Beth Shalom Early Childhood Dept

Regulation: 3270.151(a)/3270.192(3)

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

Noncompliance Area: A determination could not be made if Staff Person #1 had a health assessment conducted on 3/7/25. The form on file was signed and dated by the physician, but the results from the assessment were not completed (boxes #1, #2, and #3).

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

Description: Health and Safety Training

Noncompliance Area: Staff Person #2 completed the PA Health and Safety for Centers-Groups Part 2 training on 6/4/25 but did not complete within 90 days of their date of hire (See LIS Code Sheet).

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

Regulation: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: Staff Person #2 completed Mandated Reporter training on 6/4/25 but did not complete within 90 days of their date of hire (See LIS Code Sheet). The file for Staff Person #3, who resided in the state of Maryland within the last five years, contained Maryland Child Abuse clearance results dated 4/10/26 but was completed after the staff person's first day working in a child care setting (See LIS Code Sheet). The files are now current.

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

Regulation: 3270.95(a)/3270.95(b)

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

Noncompliance Area: Facility files contained documentation of testing the fire detection system that exceeded 30 days between testing from 05/01/25 to 06/02/25, 08/01/25 to 09/02/25, 10/02/25 to 11/03/25, and 12/02/25 to 01/02/26.

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: 3270.113(a)

Description: Supervised at all times

Noncompliance Area: Based on staff statements and video recording, on July 29, 2025, a fire drill was conducted at 10:00 AM. In Room 101, Staff Persons #1, #2, #3, and #4 evacuated two emergency cribs of 7 children leaving Child #1 behind in the room alone and unsupervised for approximately 1 minute and 28 seconds before the Head of Maintenance found Child #1 during a post-evacuation sweep.

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. Tiered LIS: Tier 1: Children must be supervised at all times. Tier 2: The legal entity, in collaboration with PA Key and ECELS, will develop and implement a Fire Drill Evaluation Tool to document staff performance, communication, and adherence to supervision expectations. The tool will capture evacuation of all staff and children, room checks, communication during evacuation and re-entry, and supervision. Leadership representatives will participate in a minimum of three hours of technical assistance with PA Key and ECELS to strengthen supervision systems through a review of current policies and practices, identification of supervision gaps, and reinforcement of open communication, staff accountability, and post-incident debriefing to support continuous learning. The legal entity will also establish backup systems for requesting assistance during drills, emergencies, or staffing transitions to prevent supervision lapses. The completed supervision plan and Fire Drill Evaluation Tool will be submitted to the Regional Office within five business days of completion. Tier 3: Once the requirements in Tier #2 are met, the legal entity will ensure all staff participate in a minimum two-hour training conducted by the PA Key and ECELS to promote consistent understanding and implementation of supervision expectations. The Director and designated staff member will work together to maintain alignment of supervision practices across classrooms. The legal entity will conduct collaborative training sessions to strengthen communication, clarify supervision responsibilities, and ensure appropriate staff-to-child ratios and supervision coverage at all times. A trauma-informed approach will be reinforced to help staff recognize and manage "fight, flight, or freeze" responses during emergencies. The legal entity will also develop and discuss backup systems for requesting assistance during drills or crisis situations, emphasizing staff accountability for assigned safety roles and responsibilities. The training sign-in sheets and assessments for all facility persons will be submitted to the Regional Office within five business days of completion. Tier 4: Once Tier #3 requirements are met and following completion of the PA Keys training, the legal entity will conduct three consecutive monthly fire drills to assess staff implementation of supervision procedures in real time. Following each drill, the legal entity will hold a staff meeting to review results, discuss observations, and provide feedback on staff performance. During the meeting, the legal entity will highlight strengths, identify areas for improvement, and reinforce supervision expectations. Documentation from each drill, including the completed Fire Drill Evaluation Tool, meeting agenda, sign-in sheets, and any supporting notes, will be maintained for review by the Certification Representative. All related documentation will be submitted to the Regional Office within five business days of each meeting.

Regulation: 3270.113(a)(1)

Description: Staff assigned to specific children

Noncompliance Area: Based on staff statements and video recording, on July 29, 2025, a fire drill was conducted at 10:00 AM. In Room 101, Staff Persons #1, #2, #3, and #4 evacuated two emergency cribs of 7 children leaving Child #1 behind in the room alone and unsupervised for approximately 1 minute and 28 seconds before the Head of Maintenance found Child #1 during a post-evacuation sweep.

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.

Regulation: 3270.51

Description: Similar Age Level

Noncompliance Area: Based on staff statements and video recording, on July 29, 2025, a fire drill was conducted at 10:00 AM. In Room 101, Staff Persons #1, #2, #3, and #4 evacuated two emergency cribs of 7 children leaving Child #1 behind in the room alone and unsupervised for approximately 1 minute and 28 seconds before the Head of Maintenance found Child #1 during a post-evacuation sweep.

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: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: The resting mats in Room 104 and Room 203 were observed to be ripping on the edges exposing foam the interior and were not in good repair.

Correction Required: Toys, play equipment and other indoor and outdoor equipment used by the children shall be clean, in good repair and free from rough edges, sharp corners, pinch and crush points, splinters and exposed bolts.

Regulation: 3270.111(b)

Description: Posted in group space

Noncompliance Area: A written plan of daily activities was not posted in Room 208.

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

Regulation: 3270.123(a)(5)

Description: Designated release persons

Noncompliance Area: The financial agreement form in the file for child #2 did not include the persons designated by the parent to whom the child may be released.

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

Regulation: 3270.123(a)(6)

Description: Admission date

Noncompliance Area: The financial agreement form in the file for child #2 did not include the date of the child's admission.

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

Regulation: 3270.124(b)(3)

Description: Parent home/work address, phone

Noncompliance Area: The emergency contact form in the file for child #1 lacked the enrolling parent's work address and telephone number.

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

Regulation: 3270.151(c)(1)

Description: Physical examination

Noncompliance Area: The file for staff person #3 has a current health assessment on file dated 1/16/25, but the previous health assessment on file dated 8/2/23 did not include a physical examination.

Correction Required: An adult health assessment must include a physical examination.

Regulation: 3270.151(c)(3)

Description: Exam communicable disease

Noncompliance Area: The health assessment on file for staff person #4 did not include an examination for communicable diseases and the results of that examination. The health assessment on file for staff person #6 included an examination for communicable diseases but did not include the results of the examination.

Correction Required: An adult health assessment must include an examination for communicable diseases and the results of that examination.

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: Staff person #1 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Health and Safety.

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

Regulation: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: The file for staff person #5, who was hired provisionally, had documentation of application for child abuse and neglect and sex offender clearance for the state of North Carolina where the staff person resided in the five years prior to employment dated 11/26/24 but was after the staff persons date of hire (See IS Code Sheet). The file for staff person #5 now has documentation of clearance results for the state of North Carolina.

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

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

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

Noncompliance Area: The file for staff person #2, identified as an assistant group supervisor, lacked qualification documents at the time of inspection.

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 following the outset of service at the facility.

Regulation: 3270.65

Description: Protective Outlet Covers 5 yrs. or less

Noncompliance Area: In Room 101, an electrical outlet was observed to be missing a protective receptacle cover and was accessible to children under 5 years of age.

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

Regulation: 3270.77(a)

Description: No peeling paint or plaster

Noncompliance Area: In the outdoor preschool playground, childrens benches were observed to be chipping paint.

Correction Required: Peeled or damaged paint or damaged plaster is not permitted on indoor or outdoor surfaces in the child care facility.

Regulation: 3270.82(h)

Description: Handwashing signs

Noncompliance Area: A handwashing sign was not posted near one sink and one toilet in the restroom between Room 101 and Room 103.

Correction Required: A facility person and an able child shall wash his hands after toileting and before eating. A sign on which this requirement is written shall be posted at each toilet, training chair, diapering area and sink in the facility.

Regulation: 3270.95(a)/3270.95(b)

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

Noncompliance Area: The facilities documentation of testing the fire detection system exceeded 30 days between multiple testings since 5/17/24.

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: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: Observed dirt and debris under the mats of the diaper changing tables in the infant and toddler rooms.

Correction Required: Toys, play equipment and other indoor and outdoor equipment used by the children shall be clean, in good repair and free from rough edges, sharp corners, pinch and crush points, splinters and exposed bolts.

Regulation: 3270.123(b)

Description: Parent receives original

Noncompliance Area: The fee agreements in the child files which were reviewed were the original documents.

Correction Required: A parent shall receive the original agreement. The facility shall retain a copy of the agreement.

Regulation: 3270.124(b)(6)

Description: Insurance coverage information

Noncompliance Area: The Emergency Contact forms in the files for Child #1 and #4 did not include health insurance coverage and policy numbers.

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

Regulation: 3270.124(b)(7)

Description: Name/address/phone release person

Noncompliance Area: The Emergency Contact forms in the files for Child #1 and #3 did not include the release persons addresses.

Correction Required: Emergency contact information must include the name, address and telephone number of the individual designated by the parent to whom the child may be released.

Regulation: 3270.131(b)(2)/3270.182(1)

Description: Toddler/preschool: updated health report every 12 months/Initial and subsequent health reports

Noncompliance Area: The most recent updated health reports in the file for Child #5, a Preschool Child, exceeded 12 months between reports.

Correction Required: The operator shall require the parent to provide an updated health report at least every 12 months for an older toddler or preschool child. A child's record shall contain initial and subsequent health reports.

Regulation: 3270.133(3)

Description: Name on bottle

Noncompliance Area: Observed in the medicine box in the toddler room, a bottle of eye drops, which were not labeled with the name of Child #2, for whom the medication was 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: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: The facility's emergency plan did not include requirements for volunteer emergency preparedness training, practice drills and continuity of operations (backing up or retrieving health and other key records/files and managing financial issues such as paying employees and bills during the aftermath of the disaster) to maintain compliance with 45 CFR § 98.41(a)(1)(vii)

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.

Regulation: 3270.151(a)/3270.192(3)

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

Noncompliance Area: The TB Screening in the file for Staff Person #2 was conducted more than 12 months prior to the staff person's start date and is not valid (See LIS Code Sheet).

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: 3270.181(c)

Description: Emergency info/agreement updated 6 mos

Noncompliance Area: The Emergency Contact Forms and Fee Agreements in the files for Child #4 and #6 have not been updated by the parents in the past six months.

Correction Required: 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: 3270.182(3)/3270.182(5)

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

Noncompliance Area: The Emergency Contact Form in the file for Child #4 did not include signed parental consent for emergency medical care for the child signed parental consent for administration of minor first-aid procedures by facility staff.

Correction Required: A child's record shall contain signed parental consent for emergency medical care for the child. Written consent is required prior to admission. A child's record shall contain signed parental consent for administration of minor first-aid procedures by facility staff. Written consent is required prior to admission.

Regulation: 3270.27(c)

Description: Training regarding plan

Noncompliance Area: The file for Staff Person #1 did not include documentation of training in the facility's Emergency Plan conducted within the past 12 months. The files for Staff Person #6, 7 and 8, who have been working at the facility for more than 90 days, did not include documentation of initial training in the facility's Emergency Plan (See LIS Code Sheet).

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(f)

Description: Health and Safety Training

Noncompliance Area: The Health and Safety Trainings in the files for Staff Person #1 and #2 were conducted more than 90 days after the staff persons' first day working in child care. The Pediatric First Aid/CPR Trainings in the files for Staff Person #3 and #5 were conducted more than 90 days after the staff persons' first day working in child care (See LIS Code Sheet).

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

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: Staff person #4 has not completed the following required pre-service training within 90 days of their date of hire: Health and Safety Training (see LIS code sheet).

Correction Required: Staff person shall complete professional development in the topics of 3270.31(f)(1 -- 10) within 90 days of hire. Staff person #4 will have until 3/12/24 to complete the required training. Until such time as the required training has been completed, staff person #4 must be supervised, when interacting with children, by an AGS or higher who has completed the required training related to this citation. If there are no staff available to supervise staff person #4, staff person #4 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: The file for Staff Person #9, an aide, did not include documentation of a high school diploma.

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: 3270.76

Description: Building Surfaces

Noncompliance Area: Observed discolored ceiling tiles from water damage in the following areas: Corner of Room #102 (Infant Nap Room), Room #103 in the middle of ceiling near sprinkler, Room #104 above diaper table, and gym restroom. The gate in the infant room was wobbly, which creates a potential toppling hazard. The closet doors under the stage in the gym were not secured, which creates a potential pinch hazard.

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

Regulation: 3270.77(a)

Description: No peeling paint or plaster

Noncompliance Area: Observed in the Infant Room #101: peeling paint at the bottom of the gate on the left side of the room. Flaking plaster at the bottom of the wall near the entrance gate.

Correction Required: Peeled or damaged paint or damaged plaster is not permitted on indoor or outdoor surfaces in the child care facility.

Regulation: 3270.94(a)(1)

Description: Every 60 days

Noncompliance Area: The fire drill log documented three times when fire drills exceeded 60 days: 2/1/23-4/20/23, 4/20/23-6/27/23, and 6/27/23-8/29/23.

Correction Required: The Director or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that fire drills are conducted at least once every 60 days.

Regulation: 3270.95(a)/3270.95(b)

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

Noncompliance Area: Based on review of the fire drill/fire system check log, the fire detection/alarm system has not been tested every 30 days.

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(8)

Description: Special diet - parent's instructions

Noncompliance Area: While having breakfast, child #1 ingested a dairy product which based on written parental instructions, the child is not permitted to have due to an allergy.

Correction Required: If a special diet is prescribed for a child and if the diet is administered to the child, written instructions and the parent's written consent shall be retained in the child's file.

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: Staff person #1 and 2 have not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): pediatric first aid and pediatric CPR

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 #1 and 2 will have until 4/12/2023 to complete the required training. 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: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: Documentation of completion of the training on the health and safety topics listed in subsections (f)1-10 was completed on 3/14/2023 by facility person #2, which was more than 90 days from their start date at the facility (see coded LIS sheet).

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

Regulation: 3270.124(b)(5)

Description: Information re: special needs

Noncompliance Area: The file for child #1 lacked emergency contact information that included information on the child's special needs, as specified by the child's parent, physician, physician's assistant or CRNP, which is needed in an emergency situation.

Correction Required: Emergency contact information must include information on the child's special needs, as specified by the child's parent, physician, physician's assistant or CRNP, which is needed in an emergency situation.

Regulation: 3270.131(d)(1)

Description: Child's health history

Noncompliance Area: The file for child #3 lacked a health report that included a review of the child's health history.

Correction Required: A health report shall include a review of the child's health history.

Regulation: 3270.131(d)(7)

Description: Free from contagious/communicable disease

Noncompliance Area: The file for child #3 lacked a health report that included a statement that the child is able to participate in child care and appears to be free from contagious or communicable disease.

Correction Required: A health report shall include a statement that the child is able to participate in child care and appears to be free from contagious or communicable disease.

Regulation: 3270.133(1)/3270.133(3)

Description: Original container/Name on bottle

Noncompliance Area: In Room 206 and Room 208 two albuterol inhalers (one in each room) were observed to not be in the original container labeled with the name of the medication and the name of the child for whom the medication is intended.

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. 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: 3270.151(a)

Description: 12 months prior to service and every 24 months thereafter

Noncompliance Area: The file for staff person #4 lacked a health assessment that was completed 12 months from the previous health assessment. The health assessments in the file are dated 1/14/20 and 2/7/22.

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.

Regulation: 3270.182(5)

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

Noncompliance Area: The file for child #2 lacked emergency contact information that included signed parental consent for administration of minor first-aid procedures by facility staff prior to admission.

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: 3270.27(c)/3270.192(2)(iii)

Description: Training regarding plan/Exp, educ., training at facility

Noncompliance Area: The file for staff person #3 lacked emergency plan training that was completed 12 months from the previous emergency plan training. The emergency plan training in the file is dated 8/26/21 and 10/22/22.

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. 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(e)(4)(ii)/3270.192(2)(iii)

Description: Fire safety - 1 yr./Exp, educ., training at facility

Noncompliance Area: The file for staff person #1 lacked firesafety training that was completed 12 months from the previous firesafety training. The firesafety training in the file is dated 1/3/22 and 1/6/23. The file for staff person #3 lacked firesafety training that was completed 12 months from the previous firesafety training. The firesafety training in the file is dated 1/4/21 and 9/7/22. The file for staff person #4 lacked firesafety training that was completed 12 months from the previous firesafety training. The firesafety training in the file is dated 1/3/22 and 1/9/23. The file for staff person #5 lacked firesafety training that was completed 12 months from the previous firesafety training. The firesafety training in the file is dated 1/3/22 and 1/6/23. The file for staff person #7 lacked firesafety training that was completed 12 months from the previous firesafety training. The firesafety training in the file is dated 1/3/22 and 1/10/23. The file for staff person #9 lacked firesafety training that was completed 12 months from the previous firesafety training. The firesafety training in the file is dated 1/3/22 and 1/7/23.

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. 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(e)/3270.192(2)(iii)

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

Noncompliance Area: The file for staff person #6 lacked 12 clock hours of child care training between 12/19/21 and 12/19/22. There were 9 hours of child care training in the file between 12/19/21 and 12/19/22. The file for staff person #8 lacked 12 clock hours of child care training. There were 9 hours of child care training in the file.

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: 3270.34(a)(6)

Description: Staff evaluations

Noncompliance Area: The file for staff person #1 lacked a staff evaluation that was completed 12 months from the previous evaluation. The staff evaluations in the file are dated 12/9/21 and 1/4/23. The file for staff person #2 lacked a staff evaluation that was completed 12 months from the previous evaluation. The staff evaluations in the file are dated 12/16/21 and 1/3/23.

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: 3270.76

Description: Building Surfaces

Noncompliance Area: On the left hand side wall on the second mat a hole was observed creating a visible hazard.

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

Regulation: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: The dramatic play area in Room 203 had a toy dishwasher that included a plastic bin which had a broken piece on the corner.

Correction Required: Toys, play equipment and other indoor and outdoor equipment used by the children shall be clean, in good repair and free from rough edges, sharp corners, pinch and crush points, splinters and exposed bolts.

Regulation: 3270.124(b)(2)

Description: Physician name, address, phone

Noncompliance Area: The emergency contact form on file for Child #1 does not include a complete address for the child's physician/health care provider.

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

Regulation: 3270.124(b)(3)

Description: Parent home/work address, phone

Noncompliance Area: The emergency contact form on file for Child #1 does not include a complete address or telephone number for where the enrolling parent works.

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

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

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

Noncompliance Area: The file for Child #2 does not include written parental consent for the facility to obtain 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(b)(5)

Description: Information re: special needs

Noncompliance Area: The emergency contact form on file for Child #2 does not indicate if the child has any special medical needs or disabilities, as required in event of an emergency.

Correction Required: Emergency contact information must include information on the child's special needs, as specified by the child's parent, physician, physician's assistant or CRNP, which is needed in an emergency situation.

Regulation: 3270.124(b)(6)

Description: Insurance coverage information

Noncompliance Area: The emergency contact form on file for Child #1 does not include the health insurance coverage and policy number for the child's health insurance coverage.

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

Regulation: 3270.124(b)(7)

Description: Name/address/phone release person

Noncompliance Area: The emergency contact form on file for Child #1 does not include a complete address for all listed release persons.

Correction Required: Emergency contact information must include the name, address and telephone number of the individual designated by the parent to whom the child may be released.

Regulation: 3270.124(c)

Description: Each child care space

Noncompliance Area: There was a child receiving care in the Infant room (101) and nap room (102) without her emergency contact form being in the room.

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

Regulation: 3270.131(d)(5)/3270.131(e)(1)

Description: Immunization record/Exemption documentation from parent/guardian

Noncompliance Area: The current immunization record on file for Child #1 does not include an influenza vaccination administered in the last calendar year. The current immunization record on file for Child #3, who is 6 months old, includes 1 of 2 Hepatitis B vaccinations, 1 of 2 Rotavirus vaccinations, 1 of 2 DTAP vaccinations, 1 of 2 Pneumococcal vaccinations, and 1 of 2 Polio vaccinations that are recommended for a child this age.

Correction Required: A health report shall include a review of the child's immunized status according to recommendations of the ACIP. The facility shall require the parent to provide updated written verification from a physician, physician's assistant, CRNP, the Department of Health or a local health department of ongoing vaccines administered to an infant, toddler or preschool child in accordance with the schedule recommended by the ACIP.

Regulation: 3270.131(e)

Description: ACIP recommended immunization record

Noncompliance Area: The initial immunization record on file for Child #1, with an enrollment date of 8/30/21, is dated 11/3/21, more than 60 days after enrollment.

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: 3270.133(5)

Description: Original label

Noncompliance Area: There was a bottle of children's Tylenol in Room 206 labeled for use by a child which had expired 1/2022.

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

Regulation: 3270.133(6)

Description: Written consent

Noncompliance Area: There was a bottler of Zyrtec in Room 103 labeled for use by a child which did not have written parental consent to administer. There was a bottler of Tylenol in Room 104 labeled for use by a child which did not have written parental consent to administer.

Correction Required: A parent shall provide written consent for administration of medication or a special diet.

Regulation: 3270.151(a)

Description: 12 months prior to service and every 24 months thereafter

Noncompliance Area: The 2 most recent health assessments on file for Staff person #9 are dated 8/6/19 and 9/7/21, more than 24 months apart. The 2 most recent health assessments on file for Staff person #10 are dated 1/3/20 and 1/24/22, more than 24 months apart. The 2 most recent health assessments on file for Staff person #11 are dated 2/21/19 and 2/22/21, more than 24 months apart.

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.

Regulation: 3270.151(c)(1)/3270.192(3)

Description: Physical examination/Health assessment, TB test

Noncompliance Area: The current health assessment on file for Staff person #13, states the physician or health care professional did not complete a physical examination.

Correction Required: An adult health assessment must include a physical examination. 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: The initial Tuberculosis screening on file for Staff person #4, with a hire date of 8/30/21, is dated 8/19/20, more than 1 year prior to hire in a child care position.

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: The file for Child #2 does not include written parental consent for the facility to administer minor first aid procedures..

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: 3270.25(a)

Description: Availability of certificate of compliance and applicable regulations

Noncompliance Area: The facility did not have verification of notifying parents of enrolled children on how to access the regulations in this chapter electronically.

Correction Required: The facility's current certificate of compliance shall be posted in a conspicuous location used by parents. The operator shall provide the parent of each child enrolled with information on how to access the regulations in this chapter electronically and with instructions for contacting the appropriate regional child care office.

Regulation: 3270.27(c)/3270.192(2)(iii)

Description: Training regarding plan/Exp, educ., training at facility

Noncompliance Area: The file for Staff person #3, with a hire date of 8/30/21, does not include verification of emergency plan training at hire. The most recent emergency plan training on file for Staff person #9, dated 10/6/21, more than 1 year after the previous training, dated 8/19/19. The file for Staff person #12, with a hire date of 11/1/21, includes verification of emergency plan training completed 1/27/22, not at hire.

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. 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(e)/3270.192(2)(iii)

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

Noncompliance Area: The file for Staff person #9, who was hired prior to 12/19/20, does not include 12 hours of annual training between 12/19/20-12/19/21, as required by Announcement C-21-09. The file for Staff person #11, who was hired prior to 12/19/20, does not include 12 hours of annual training between 12/19/20-12/19/21, as required by Announcement C-21-09. The file for Staff person #13, who was hired prior to 12/19/20, does not include 12 hours of annual training between 12/19/20-12/19/21, as required by Announcement C-21-09.

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)(10)/3270.192(2)(iii)

Description: Health and Safety Training - Pediatric First Aid and CPR/Exp, educ., training at facility

Noncompliance Area: The file for Staff person #6, with a hire date of 11/15/21, lacked documentation of current certification in pediatric first-aid and CPR, which was due 90 days (2/13/22) following the hire date. The file for Staff person #7, with a hire date of 9/3/21, lacked documentation of current certification in pediatric first-aid and CPR, which was due 90 days (12/2/21) following the hire date. The file for Staff person #8, with a hire date of 10/6/21, lacked documentation of current certification in pediatric first-aid and CPR, which was due 90 days (1/4/22) following the hire date. The files for Staff #13, an existing staff member, lacked documentation of current certification in pediatric first-aid and CPR, which was due180 days following the implementation of the current regulations.

Correction Required: Staff persons shall complete professional development in pediatric first aid and pediatric cardiopulmonary resuscitation within 90 days of hire. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

Regulation: 3270.32(a)/3270.192(2)(iii)

Description: Comply with CPSL/Exp, educ., training at facility

Noncompliance Area: The file for Staff person #1, with a hire date of 3/8/21, has verification of completed mandated reporter training dated 6/9/21, more than 90 days after hire.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The NSOR certificate on file for Staff person #2, a provisional hire, with a hire date of 8/30/21, is dated 10/21/21, more than 45 days after hire. The disclosure statement on file for Staff person #5, with a hire date of 11/19/21, is dated 1/19/22, after hire. The signed disclosure statement on file for Staff person #6 is not dated.

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

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The file for Staff person #4, with a hire date of 8/30/21, has a PA Child Abuse clearance, dated 7/21/20, that was obtained for volunteer purposes. The file for Staff person #6, with a hire date of 11/15/21, and who requires out of state clearances from Delaware, where she resided in the previous 5 years, does not include a Delaware Child Abuse and Neglect clearance or Delaware Sex Offender registry check. The file for Staff person #8, with a hire date of 10/6/21, and who requires out of state clearances from Virginia, where she resided in the previous 5 years, does not include a Virginia Child Abuse and Neglect 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 #4, #6, #8 may not work in a child care position at the facility.

Regulation: 3270.34(a)(6)

Description: Staff evaluations

Noncompliance Area: The 2 most recent staff evaluations on file for Staff person #9 are dated 1/12/20 and 1/26/22, more than 1 year apart.

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: 3270.37(c)

Description: Aides supervised all times

Noncompliance Area: During the renewal inspection on 2/16/22, at approximately 10:00 AM, a staff person, who is classified as an aide, was observed to be unsupervised in the infant nap room with 4 infants on several brief occasions over a 3-5 minute period while infants were being transferred from the infant room to the infant nap room by another staff person, through the diaper changing room which is approximately 7 foot long room and separates the infant room and nap room.

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: 3270.65

Description: Protective Outlet Covers 5 yrs. or less

Noncompliance Area: There was an outlet under the chalkboard, which is accessible to children in Room 201 that did not have outlet covers. There was an extension cord in use in Room 201 which is accessible to children that had an unused plug that did not have an outlet cover.

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

Regulation: 3270.76

Description: Building Surfaces

Noncompliance Area: There was a hole in the wall, with exposed drywall, in Room 201, next to the "Sight words" wall hanging. There were five holes in the padding on the wall in the gym, with exposed foam filling.

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: 3270.77(a)

Description: No peeling paint or plaster

Noncompliance Area: The benches in the outdoor playground had several areas of peeling paint.

Correction Required: Peeled or damaged paint or damaged plaster is not permitted on indoor or outdoor surfaces in the child care facility.

Regulation: 3270.94(a)(1)

Description: Every 60 days

Noncompliance Area: The fire drill log included fire drills dated 1/6/21-3/10/21; 3/10/21-5/11/21; 5/11/21-7/29/21; 7/29/21-10/7/21-1/3/22, which are all more than 60 days apart.

Correction Required: The Director or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that fire drills are conducted at least once every 60 days.

Regulation: 3270.95(a)/3270.95(b)

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

Noncompliance Area: The 30 day test log for the fire alarm testing are dated 2/1/21-3/10/21; 3/10/21-4/15/21; 6/7/21-7/29/21; 9/6/21-10/7/21; and 10/7/21-11/8/21, which are all more than 30 days apart. The facility does not have proof of purchase of the fire alarm detection system, as required by L&I and Act 62.

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.