission from child #1 parent(s) for administration of the medication. Staff #9 admitted to allowing child #1 to house the unsecured medication in the refrigerator, accessible by children in care.

Correction Required: Cleaning materials and other toxic materials shall be kept in an area or container that is locked or made inaccessible to children. Medication shall be stored in a locked area of the facility or in an area that is out of the reach of children.

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

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

Noncompliance Area: The facility self-reported that on 5/21/26 child #1 was left alone and unsupervised in the bathroom on the school age floor of the facility for approximately 24 minutes.

Correction Required: Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. 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. Outdoor play space used by the facility is considered part of the facility premises. TIERED LIS: 1. Children must be supervised at all times. The correction date for this must be immediate. 2. The legal entity must arrange for all staff to receive a minimum of three hours of training regarding supervision of children. The training must be PQAS approved, in-person, and outside of childcare hours. The legal entity must receive approval from the DHS Northeast Regional Office regarding the training content prior to scheduling the training. The correction date for this should allow you the time to arrange for and obtain the required training and follow up with the quality coach. Providing a date that is at least 6 weeks out should give sufficient time for all of the above. 3. The facility will be subject to two unannounced monitoring visits by DHS following the completion of the three hours of PQAS approved, in person training related to supervision. These unannounced monitoring visits will be conducted to ensure that both supervision and care of children are being adhered to and that no further instances of noncompliance are observed. The correction date should reflect a date that allows for at least 6 weeks from the completion of the required trainings for DHS to complete.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: Facility person #1 was observed having direct contact with children and staff reported that facility person #1 worked alone with children and was assigned the supervision of specific children. Staff #1had a volunteer PA Child Abuse on file and not employment clearances as is required (See LIS Code Sheet for DOH).

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). The CPSL was revised to include a requirement that all clearances be updated and on file at least every 60 months. As of 2/1/25 If staff are going to be hired under the 45-day provisional hire basis, the following conditions must be met; facility received the results of the applicant's PA Child Abuse History Clearance, NSOR Clearance, completed out-of-state clearances (if applicable), a signed disclosure statement, prior to employment and have received the result of the applicant's Pennsylvania State Police OR the FBI finger-print results prior to employment. Proof of submission must be on file for either the FBI or PA State Police Clearance. The employer, administrator, supervisor or other person responsible for employment decisions has no knowledge of information pertaining to the applicant which would disqualify him from employment based on CPSL. TIERED LIS: 1. The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Staff #1 may not work in a childcare position with direct contact and routine interaction with children. The correction date for this portion of the plan must be immediate. Not Implemented 7/30/26. 2. The facility must develop a hiring policy that includes a review of the completed file by a second person that has attended existing provider training before the new hire may begin to have direct contact or routine interaction with children. The correction date for this should reflect a date that allows for the development and review of the hiring policy. Implemented on 7/30/26

Regulation: 3270.52

Description: Mixed Age Level

Noncompliance Area: While present at the facility unannounced on 3/13/26 the inspector observed a recording from 3/2/26 that showed staff #1 alone in the young toddler room with nine mixed aged children (4 young toddlers, 4 older toddlers, and 1 preschool aged child) for roughly 30 minutes (approximately 7:03am until 7:38am).

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). TIERED LIS: 1. The required staff: child ratios must be maintained at all times. The correction date for this shall be immediate. 2. The director shall develop a ratio policy and procedures for maintaining required staff:child ratios. The ratio policy and procedures will include specific directives for both staff and parents regarding early drop off, late pick up, when to deny children care due to the inability to meet state required ratio, staff call offs and no shows, the proper implementation and utilization of a system to move children as needed for ratio compliment. The ratio policy and procedures must be submitted to the DHS Northeast Regional Office prior to implementation for approval. Once it is accepted by the DHS Northeast Regional Office the director will ensure all staff and parents review the policy and procedures and sign off. The correction date for this should reflect a date that allows for the development and review of the plan as well as time to train staff on this as well as time to update the parents and the parent handbook. 3. The facility will be subject to three unannounced monitoring visits by DHS following the implementation of the ratio policy and procedures. These unannounced monitoring visits will be conducted to ensure that the ratio policy and procedures are being adhered to and that no further instances of noncompliance related to ratio are observed. The correction date should reflect at date that allows for at least 8 weeks from the implementation of the ratio policy and procedures for DHS to complete.

Regulation: 3270.104(a)

Description: Clean, good repair, proper size

Noncompliance Area: During the course of the unannounced renewal inspection on 10/23/25 the inspector observed a broken desk in the Innovations room.

Correction Required: Furniture must be durable, safe, easily cleaned and appropriate for the child's size, age and special needs.

Regulation: 3270.107

Description: Refrigerator

Noncompliance Area: During the course of the unannounced renewal inspection on 10/23/25 the inspector observed a broken thermometer in the refrigerator in preschool 2 room.

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

Regulation: 3270.113(a)(1)

Description: Staff assigned to specific children

Noncompliance Area: During the course of the unannounced renewal inspection on 10/23/25 the inspector asked staff #1 and then staff #2 to name and point to the group of children they were assigned to. Both staff #1and staff #2 failed to name a child in the group. Eight children were named and nine were present in care.

Correction Required: Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises. TIERED LIS: 1. Children must be supervised at all times. This portion of the plan must have an immediate correction date. 2.The legal entity must arrange for staff #1 and #2 to receive a minimum of two hours of training regarding supervision of children. The legal entity must receive DHS approval of the training content prior to scheduling the training. The operator shall provide a date for when this training is completed.

Regulation: 3270.124(b)(3)

Description: Parent home/work address, phone

Noncompliance Area: During the course of the unannounced renewal inspection on 10/23/25 the inspector reviewed child files and observed that child file #2 was missing work the address and telephone number of the enrolling parent.

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

Regulation: 3270.131(a)

Description: Health information

Noncompliance Area: During the course of the unannounced renewal inspection on 10/23/25 the inspector reviewed child files and observed that child file #1 was missing an initial health assessment that was required within 60 days.

Correction Required: 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.

Regulation: 3270.131(c)

Description: Completed or signed by physician, PA, or CRNP

Noncompliance Area: During the course of the unannounced renewal inspection on 10/23/25 the inspector reviewed child files and observed that child file #3 and found that it did not have the required signature and date on the health report.

Correction Required: 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.

Regulation: 3270.131(e)

Description: ACIP recommended immunization record

Noncompliance Area: During the course of the unannounced renewal inspection on 10/23/25 the inspector reviewed child files and observed that child file #1 was missing an initial health assessment that was required within 60 days and not removed from care.

Correction Required: 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.

Regulation: 3270.37(c)

Description: Aides supervised all times

Noncompliance Area: During the course of the unannounced renewal inspection on 10/23/25 the inspector observed staff #1, who qualifies as an Aide, alone in the bathroom with children.

Correction Required: An aide or a combination of aides shall be supervised at all times by a staff person qualified at minimum as an assistant group supervisor.

Regulation: 3270.67(d)

Description: Contaminated trash in closed plastic-lined receptacle

Noncompliance Area: During the course of the unannounced renewal inspection on 10/23/25 the inspector observed trash cans in the bathrooms that were not lidded as required.

Correction Required: Trash that has been contaminated by human secretions or excrement shall be contained in closed, plastic-lined receptacles.

Regulation: 3270.75(c)

Description: Has all items

Noncompliance Area: During the course of the unannounced renewal inspection on 10/23/25 the inspector found that the first aid kit in the Preschool 1 room was missing the required tweezers.

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: 3270.76

Description: Building Surfaces

Noncompliance Area: During the course of the unannounced renewal inspection on 10/23/25 the inspector observed evidence of leaking on the ceiling tiles in the children's bathroom.

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(b)

Description: Surfaces cleaned

Noncompliance Area: While at the facility unannounced on 10/08/25 the inspector observed two changing mats (toddler and preschool room) that were cracked allowing the foam underneath to show through. This rendered both mats unable to be cleaned.

Correction Required: Diaper changing surfaces shall be cleaned after each use by wiping the surface with a sanitizing solution or by changing a pad or other surface covering.

Regulation: 3270.66(b)

Description: Original container

Noncompliance Area: While at the facility unannounced on 10/08/25 the inspector observed Dawn dish detergent, 365 hand sanitizer, Coppertone sunscreen, Water Babies sunscreen (labeled Keep out of Reach of Children), sharing the same space as a banana, bread, Nutri Grain bars, and apple sauce.

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: 3270.95(a)/3270.95(b)

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

Noncompliance Area: While at the facility unannounced on 10/08/25 the inspector observed that a manual test of the fire alarm system was not conducted evidenced by

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: 3270.133(1)

Description: Original container

Noncompliance Area: During the unannounced visit to the Ber Vaughn Pool the inspector observed two inhalers and an Eppi-Pen missing their original containers.

Correction Required: A prescription or nonprescription medication may be accepted only in an original container. The medication shall remain in the container in which it was received.

Regulation: 3270.133(3)

Description: Name on bottle

Noncompliance Area: During the unannounced visit to the Ber Vaughn Pool the inspector observed two inhalers and an Eppi-Pen missing the names of the children for whom the medications were intended.

Correction Required: The label of a medication container shall identify the name of the medication and the name of the child for whom the medication is intended. Medication shall be administered to only the child whose name appears on the container.

Regulation: 3270.133(5)

Description: Original label

Noncompliance Area: During the unannounced visit to the Ber Vaughn Pool the inspector observed an expired inhaler (exp 6/2025) for child #1.

Correction Required: Medication shall be stored in accordance with the manufacturer's or health professional's instructions on the original label.

Regulation: 3270.31(e)(4)(iv)/3270.115(a)(8)

Description: Water safety/Included in ratio/annual training

Noncompliance Area: During the unannounced visit to the Ber Vaughn Pool on 7/30/25 the inspector observed staff #1, #2, # 3, and #4 in swim ratio with children. Staff #1 had an expired water safety training certificate on file. Staff #2, #3, and #4 did not have water safety training. Staff #2 and #4 were provided water safety training following the inspector's visit to the pool. On 7/31/25 the inspector was provided with the water safety certificates via email for staff #2 and #4 dated 7/30/25. This was confirmed by the water safety instructor on 8/20/25. Although requested, the inspector has not received water safety training for staff #3.

Correction Required: Competence in water safety instruction is demonstrated by the completion of basic instruction in water safety from a certified lifeguard. A facility person who is counted in the staff-child swimming ratio shall annually complete water safety instruction.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: Continued Non-Compliance: During the annual unannounced renewal, the inspector reviewed the file for staff #2 and found that this staff was working in direct care with children did not have a completed FBI clearance on file, Pa State Police clearance was not obtained until 8/4/24, a Pa Child Abuse clearance was not obtained until 8/9/24, and a NSOR was not obtained until 8/7/24. Staff #3 was working in direct care with children and did not have an NSOR and obtained a PDE FBI and not the required DHS FBI. Staff #7 was working in direct care with children and did not have an FBI on file until 6/5/24. Staff #9 was working in direct care with children and did not have a Pa State Police clearance on file or an NSOR. Staff #10 was working in direct care with children and did not obtain a NSOR until 12/20/23. Staff #13 was working in direct care with children and did not obtain a NSOR until 9/4/24. Staff #14 was working in direct care with children and did not obtain an FBI until 6/27/24, and an NSOR until 8/7/24. Staff #15 was working in direct with children and did not obtain an NSOR until 10/9/24. Staff #16 was working in direct care with children and did not have an FBI clearance until 10/18/24, and an NSOR until 9/16/24. Staff #17 was working in direct care with children and did not obtain a PA State Police clearance until 4/19/24, and an FBI clearance until 4/22/24, and an NSOR until 11/7/24. Staff # 18 was working in direct care with children and did not obtain a PA Child Abuse until 8/16/24, an FBI until 8/15/24, and an NSOR until 8/23/24 (see LIS code sheet for DOH). The facility's acceptable plan of correction indicated the correction would be implemented by 2/14/25. On 5/21/25 an unannounced inspection was conducted at the facility. The inspector observed staff #1 working directly with children during this inspection. The inspector reviewed the file for staff #1and noted that this staff was missing required out of state clearances since hire (see LIS code sheet) and self-reported that they were working directly with children since the end of February 2025 (exact date was not provided).

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Facility Person # 1 may not work in a childcare position at the facility. The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Staff #1 may not work in a childcare position at the facility. As of 2/1/25 If staff are going to be hired under the 45-day provisional hire basis, the following conditions must be met; facility received the results of the applicant's PA Child Abuse History Clearance, NSOR Clearance, completed out-of-state clearances (if applicable), a signed disclosure statement, prior to employment and have received the result of the applicant's Pennsylvania State Police OR the FBI finger-print results prior to employment. Proof of submission must be on file for either the FBI or PA State Police Clearance. The employer, administrator, supervisor or other person responsible for employment decisions has no knowledge of information pertaining to the applicant which would disqualify him from employment based on CPSL. TIERED LIS 1. The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). The correction date for this portion of the plan must be immediate. 2. The facility director, VP of Operations, and any other persons involved in the hiring of staff must arrange for and attend an Existing Provider Training held in the Northeast Regional Office of DHS, Scranton Office. To register for this required training, you must call the Northeast Regional Office at 1 800 222 2108.The correction date for this portion of the plan must coincide with the next Existing Provider Training which is being held on 8/6/25. 3. In order to demonstrate compliance in this area, the director or legal entity representative will send completed staff files for all new hires for the next three months to the Northeast Regional Office for review. The staff files must include all clearance requests, completed clearances, (including out of state clearances and requests if necessary) signed and dated disclosure statement, health assessment and TB screening, two nonfamily references, proof of education and experience (officially translated if needed). The Northeast Regional Office will review the newly hired and completed staff files prior to hire within five business days of receipt and report back to the facility. The correction date for this portion of the plan must be three months from the acceptance of the plan by The Northeast Regional Office.

Regulation: 3270.106(f)

Description: 2 feet apart

Noncompliance Area: On 3/7/25 an unannounced investigation was conducted at the facility. While the inspector was present in the infant room an infant was observed in a crib that was in a row of four, all touching each crib and the wall, with no separation on three sides.

Correction Required: At least 2 feet of space is required on three sides of a bed, cot, crib or other rest equipment while the equipment is in use.

Regulation: 3270.112

Description: Infant/Toddler Stimulation

Noncompliance Area: On 3/7/25 an unannounced complaint investigation was conducted at the facility. It was learned (through video footage) that on 2/28/25 an infant was left in a bouncer from drop off at 7:44am until 8:36am with no contact from staff including being spoken to, played with or otherwise cared for.

Correction Required: Infants and toddlers shall be provided stimulation by being held, rocked, talked to, played with and carried.

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

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

Noncompliance Area: Continued Non-Compliance: On 2/14/25 an unannounced, self-reported complaint investigation was conducted at the facility. It was learned that on 2/7/25 at roughly 3:33pm, child #1 was, in fact left alone in the preschool room for roughly four minutes after staff #1 left the room with another child to go to the gym. Child #1 was found by a parent and brought to the staff's attention. An acceptable plan of correction was received with a correction date of 2/10/25. On 3/7/25 an unannounced complaint investigation was conducted at the facility. It was learned (through video footage) that on 2/28/25 and 3/3/25 staff #2 was observed on their phone from 8:18am until 8:22am, was observed several times looking through the window, watching her child in the classroom next door, for several minutes each time, observed leaving the infant room and the group of five infants with staff #3 alone.

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. Tiered LIS: 1. Children must be supervised at all times. The correction date for this must be immediate. 2. The legal entity must arrange for all staff to receive a minimum of three hours of training regarding Supervision. The training must be PQAS approved, in-person, and outside of childcare hours. The legal entity must receive approval from the DHS Northeast Regional Office regarding the training content prior to scheduling the training. The operator must provide a correction date for when this training will be completed. 3. The facility director will develop and implement a supervision policy that will ensure staff fully understand their responsibility regarding the supervision of children at all times. This policy must be submitted to the DHS Northeast Regional Office prior to implementation for approval. Once this policy is accepted by the DHS Northeast Regional Office the director will ensure all staff and facility persons sign off on this policy as well as all new hires moving forward. The operator must provide a correction date, which is after completion of the training, for when this portion of the plan will be completed.

Regulation: 3270.135(a)(3)

Description: Disposable diapers

Noncompliance Area: On 3/7/25 an unannounced investigation was conducted at the facility. While the inspector was present in the infant room the inspector observed staff #2 changing a diaper and using their hand, with the soiled diaper in it, to pick up the lid on the garbage can to place the diaper inside and not the foot pedal.

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: 3270.135(b)

Description: Surfaces cleaned

Noncompliance Area: On 3/7/25 an unannounced investigation was conducted at the facility. It was learned (through video footage) that on 2/28/25 staff #2 and #3 did not clean the diaper changing surface after each use and were, in fact, observed changing multiple infants without cleaning the diaper area.

Correction Required: Diaper changing surfaces shall be cleaned after each use by wiping the surface with a sanitizing solution or by changing a pad or other surface covering.

Regulation: 3270.152

Description: Adult Hygiene

Noncompliance Area: On 3/7/25 an unannounced investigation was conducted at the facility. It was learned (through video footage) that on 2/28/25 staff #2 and #3 did not wash their hands following diapering and did, in fact, change several diapers consecutively without washing their hands. it was also observed that staff #2 changed a diaper, did not wash their hands, and proceeded to prepare food for an infant.

Correction Required: A facility person shall wash his hands before meals and snacks, and after toileting and after diapering a child.

Regulation: 3270.166(1)/3270.166(2)

Description: Written statement/New foods - parent's consent

Noncompliance Area: On 3/7/25 an unannounced complaint investigation was conducted at the facility. It was learned through direct discussion and observation of and with staff #2 and staff #3 that there were no written parental statements giving the formula and feeding schedules for any of the infants in care and that there was no consultation with any of the five infant's parents on new foods being introduced.

Correction Required: A written statement giving the formula and feeding schedule for an infant shall be obtained from the parent. New foods shall be introduced to an infant only after consultation with the child's parent.

Regulation: 3270.166(3)

Description: Disposable nursers or parents

Noncompliance Area: On 3/7/25 an unannounced complaint investigation was conducted at the facility. It was learned through direct discussion and observation of and with staff #2 and staff #3 that both staff handwashed bottles for reuse throughout the day for all five infants in care.

Correction Required: Disposable nursers shall be used for infants unless bottles are provided by the parent or unless a commercial dishwasher is used by the facility.

Regulation: 3270.166(5)

Description: Six-months-old held

Noncompliance Area: On 3/7/25 an unannounced complaint investigation was conducted at the facility. It was learned (through video footage that on 2/28/25 and 3/3/25 child#1, #2, #3, #4, and #5 were all present in the infant room with staff #2 and #3. The video clearly showed four of the five infants in baby bouncers, with bottles propped by blankets, that were implemented by staff #2. One infant was being held by staff #3 while being fed. Two of the five infants were under six months old (Please refer to the LIS Code Sheet for DOB).

Correction Required: An infant 6 months of age or younger shall be held while being bottle fed.

Regulation: 3270.51

Description: Similar Age Level

Noncompliance Area: On 3/7/25 an unannounced investigation was conducted at the facility. It was learned (through video footage that on 2/28/25 staff #2 left the infant room leaving staff #3 alone with five infants in care.

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. TIERED LIS: 1. The required staff: child ratios must be maintained at all times. The date of correction for this must be immediate. 2. The facility will be required to post childcare ratios in each measured childcare space. The operator will provide a correction date for when this portion of the plan will be completed.

Regulation: 3270.69(b)

Description: 110º F or less

Noncompliance Area: On 3/7/25 an unannounced investigation was conducted at the facility. While the inspector was present in the infant room a temperature check of the crock pot used to warm bottles was conducted. The crock pot was sitting on the countertop where meals are prepared and where the sink is for handwashing, making it directly accessible. The inspector inserted a thermometer into the water in the crock pot and found the temperature to read 124.7 degrees. The inspector asked staff #3 to confirm this reading and staff #3 too stated that the temperature read 124.7 degrees.

Correction Required: Hot water temperature, in areas accessible to children, may not exceed 110° F.

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

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

Noncompliance Area: The facility self-reported that on 2/7/25 at roughly 3:330pm, child #1 was, in fact left alone in the preschool room for roughly four minutes after staff #1 left the room with another child to go to the gym. Child #1 was found by a parent and brought to the staff's attention.

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. Children must be supervised at all times The facility director will develop and implement a supervision policy that will ensure staff fully understand their responsibility regarding the supervision of children at all times. This policy must be submitted to the DHS Northeast Regional Office prior to implementation for approval. Once this policy is accepted by the DHS Northeast Regional Office the director will ensure all staff and facility persons sign off on this policy as well as all new hires moving forward.

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

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

Noncompliance Area: The facility self-reported that on 2/7/25 at roughly 3:330pm, child #1 was, in fact left alone in the preschool room for roughly four minutes after staff #1 left the room with another child to go to the gym. Child #1 was found by a parent and brought to the staff's attention.

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. Children must be supervised at all times.

Regulation: 3270.124(b)(3)

Description: Parent home/work address, phone

Noncompliance Area: Durning the annual unannounced renewal inspection the inspector reviewed the files for child #1, #2, #3, #4, and #5 and observed that all five child files were missing the work addresses and telephone numbers of the enrolling parent as is required.

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

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

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

Noncompliance Area: During the annual unannounced renewal, the inspector reviewed the files for staff #2, #4, #7, #14, #17, #18, had been working in direct care with children prior to obtaining a health assessment and TB screening. Staff #13 had been working in direct care with children prior to obtaining a TB screening. Staff #16 had been working in direct care with children prior to obtaining a health assessment. Staff #20 had been working in direct care with children without a current health assessment and TB screening.

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: Durning the annual unannounced renewal inspection the inspector did not observe posted safe routes and when asked the director stated they were unaware that they had to be posted.

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(2)(iv)

Description: Transcript, diploma and letters

Noncompliance Area: During the annual unannounced renewal, the inspector reviewed the files for staff #3, #9, #13, #16, were all missing proof of education or training is a transcript or a diploma or a letter signed by a representative of the experiential, educational or training entity.

Correction Required: 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: 3270.192(3)

Description: Health assessment, TB test

Noncompliance Area: Staff #17 had been working in direct care with children prior to obtaining a health assessment and TB screening and once obtained the health assessment states that this staff a communicable disease (see LIS code sheet for DOH).

Correction Required: A facility person's record shall include a written report of initial and subsequent health assessments, including the results of initial and subsequent tuberculin skin tests, x-rays or other medical documentation necessary to confirm freedom from communicable tuberculosis.

Regulation: 3270.192(5)

Description: Two written references

Noncompliance Area: During the annual unannounced renewal, the inspector reviewed the files for staff #6, #12, #16, #17, and #20 only had one nonfamily reference on file whereas staff #9, and #19 had no references on file.

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: 3270.31(e)(4)(i)

Description: Age and Training

Noncompliance Area: During the annual unannounced renewal, the inspector reviewed the file for staff #6 and found that this staff did not renew their certification in pediatric first aid and pediatric cardiopulmonary resuscitation (CPR) on or before the expiration of the most current certification.

Correction Required: 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.

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

Description: Fire safety - 1 yr.

Noncompliance Area: During the annual unannounced renewal, the inspector reviewed the files for staff #20 and #21 both last had annual fire safety training on 10/10/23.

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: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: During the unannounced renewal inspection, the inspector reviewed the staff files and noted that staff #3, and #4, did not completed the following required pre-service training within 90 days of their date of hire (see LIS Code Sheet) Pediatric First Aid and CPR from a PQAS approved trainer and a PQAS approved curriculum. Staff #3 and staff #9 have not completed the following required pre-service training within 90 days of their date of hire (see LIS Code Sheet), Health and Safety training. Staff #13, #16, and #17 completed the required pre-service training (see LIS Code Sheet), Health and Safety training over the 90 daytime frame allotted since hire.

Correction Required: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10. Until such time as the required training is completed, staff persons #3 and #4 must be supervised when interacting with children by an Assistant Group Supervisor who has completed the required training related to the citation. If there are no staff available to supervise staff persons #3 and #4 staff persons #3 and #4 may not work in a childcare position at the facility.

Regulation: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: Staff #8, #9, #13, and #17 did not complete the Pa Mandated Reporter training following 90 days of hire (see LIS code sheet).

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

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: During the annual unannounced renewal, the inspector reviewed the file for staff #2 and found that this staff was working in direct care with children did not have a completed FBI clearance on file, Pa State Police clearance was not obtained until 8/4/24, a Pa Child Abuse clearance was not obtained until 8/9/24, and a NSOR was not obtained until 8/7/24. Staff #3 was working in direct care with children and did not have an NSOR and obtained a PDE FBI and not the required DHS FBI. Staff #7 was working in direct care with children and did not have an FBI on file until 6/5/24. Staff #9 was working in direct care with children and did not have a Pa State Police clearance on file or an NSOR. Staff #10 was working in direct care with children and did not obtain a NSOR until 12/20/23. Staff #13 was working in direct care with children and did not obtain a NSOR until 9/4/24. Staff #14 was working in direct care with children and did not obtain an FBI until 6/27/24, and an NSOR until 8/7/24. Staff #15 was working in direct with children and did not obtain an NSOR until 10/9/24. Staff #16 was working in direct care with children and did not have an FBI clearance until 10/18/24, and an NSOR until 9/16/24. Staff #17 was working in direct care with children and did not obtain a PA State Police clearance until 4/19/24, and an FBI clearance until 4/22/24, and an NSOR until 11/7/24. Staff # 18 was working in direct care with children and did not obtain a PA Child Abuse until 8/16/24, an FBI until 8/15/24, and an NSOR until 8/23/24 (see LIS code sheet for DOH).

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). In order to demonstrate compliance in this area, the director or legal entity representative will send completed staff files for all new hires for the next three months to the Northeast Regional Office for review. The staff files must include all clearance requests, completed clearances, (including out of state clearances and requests if necessary) signed and dated disclosure statement, health assessment and TB screening, two nonfamily references, proof of education and experience (officially translated if needed). The Northeast Regional Office will review the newly hired and completed staff files within three days of receipt.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: During the annual unannounced renewal, the inspector reviewed the file for staff #2 and found that this staff was working in direct care with children did not have a completed FBI clearance on file, Pa State Police clearance was not obtained until 8/4/24, a Pa Child Abuse clearance was not obtained until 8/9/24, and a NSOR was not obtained until 8/7/24. Staff #3 was working in direct care with children and did not have an NSOR and obtained a PDE FBI and not the required DHS FBI. Staff #7 was working in direct care with children and did not have an FBI on file until 6/5/24. Staff #9 was working in direct care with children and did not have a Pa State Police clearance on file or an NSOR. Staff #10 was working in direct care with children and did not obtain a NSOR until 12/20/23. Staff #13 was working in direct care with children and did not obtain a NSOR until 9/4/24. Staff #14 was working in direct care with children and did not obtain an FBI until 6/27/24, and an NSOR until 8/7/24. Staff #15 was working in direct with children and did not obtain an NSOR until 10/9/24. Staff #16 was working in direct care with children and did not have an FBI clearance until 10/18/24, and an NSOR until 9/16/24. Staff #17 was working in direct care with children and did not obtain a PA State Police clearance until 4/19/24, and an FBI clearance until 4/22/24, and an NSOR until 11/7/24. Staff # 18 was working in direct care with children and did not obtain a PA Child Abuse until 8/16/24, an FBI until 8/15/24, and an NSOR until 8/23/24 (see LIS code sheet for DOH).

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Facility Person # 2, #3, #9, may not work in a childcare position at the facility. If staff are going to be hired under the 45-day provisional hire basis, the following conditions must be met; facility received the results of the applicant's PA Child Abuse History Clearance prior to employment. and a signed disclosure statement, Facility received the result of the applicant's Pennsylvania State Police OR the FBI finger-print results prior to employment. The applicant has applied for the remaining required checks and the applicant provides a copy of the appropriate completed request forms to the employer, administrator, supervisor or other person responsible for employment decisions. The outstanding checks are: Pennsylvania State Police Criminal Record Check OR the FBI Criminal History Background Check, the National Sex Offender Registry (NSOR) check, and for an applicant who, in the past five years has resided outside of Pennsylvania, criminal history, child abuse, and sex offender registry checks from every state where the applicant lived within the past five years.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: During the annual unannounced renewal, the inspector reviewed the file for staff #2 and found that this staff was working in direct care with children did not have a completed FBI clearance on file, Pa State Police clearance was not obtained until 8/4/24, a Pa Child Abuse clearance was not obtained until 8/9/24, and a NSOR was not obtained until 8/7/24. Staff #3 was working in direct care with children and did not have an NSOR and obtained a PDE FBI and not the required DHS FBI. Staff #7 was working in direct care with children and did not have an FBI on file until 6/5/24. Staff #9 was working in direct care with children and did not have a Pa State Police clearance on file or an NSOR. Staff #10 was working in direct care with children and did not obtain a NSOR until 12/20/23. Staff #13 was working in direct care with children and did not obtain a NSOR until 9/4/24. Staff #14 was working in direct care with children and did not obtain an FBI until 6/27/24, and an NSOR until 8/7/24. Staff #15 was working in direct with children and did not obtain an NSOR until 10/9/24. Staff #16 was working in direct care with children and did not have an FBI clearance until 10/18/24, and an NSOR until 9/16/24. Staff #17 was working in direct care with children and did not obtain a PA State Police clearance until 4/19/24, and an FBI clearance until 4/22/24, and an NSOR until 11/7/24. Staff # 18 was working in direct care with children and did not obtain a PA Child Abuse until 8/16/24, an FBI until 8/15/24, and an NSOR until 8/23/24 (see LIS code sheet for DOH).

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). The VP of Operations must arrange for both the VP of Operations and the director of the facility to attend an Existing Provider Training held in the Northeast Regional Office of DHS, Scranton Office. To register for this required training, you must call the Northeast Regional Office at 1 800 222 2108.

Regulation: 3270.34(a)(6)

Description: Staff evaluations

Noncompliance Area: During the annual unannounced renewal, the inspector reviewed the files for staff #6 and found that this staff had an evaluation on file dated 12/2/22 and then not again until 12/9/24.Staff #8 had an evaluation dated 2/24/23 and not again until 12/9/24.Staff #10 and #11 had both been employed over a year and did not have an annual evaluation on file. Staff # 20 last had an evaluation 7/13/23.Staff #21 had an evaluation on file dated 2/3/22 and then not again until 5/7/24.

Correction Required: A director is responsible for written evaluation of staff persons on a regular basis, a minimum of one evaluation every 12 months.

Regulation: 3270.74

Description: Emergency Numbers Posted

Noncompliance Area: Durning the annual unannounced renewal inspection the inspector did not observe emergency phone numbers and when asked the director stated they were unaware that they had to be posted.

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: 3270.94(a)(5)

Description: Evacuation routes posted

Noncompliance Area: Durning the annual unannounced renewal inspection the inspector did not observe evacuation routes on the second floor and gym and when asked the director stated they were unaware that they had to be posted.

Correction Required: The Director or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that evacuation routes are posted in a conspicuous location on each floor of the facility.

Regulation: 3270.103

Description: Small Toys and Objects

Noncompliance Area: While at the facility unannounced on 7/26/24 for an allocated unannounced visit the inspector observed the infant room and found an infant in a highchair mouthing the top/lid of a squeeze style food pouch, that was less than one inch in diameter.

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

Regulation: 3270.124(d)

Description: Excursions

Noncompliance Area: While at the public pool on 7/26/24 for an unannounced swim activity monitoring. the inspector asked to view the emergency contact information for the children present. Staff #1 stated that they were unaware that having the emergency contact information for the children was required.

Correction Required: When children leave the facility on walking and riding excursions, emergency contact information specific to each child on the excursion shall accompany a staff person on the excursion.

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: Staff person #2 was 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; Pediatric first aid and CPR from an approved course and PQAS approved trainer.

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 training is completed, staff #2 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, staff person #2 may not work in a childcare 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: While at the facility unannounced on 7/26/24 for an allocated unannounced visit the inspector was unable to given access to the staff files. Following this, the inspector was forwarded requested documents, and it was learned that staff #1, who had been observed working directly with children, was missing the required staff health assessment and TB screening prior to employment.

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(6)

Description: Signed parental consent for transportation, walking excursions, swimming and wading

Noncompliance Area: While at the public pool on 7/26/24 for an unannounced swim activity monitoring. the inspector asked to view the signed parental consent for transportation, walking excursions, swimming and wading for the children present. Staff #1 stated that they were unaware that having this specific information for the children present was required.

Correction Required: A child's record shall contain signed parental consent for transportation, walking excursions, swimming and wading.

Regulation: 3270.21/3270.104(a)

Description: General Health and Safety/Clean, good repair, proper size

Noncompliance Area: While at the facility unannounced on 7/26/24 for an allocated unannounced visit the inspector observed the infant room and found an infant in a highchair and not strapped into the highchair rendering the highchair unsafe.

Correction Required: Conditions at the facility may not pose a threat to the health or safety of the children. Furniture must be durable, safe, easily cleaned and appropriate for the child's size, age and special needs.

Regulation: 3270.27(a)(1)

Description: Emergency plan

Noncompliance Area: While at the facility unannounced on 7/26/24 for an allocated unannounced visit the inspector was unable to given access to the files. Following this, the inspector was forwarded the facility emergency plan, and it was missing 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.

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.

Regulation: 3270.27(a)(3)/3270.27(a)(4)

Description: Contact when arises/Contact when ended

Noncompliance Area: While at the facility unannounced on 7/26/24 for an allocated unannounced visit the inspector was unable to given access to the files. Following this, the inspector was forwarded the facility emergency plan, and it was missing method(s) for facility persons to contact parents as soon as reasonably possible when an emergency situation arises. The facility shall have an emergency plan that provides for a method for facility persons to inform parents that the emergency has ended and to provide instruction as to how parents can safely be reunited with their children.

Correction Required: The facility shall have an emergency plan that provides for a method for facility persons to contact parents as soon as reasonably possible when an emergency situation arises. The facility shall have an emergency plan that provides for a method for facility persons to inform parents that the emergency has ended and to provide instruction as to how parents can safely be reunited with their children.

Regulation: 3270.27(a)(5)

Description: Emergency plan

Noncompliance Area: While at the facility unannounced on 7/26/24 for an allocated unannounced visit the inspector was unable to given access to the files. Following this, the inspector was forwarded the facility emergency plan, and it was missing accommodations for infants, toddlers, children with disabilities, and 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(c)

Description: Training regarding plan

Noncompliance Area: While at the facility unannounced on 7/26/24 for an allocated unannounced visit the inspector was unable to given access to the staff files. Following this, the inspector was forwarded requested documents, and it was learned that staff #1 and #3 did not have proof of having had emergency plan training.

Correction Required: 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.

Regulation: 3270.31(e)(4)(iv)

Description: Water safety

Noncompliance Area: While at the public pool on 7/26/24 for an unannounced swim activity monitoring visit, the inspector observed staff #1, #2, #3, #4, #5 supervising children at the pool. Following this unannounced visit the inspector requested the water safety certificates of these staff members and as of 8/2/24 none were received.

Correction Required: Competence in water safety instruction is demonstrated by the completion of basic instruction in water safety from a certified lifeguard.

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: Staff person #2 was 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; Pediatric first aid and CPR from an approved curriculum and PQAS approved trainer.

Correction Required: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10 within 90 days of hire. Staff person #2 will have until 8/28/24 to complete the required training. Until such time as the required training has been completed, staff person #2 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, staff person #2 may not work in a childcare position at the facility.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: While at the facility unannounced on 7/26/24 for an allocated unannounced visit the inspector was unable to given access to the staff files. Following this, the inspector was forwarded requested documents, and it was learned that staff #3, who had been observed working directly with children, was missing the required NSOR clearance.

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. Facility Person # 3 may not work in a childcare position at the facility.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: While at the public pool on 7/26/24 for an unannounced swim activity monitoring visit, the inspector observed staff #6 serving as the facility lifeguard. Following this unannounced visit the inspector was sent the file for the lifeguard and the inspector observed staff #6 had a Pa Mandated Reporter Training dated 2/22/16 and did not update this training until 8/3/24. This training is required to be updated every 60 months. Staff #6 also had no proof of having applied for and obtained a NSOR.

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. Facility Person #6 may not work in a childcare position at the facility.

Regulation: 3270.34(c)

Description: Employed and present 30 hrs/wk

Noncompliance Area: While at the facility unannounced on 7/26/24 for an allocated unannounced visit the inspector was told that the facility director resigned in May, leaving the facility without a director since that time.

Correction Required: A director shall be employed by a facility and be present at the facility site a minimum of 30 hours per week.

Regulation: 3270.95(a)/3270.95(b)

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

Noncompliance Area: While at the facility unannounced on 7/26/24 for an allocated unannounced visit the inspector was unable to given access to the files. Following this, the inspector was forwarded the facility fire drill/detection log, and it was noted that the facility did not test the smoke detectors every 30 calendar days as is required. The testing dates in question were 5/28/24 to 7/1/24.

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: 3270.151(c)(2)/3270.192(3)

Description: Mantoux TB/Health assessment, TB test

Noncompliance Area: An unannounced inspection occurred at the facility on 2/26/24. A review of staff files was conducted at that time. See the code sheet for the dates of hire for staff. Staff #1 and #2 were observed working in child care and the file did not contain documentation of an initial Tuberculosis screening.

Correction Required: 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. A facility person's record shall include a written report of initial and subsequent health assessments, including the results of initial and subsequent tuberculin skin tests, x-rays or other medical documentation necessary to confirm freedom from communicable tuberculosis.

Regulation: 3270.123(a)(3)

Description: Services proceeded

Noncompliance Area: A renewal inspection occurred at the facility. A review of children's files was conducted. Regulation requires child service reports to be completed every 6-months. The following children did not have a child service report competed every 6-months: Child # 3 and # 4. These children had current reports for this inspection.

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).

Regulation: 3270.124(b)(4)/3270.182(3)

Description: Written consent/Consent for emergency medical care required prior to admission

Noncompliance Area: A renewal inspection occurred at the facility. A review of children's files was conducted. The file of Child # 10 did not contain consent signed by a parent for emergency medical care.

Correction Required: Emergency contact information must include the written consent signed by a parent for emergency medical care. A child's record shall contain signed parental consent for emergency medical care for the child. Written consent is required prior to admission.

Regulation: 3270.124(f)/3270.181(c)

Description: Updated every 6 months/Emergency info/agreement updated 6 mos

Noncompliance Area: A renewal inspection occurred at the facility. A review of children's files was conducted. Regulation requires children's emergency contact and agreement forms to be updated every 6-months. The following children's forms were not updated every 6-months: Child # 1, # 3, and # 4. The emergency contact and agreement form of Child # 1 was dated 4/17/23 and was not updated until 12/7/23. The emergency contact form of Child # 3 was dated 6/10/21 and was not updated until 12/7/23. The agreement form of Child # 3 was dated 12/15/21 and was not updated until 12/8/23. The agreement form of Child # 4 was dated 1/8/23 and was not updated until 11/14/23.

Correction Required: The parent shall update in writing emergency contact information once in a 6-month period or as soon as there is a change in the information. A parent is required to review and update the emergency contact information and the financial agreement at least once in a 6-month period or as soon as there is a change in the information.

Regulation: 3270.131(a)/3270.182(1)

Description: Health information/Initial and subsequent health reports

Noncompliance Area: A renewal inspection occurred at the facility. A review of children's files was complete. See the code sheet for the enrollment date. Child # 1 did not receive a health report until 11/30/23.

Correction Required: 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.

Regulation: 3270.151(a)/3270.192(3)

Description: 12 months prior to service and every 24 months thereafter/Health assessment, TB test

Noncompliance Area: An unannounced inspection occurred at the facility. A review of staff files was conducted. The file of Staff # 2 did not contain a health assessment and Staff # 2 was working in childcare at the time of this inspection. An acceptable plan of correction was received on 10/17/23. An inspection occurred at the facility on 12/13/23. A review of staff files was completed. See the code sheet or the date of hire of staff. The following staff did not update their health assessments every 24 months as required by regulation: Staff # 11, 9 and # 17. Staff # 11 has a health assessment dated 7/28/21 and this assessment has not yet been updated. Staff # 9 had a health assessment dated for 8/30/21 and the health assessment was not updated until 12/15/23. Staff # 17 had a health assessment dated for 3/19/21 and the health assessment was not updated until 12/19/23. The following staff did not obtain a health assessment as required by regulation prior to employment: Staff # 12, 13, 24, # 27, # 29, # 30 and # 2. Staff # 12 did not obtain a health assessment until 9/25/23. Staff # 13 did not obtain a health assessment until 11/29/23. Staff # 24 did not obtain a health assessment until 12/14/23. The file of Staff # 27 did not contain a health assessment. The file of Staff # 29 did not contain a health assessment. The file of Staff # 30 did not contain a health assessment. Staff # 2 did not receive a health assessment until 12/4/23.

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. A facility person's record shall include a written report of initial and subsequent health assessments, including the results of initial and subsequent tuberculin skin tests, x-rays or other medical documentation necessary to confirm freedom from communicable tuberculosis.

Regulation: 3270.151(c)(2)/3270.192(3)

Description: Mantoux TB/Health assessment, TB test

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. See the code sheet for the date of hire. The following staff did not receive a tuberculosis (TB) screening prior to employment as required by regulation: Staff # 12, # 26, # 27, # 29 and # 30. Staff # 12 received a TB screening on 8/23/23. Staff # 26 received a TB screening on 8/28/23.

Correction Required: 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. A facility person's record shall include a written report of initial and subsequent health assessments, including the results of initial and subsequent tuberculin skin tests, x-rays or other medical documentation necessary to confirm freedom from communicable tuberculosis.

Regulation: 3270.182(5)

Description: Consent for administration of minor first-aid required prior to admission

Noncompliance Area: A renewal inspection occurred at the facility. A review of children's files was conducted. The file of Child # 10 did not contain consent signed by a parent for administration of minor first-aid procedures by facility staff.

Correction Required: 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(5)

Description: Two written references

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. The following staff were missing 2-letters of written reference in their file: Staff # 25, # 27, # 29, # 30 and # 1 (missing only 1 letter).

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)(6)

Description: Emergency plan

Noncompliance Area: A renewal inspection occurred at the facility. At the time of the inspection, the facility was unable to provide documentation of when the facility participated in the annual emergency drill.

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

Regulation: 3270.27(c)

Description: Training regarding plan

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. At the time of the inspection, the facility was unable to provide documentation that the following staff had reviewed the emergency plan on an annual basis: Staff # 17. The following staff did not review the emergency plan at the time of initial hire (see the code sheet for the date of hire) :# 26 and # 1. Staff # 26 and # 1 reviewed the emergency plan on 11/14/23.

Correction Required: 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.

Regulation: 3270.31(e)(4)(i)

Description: Age and Training

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. Staff person # 11 does not have current pediatric first-aid/CPR training. This is evidenced by the previously documented pediatric first-aid/CPR training expiration date of 6/16/21. Staff person # 5 does not have current pediatric first-aid/CPR training. This is evidenced by the previously documented pediatric first-aid/CPR training expiration date of 5/26/21. The following staff did not update their pediatric first aid/CPR training prior to expiration: Staff # 14, # 15, # 17, # 18 and # 21. Staff # 14 took the training on 5/26/21 but did not take the training again until 12/17/23. Staff # 15 took the training on 1/13/21 but did not take the training again until 1/17/23. Staff # 17 took the training on 5/26/21 but did not take the training again until 12/17/23. Staff # 18 took the training on 7/22/21 but did not take the training again until 12/17/23. Staff # 21 took the training on 5/16/21 but did not take the training again until 11/27/23.

Correction Required: Competence is the completion of training by a professional in the field of first-aid and cardiopulmonary resuscitation (CPR). All staff persons shall renew their certification in pediatric first aid and pediatric cardiopulmonary resuscitation (CPR) on or before the expiration of the most current certification. Staff person # 5 and # 11 will have until 1/27/24 to complete the required training. Until such time as the required training is completed, staff person # 5 and # 11 must be supervised, when interacting with children, by a AGS who has completed the required training related to this citation. If there are no staff person(s) available to supervise staff person # 5 and # 11, staff person # # 5 and # 11 may not work in a child care position at the facility.

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

Description: Fire safety - 1 yr.

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. At the time of the inspection, the facility was unable to provide documentation that the following staff had participated in annual fire safety training: # 10, # 11, # 4, # 14, # 15, # 16, # 9, # 18, # 19, # 20, and # 21. Staff # 10 last took fire safety training on 10/8/22. Staff # 19 last participated in fire safety training on 1/11/22. Staff # 11, # 4, # 14, # 15, # 16, # 9, # 18, # 20, and # 21 last took fire safety training on 11/8/22.

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: 3270.31(e)/3270.192(2)(iii)

Description: Age and Training/Exp, educ., training at facility

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. At the time of the inspection, the facility was unable to provide the 12-hours of annual child care training for the following staff: Staff # 11, # 20, and # 21.

Correction Required: A staff person shall obtain an annual minimum of 12 clock hours of child care training. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. Staff person # 22 and # 26 have 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 # 26 completed this training on 8/29/23. Staff person # 20 , # 23 and # 1 have not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): health and safety.

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 # 22 will have until 1/27/24 to complete the required training. Until such time as the required training has been completed, staff person # 22 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 # 22, staff person # 22 may not work in a child-care position at the facility.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: An unannounced inspection occurred at the facility. A review of staff files was conducted. See the code sheet for the dates of hire. Staff # 2 was hired incorrectly per the CPSL. Staff # 2 was hired using a volunteer state police clearance dated 8/4/22 and the file did not contain the correct state police clearance until 7/20/23. Staff # 2 was also hired using a volunteer child abuse clearance dated 8/10/22 and the file did not contain the correct child abuse clearance until 7/26/23. Staff # 2 was hired using a Department of Education FBI clearance dated 8/5/22. The file did not contain documentation that the correct FBI clearance was applied for. The file for Staff # 2 also did not contain documentation the NSOR clearance was applied for. Staff # 2 was hired incorrectly as a provisional hire per the CPSL and was working with children during this time. Staff # 7 lived in New Jersey and the file of staff # 7 did not contain the appropriate clearances from New Jersey. Staff # 7 was working in childcare without documentation of applying for or receiving the clearances from New Jersey. Staff # 8 was hired incorrectly per the CPSL. The file of Staff # 8 did not contain documentation that the FBI clearance was applied for. Staff # 8 did not receive an FBI clearance until 8/31/22 which was after Staff # 8 began working with children. An acceptable plan of correction was received 10/17/23. On 12/13/23 an inspection occurred at the facility. A review of staff files was conducted. Staff # 2 still did not have the appropriate DHS FBI clearance in their file. Staff # 2 still did not have an NSOR clearance in their file. Staff # 12 was hired incorrectly as a provisional hire. Staff # 12 did not receive a child abuse clearance until 8/22/23 which was after this staff worked in child care. Per the CPSL, the child abuse clearance must be received before a staff an begin employment as a provisional hire. Staff # 15 has not updated their FBI clearance since 12/14/23. Staff # 15 was working unsupervised during this inspection. Staff # 16 did not update their FBI clearance every 60 months as required by the CPSL. The previous FBI clearance was dated 10/3/18 and not updated again until 12/18/23. Staff # 25 was not hired correctly as a provisional hire. The file did not contain documentation that Staff # 25 applied for the state police clearance prior to working in a child care position at the facility. Staff # 25 was working at the time of this inspection. Staff # 27 was hired incorrectly as a provisional hire. The file of Staff # 27 did not contain a disclosure statement that was also signed by a witness or dated. The disclosure statement was only signed by Staff # 27. Staff # 27 was working at the time of the inspection. Staff # 28 was hired incorrectly as a provisional hire. Staff # 28 was hired using a volunteer child abuse clearance and the file did not contain documentation this Staff # 28 applied for the NSOR clearance prior to working in child care. Staff # 29 was hired incorrectly as a provisional hire. The file of Staff # 29 did not contain a disclosure statement that was also signed by a witness or dated. The disclosure statement was only signed by Staff # 29. The file also did not contain documentation that Staff # 29 applied for the NSOR clearance. Staff # 30 was hired incorrectly as a provisional hire. The file of Staff # 30 did not contain a disclosure statement that was also signed by a witness or dated. The disclosure statement was only signed by Staff # 30. The file also did not contain documentation that Staff # 30 applied for the state police clearance.

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. Facility Person # 2, # 15, # 25, # 27, # 28, # 29 and # 30 may not work in a child care position at the facility. The Legal Entity / Director will establish a hiring policy of checks and balances to ensure complete files and staff are hired appropriately per regulations and Federal/State laws. The policy will include how the facility will ensure the new staff's file is initially reviewed for completeness. A second level review will also be instituted to ensure completeness. These level reviews will be indicated by signatures of those who reviewed the file, located in the file. The policy will be submitted to the Department prior to implementation for approval. Once approved by the Department, this policy will be instituted.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: An unannounced inspection occurred at the facility. A review of staff files was conducted. See the code sheet for the dates of hire. Staff # 2 was hired incorrectly per the CPSL. Staff # 2 was hired using a volunteer state police clearance dated 8/4/22 and the file did not contain the correct state police clearance until 7/20/23. Staff # 2 was also hired using a volunteer child abuse clearance dated 8/10/22 and the file did not contain the correct child abuse clearance until 7/26/23. Staff # 2 was hired using a Department of Education FBI clearance dated 8/5/22. The file did not contain documentation that the correct FBI clearance was applied for. The file for Staff # 2 also did not contain documentation the NSOR clearance was applied for. Staff # 2 was hired incorrectly as a provisional hire per the CPSL and was working with children during this time. Staff # 7 lived in New Jersey and the file of staff # 7 did not contain the appropriate clearances from New Jersey. Staff # 7 was working in childcare without documentation of applying for or receiving the clearances from New Jersey. Staff # 8 was hired incorrectly per the CPSL. The file of Staff # 8 did not contain documentation that the FBI clearance was applied for. Staff # 8 did not receive an FBI clearance until 8/31/22 which was after Staff # 8 began working with children. An acceptable plan of correction was received 10/17/23. On 12/13/23 an inspection occurred at the facility. A review of staff files was conducted. Staff # 2 still did not have the appropriate DHS FBI clearance in their file. Staff # 2 still did not have an NSOR clearance in their file. Staff # 12 was hired incorrectly as a provisional hire. Staff # 12 did not receive a child abuse clearance until 8/22/23 which was after this staff worked in child care. Per the CPSL, the child abuse clearance must be received before a staff an begin employment as a provisional hire. Staff # 15 has not updated their FBI clearance since 12/14/23. Staff # 15 was working unsupervised during this inspection. Staff # 16 did not update their FBI clearance every 60 months as required by the CPSL. The previous FBI clearance was dated 10/3/18 and not updated again until 12/18/23. Staff # 25 was not hired correctly as a provisional hire. The file did not contain documentation that Staff # 25 applied for the state police clearance prior to working in a child care position at the facility. Staff # 25 was working at the time of this inspection. Staff # 27 was hired incorrectly as a provisional hire. The file of Staff # 27 did not contain a disclosure statement that was also signed by a witness or dated. The disclosure statement was only signed by Staff # 27. Staff # 27 was working at the time of the inspection. Staff # 28 was hired incorrectly as a provisional hire. Staff # 28 was hired using a volunteer child abuse clearance and the file did not contain documentation this Staff # 28 applied for the NSOR clearance prior to working in child care. Staff # 29 was hired incorrectly as a provisional hire. The file of Staff # 29 did not contain a disclosure statement that was also signed by a witness or dated. The disclosure statement was only signed by Staff # 29. The file also did not contain documentation that Staff # 29 applied for the NSOR clearance. Staff # 30 was hired incorrectly as a provisional hire. The file of Staff # 30 did not contain a disclosure statement that was also signed by a witness or dated. The disclosure statement was only signed by Staff # 30. The file also did not contain documentation that Staff # 30 applied for the state police clearance.

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. Facility Person # 2, # 15, # 25, # 27, # 28, # 29 and # 30 may not work in a child care position at the facility.

Regulation: 3270.33(a)/3270.192(2)(ii)

Description: Each staff person meets quals/Exp, educ., training prior to facility

Noncompliance Area: An unannounced inspection occurred at the facility. A review of staff files was conducted. Staff # 1 and Staff # 2 were working together and both staff did not have the appropriate educational documentation to qualify these staff to work in a childcare role at the facility. An acceptable plan of correction was received on 10/17/23. An inspection occurred on 12/13/23. At the time of the inspection, the facility was unable to provide documentation or proof of the following staff's level of education: Staff # 13, # 29 and # 30.

Correction Required: A staff person or a substitute staff person shall meet one of the applicable staff qualifications for the position in which the person is performing. A facility person's record shall include verification of child care experience, education and training prior to service at the facility.

Regulation: 3270.34(a)(6)

Description: Staff evaluations

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. See the code sheet for dates of hire. At the time of the inspection, the facility was unable to provide documentation of a completed annual staff evaluation on the following staff: # 14 (previous 11/13/22), # 20 (no previous), # 21 (previous 11/3/22), and # 23 (no previous).

Correction Required: A director is responsible for written evaluation of staff persons on a regular basis, a minimum of one evaluation every 12 months.

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

Description: HS/GED + 2 yrs/Exp, educ., training prior to facility

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. The facility was attempting to qualify Staff # 13, # 29, and # 30 as an AGS but the files did not contain proof of education so the staff could be appropriately qualified as an AGS.

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 verification of child care experience, education and training prior to service at the facility.

Regulation: 3270.113(b)

Description: No physical punishment

Noncompliance Area: Through staff interviews and facility documentation, it has been determined that on 8/31/23, Staff # 2 slapped Child # 1 as witnessed by Staff # 1.

Correction Required: A facility person may not use any form of physical punishment, including spanking a child. The legal entity must arrange for Staff # 2 to receive a minimum of three hours of PQAS-approved in-person training, including technical assistance, regarding behavior management and appropriate discipline of children. This training must be completed as a live training or in-person. The legal entity must receive DHS approval of the training content prior to scheduling the training.

Regulation: 3270.113(b)

Description: No physical punishment

Noncompliance Area: Through staff interviews and facility documentation, it has been determined that on 8/31/23, Staff # 2 slapped Child # 1 as witnessed by Staff # 1.

Correction Required: A facility person may not use any form of physical punishment, including spanking a child.

Regulation: 3270.19(a)/3270.19(b)

Description: Required to report/Child abuse reporting

Noncompliance Area: Through staff interviews and facility documentation, it has been determined that on 8/31/23, Staff # 2 slapped Child # 1 as witnessed by Staff # 1. Staff # 1 reported the incident to Staff # 3 and # 4 but Staff # 1, # 2, or # 3 as mandated reporters, never reported the incident to Childline as mandated by the CPSL.

Correction Required: An operator or a staff person who has reason to believe that a child enrolled in the facility has been abused is required to report suspected child abuse to ChildLine as mandated by the CPSL. A facility person who has reasonable cause to suspect that a child is a victim of child abuse shall immediately make a report of suspected child abuse to ChildLine through the hotline at (800) 932-0313, online, or any other method as prescribed by the Department.

Regulation: 3270.19(a)/3270.19(b)

Description: Required to report/Child abuse reporting

Noncompliance Area: Through staff interviews and facility documentation, it has been determined that on 8/31/23, Staff # 2 slapped Child # 1 as witnessed by Staff # 1. Staff # 1 reported the incident to Staff # 3 and # 4 but Staff # 1, # 2, or # 3 as mandated reporters, never reported the incident to Childline as mandated by the CPSL.

Correction Required: An operator or a staff person who has reason to believe that a child enrolled in the facility has been abused is required to report suspected child abuse to ChildLine as mandated by the CPSL. A facility person who has reasonable cause to suspect that a child is a victim of child abuse shall immediately make a report of suspected child abuse to ChildLine through the hotline at (800) 932-0313, online, or any other method as prescribed by the Department. The legal entity must arrange for all facility staff to receive a minimum of two hours of PQAS-approved training, regarding mandated reporting. The legal entity will receive approval of the training prior to scheduling the training. Once completed, the legal entity will provide the completed training proof to the regional office.

Regulation: 3270.51

Description: Similar Age Level

Noncompliance Area: See IS 00229480 8/24/23-9/5/23 and IS 00230282 8/24/23-9/5/23.

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.

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: An unannounced inspection occurred at the facility. A review of staff files was conducted. Staff person # 1 was working unsupervised and has not completed the following required pre-service training: pediatric first aid and CPR. Staff person # 2 was working unsupervised and has not completed the following required pre-service training: health and safety topics.

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. Staff person(s) shall complete professional development in the topics of 3270.31(f)(1 -- 10). Until such time as the required training has been completed, staff person # 1 and # 2 must be supervised, when interacting with children, by an AGS who has completed the required training related to this citation. If there are no staff available to supervise staff person # 1 and # 2, staff person # 1 and # 2 may not work in a child-care position at the facility.

Regulation: 3270.151(a)/3270.192(3)

Description: 12 months prior to service and every 24 months thereafter/Health assessment, TB test

Noncompliance Area: An unannounced inspection occurred at the facility. A review of staff files was conducted. The file of Staff # 2 did not contain a health assessment and Staff # 2 was working in childcare at the time of this inspection.

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. A facility person's record shall include a written report of initial and subsequent health assessments, including the results of initial and subsequent tuberculin skin tests, x-rays or other medical documentation necessary to confirm freedom from communicable tuberculosis.

Regulation: 3270.31(e)(4)(iv)/3270.115(a)(8)

Description: Water safety/Included in ratio/annual training

Noncompliance Area: An unannounced inspection occurred at the facility. A review of staff files was conducted. The following staff would supervise children at the pool while swimming and the staff did not have documentation of water safety training in the file at the time of this inspection: Staff # 1, # 2, # 3, # 4, # 5, # 6, # 7 and # 9.

Correction Required: Competence in water safety instruction is demonstrated by the completion of basic instruction in water safety from a certified lifeguard. A facility person who is counted in the staff-child swimming ratio shall annually complete water safety instruction.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: An unannounced inspection occurred at the facility. A review of staff files was conducted. See the code sheet for the dates of hire. Staff # 2 was hired incorrectly per the CPSL. Staff # 2 was hired using a volunteer state police clearance dated 8/4/22 and the file did not contain the correct state police clearance until 7/20/23. Staff # 2 was also hired using a volunteer child abuse clearance dated 8/10/22 and the file did not contain the correct child abuse clearance until 7/26/23. Staff # 2 was hired using a Department of Education FBI clearance dated 8/5/22. The file did not contain documentation that the correct FBI clearance was applied for. The file for Staff # 2 also did not contain documentation the NSOR clearance was applied for. Staff # 2 was hired incorrectly as a provisional hire per the CPSL and was working with children during this time. Staff # 7 lived in New Jersey and the file of staff # 7 did not contain the appropriate clearances from New Jersey. Staff # 7 was working in childcare without documentation of applying for or receiving the clearances from New Jersey. Staff # 8 was hired incorrectly per the CPSL. The file of Staff # 8 did not contain documentation that the FBI clearance was applied for. Staff # 8 did not receive an FBI clearance until 8/31/22 which was after Staff # 8 began working with children.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Facility Person # 2, # 7, and # 8 may not work in a child care position at the facility. The Legal Entity, Director, Site Supervisor or anyone involved with the hire of staff or staff files, will schedule and attend Existing Provider Orientation at the Northeast Regional Office. The training can be scheduled by calling 800-222-2108. The training date is 11/29/23. 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.