Bethlehem Ymca Childcare

Regulation: 3270.135(e)

Description: 2 hour diaper check

Noncompliance Area: A complaint investigation was conducted 7/31/26. It was discovered that on 7/20/26, Child #1 did not have their diaper changed at least every 2 hours. Through staff interviews and a review of center diaper logs, it was found that Child #1 had their diaper changed at approximately 3:00pm. When the child's parent arrived at the facility sometime after 5:00pm, the child had a soiled diaper. The child had not been changed since 3:00pm. The sign out sheet indicated that the parent had picked up the child at 5:45pm.

Correction Required: A staff person shall check a child's diaper at least every 2 hours and whenever the child indicates discomfort or exhibits behavior that suggests a soiled diaper. A staff person shall change a child's diaper when the diaper is soiled.

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

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

Noncompliance Area: An inspection was conducted on 6/24/26 regarding self-reported noncompliance at the child care center. On 6/18/26 at approximately 1:25pm, Staff Person #1 took a group of nine school age children to use the bathroom inside the men's locker room. Staff Person #1 exited the bathroom with a group of eight school age children and returned to the playground. Child #1 was forgotten in the men's locker room. Child #1 exited the locker room and was able to call a parent for help in order to be reunited with the other school age children. Staff Person #1 was terminated from employment at the facility. Their last date of employment was 6/18/26.

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. 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 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. Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises. This portion of the plan shall have an immediate correction date. 2. The legal entity must arrange for all staff to complete an online training regarding Supervision that they have not previously completed through Better Kid Care. The legal entity must receive DHS approval of the training content prior to staff completing the training. The operator shall provide a correction date for when the trainings will be completed.

Regulation: 3270.113(b)/3270.113(e)

Description: No physical punishment /Restraints prohibited

Noncompliance Area: An inspection was conducted on 6/24/26 regarding self-reported noncompliance at the child care center. On 6/19/26, at approximately 12:15pm, Staff Person #2 is seen approaching Child #2 as Child #2 starts to run from the staff. Staff Person #2 grabs the child roughly by the left arm, pulling the child toward them. Staff Person #2 then lifts the child under their armpits and takes the child to the lunch table. The view of the lunch table is obscured by a pole in the middle of the room. Ten seconds later, Staff Person #2 is seen carrying Child #2 by lifting them under their armpits to their cot, where the staff forcefully lays the child on the cot. Staff Person #2 is then seen holding the child down on the cot while Child #2 struggles beneath their hold. Staff Person #2 holds Child #2 down for approximately 45 seconds until it appears that Child #2 stops resisting. Staff Person #2 then covers Child #2 with a blanket. Child #2 stays on their cot after this, curled under their blanket. Staff Person #2 was terminated from employment at the facility on 6/19/26.

Correction Required: A facility person may not use any form of physical punishment, including spanking a child. A facility person may not restrain a child by using bonds, ties or straps to restrict a child's movement or by enclosing the child in a confined space, closet or locked room. The prohibition against restraining a child does not apply to the use of adaptive equipment prescribed for a child with special needs. TIERED LIS: 1. A facility person may not use any form of physical punishment, including spanking a child. A facility person may not restrain a child by using bonds, ties or straps to restrict a child's movement or by enclosing the child in a confined space, closet or locked room. The prohibition against restraining a child does not apply to the use of adaptive equipment prescribed for a child with special needs. This portion of the plan shall have an immediate correction date. 2. The legal entity must create a discipline policy. This policy must specifically include positives strategies for guiding children's behavior. The discipline policy must address compliance with 3270.113b, 3270.113c, 3270.113d, and 3270.113e. The discipline policy must include procedures that staff should follow when they are feeling overwhelmed or frustrated. The discipline policy must include what to do if a staff person observes another staff person not following the discipline policy. The legal entity must receive approval of the policy from the Regional Office. Once approved by the Regional Office, the legal entity must review policy with all current staff and have staff sign off that they understand and will follow the discipline policy. All new staff hired must review the discipline policy with the director at their time of hire and must sign off that they understand and will follow the discipline policy. The operator shall provide a correction date for when the policy will be reviewed with all staff.

Regulation: 3270.123(a)(6)

Description: Admission date

Noncompliance Area: A renewal inspection was conducted 12/16/25. At that time, the financial agreements for the following children did not include the child's date of admission: Child #2, Child #3, Child #4, Child #5, Child #6, Child #7, and Child #8.

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: A renewal inspection was conducted 12/16/25. At that time, the child files were reviewed. The emergency contact forms for Child #1, Child #2, Child #4, and Child #8 did not include the business name, address, and phone number of the parents.

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

Regulation: 3270.124(b)(7)

Description: Name/address/phone release person

Noncompliance Area: A renewal inspection was conducted 12/16/25. At that time, the child files were reviewed. The emergency contact forms for Child #4 and Child #8 did not include the address of the 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(e)

Description: Written emergency plan posted

Noncompliance Area: A renewal inspection was conducted 12/16/25. At that time, the emergency transportation plan was not posted in Room 12.

Correction Required: A written plan identifying the means of transporting a child to emergency care and staffing provisions in the event of an emergency shall be displayed conspicuously in every child care space and shall accompany a staff person who leaves on an excursion with children.

Regulation: 3270.151(a)

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

Noncompliance Area: A renewal inspection was conducted 12/16/25. At that time, the staff files were reviewed. The health assessment for Staff Person #1 was not updated within 24 months. This is evidenced by the health assessments on file being dated 3/28/23 and 5/19/25.

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: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: A renewal inspection was conducted 12/16/25. At that time, the staff files were reviewed. The file for Staff Person #2 did not include the required preservice training: PA Required Health and Safety for Centers-Group Child Care Part 2. Staff Person #2 has been employed more than 90 days.

Correction Required: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10. Staff Person #2 must complete PA Required Health and Safety for Centers-Group Child Care Part 2.

Regulation: 3270.65

Description: Protective Outlet Covers 5 yrs. or less

Noncompliance Area: A renewal inspection was conducted 12/16/25. At that time, a power strip was observed on the floor in the PreK C room that was plugged into a wall outlet. Three of the outlets in the power strip were not equipped with protective covers. Children under the age of 5 were observed in the room.

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

Regulation: 3270.75(c)/3270.75(d)

Description: Has all items/On excursions

Noncompliance Area: A renewal inspection was conducted 12/16/25. At that time, the first aid kit in Room 13 did not include gauze or water. Staff indicated that this first aid kit is brought on the bus when transporting children.

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. One first-aid kit per child care group must accompany children and facility persons on excursions from the facility. Each first aid kit taken on an excursion must contain a bottle of water in addition to the items specified at §3270.75(c).

Regulation: 3270.76

Description: Building Surfaces

Noncompliance Area: A renewal inspection was conducted 12/16/25. At that time, water stained ceiling tiles were observed in the Pre-K A Room.

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: A renewal inspection was conducted 12/16/25. At that time, peeling paint was observed under the window in the Young Toddler Room.

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

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

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

Noncompliance Area: An unannounced inspection was conducted on 1/17/25. At approximately 10:45am, Staff Person #1 was observed walking out of a classroom followed by a group of school age children who were leaving for school following a two-hour delayed opening. Approximately two minutes later, Child #1 opened the door and asked the director for help packing his backpack. Child #1 was alone in the classroom.

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. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises.

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

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

Noncompliance Area: An unannounced inspection was conducted on 1/17/25. At approximately 10:45am, Staff Person #1 was observed walking out of a classroom followed by a group of school age children who were leaving for school following a two-hour delayed opening. Approximately two minutes later, Child #1 opened the door and asked the director for help packing his backpack. Child #1 was alone in the classroom.

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. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises. The legal entity must arrange for Staff Person #1 to receive a minimum of two hours of training regarding Supervision. This must be a live training and must be PQAS approved. The legal entity must receive DHS approval of the training content prior to scheduling the training.

Regulation: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: A renewal inspection was conducted on 12/3/24. At that time, exposed bolts were observed along the fencing of the toddler playground and preschool playground.

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: 3270.102(c)

Description: Outdoor equip.- protective surfacing

Noncompliance Area: A renewal inspection was conducted on 12/3/24. At that time, the embedded equipment on the playground had between 5-6 inches of mulch underneath.

Correction Required: Outdoor equipment that requires embedded mounting must be mounted over a loose-fill or unitary playground protective surface covering that meets the recommendations of the United States Consumer Product Safety Commission. The equipment must be anchored firmly and be in good repair.

Regulation: 3270.124(b)(2)

Description: Physician name, address, phone

Noncompliance Area: A renewal inspection was conducted on 12/3/24. At that time, the child files were reviewed. The emergency contact form for Child #7 did not include the phone number of the child's physician. The emergency contact form for Child #8 did not include the address of the child's physician.

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: A renewal inspection was conducted on 12/3/24. At that time, the child files were reviewed. The emergency contact forms for Child #1, Child #2, Child #4, Child #5, Child #6, and Child #8 did not include the business name, address, and phone number of the parents.

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

Regulation: 3270.124(b)(6)

Description: Insurance coverage information

Noncompliance Area: A renewal inspection was conducted on 12/3/24. At that time, the child files were reviewed. The emergency contact form for Child #3 did not include the health insurance policy information.

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

Regulation: 3270.124(b)(7)

Description: Name/address/phone release person

Noncompliance Area: A renewal inspection was conducted on 12/3/24. At that time, the child files were reviewed. The emergency contact forms for Child #2, Child #4, Child #5 and Child #6 did not include the address of the 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: 3270.131(a)/3270.182(1)

Description: Health information/Initial and subsequent health reports

Noncompliance Area: A renewal inspection was conducted on 12/3/24. At that time, the child files were reviewed. There is no health assessment on file for Child #3, who has been enrolled at the facility longer more than 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. A child's record shall contain initial and subsequent health reports.

Regulation: 3270.36(b)(5)

Description: HS/GED + 2 yrs

Noncompliance Area: A renewal inspection was conducted 12/11/24. At that time, the staff files were reviewed. The file for Staff Person #1 contained education from the Dominican Republic that had not been evaluated by a service that is a member of the National Association of Credential Evaluation Services (NACES) or the Association of International Credential Evaluators (AICE).

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

Regulation: 3270.76

Description: Building Surfaces

Noncompliance Area: A renewal inspection was conducted on 12/3/24. At that time, fraying carpet was observed along the back wall of the Teen Room. A cracked outlet faceplate was observed along the wall to the left of the Teen Room.

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.

Noncompliance Area: During the Renewal Inspection on 11/15/2019, The most recent health report and child immunized status on file for Child #1, an older toddler was dated 7/25/2017. Child #2 also did not have the child's immunized status according to recommendations of the ACIP on file.

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 health report shall include a review of the child's immunized status according to recommendations of the ACIP.

Noncompliance Area: During the Renewal Inspection on 11/15/2019, Staff #1 re-hired on 10/28/2019 did not have an initial health assessment with a tuberculosis screening by the Mantoux method within the previous 12 months on file.

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.

Noncompliance Area: During the Renewal Inspection on 11/15/2019, it was discovered that Staff #1, a previous employee was re-hired on 10/28/2019. Effective 10/1/2019, newly hired staff are required to have the NSOR (National Sex Offender Registry) request on file prior to working in a child care position at the facility.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Staff #1 may not work in a child care position at the facility until her NSOR clearance is on file at the facility.

Noncompliance Area: During the Renewal Inspection on 11/15/2019, there were 4 electrical outlets in the Infant classroom and 2 in the Pre-K Counts C classroom that did not have protective receptacle covers.

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

Noncompliance Area: During the Renewal Inspection on 11/15/2019, a shed located on the outdoor playground had small nails sticking out of the side. Rust was also seen on the stalls in the boys bathroom by the offices and in the boys 3 and 4 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.

Noncompliance Area: During the Renewal Inspection on 11/15/2019, peeling paint was seen by the lockers in the After Care classroom.

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

Noncompliance Area: On 4/23/2019, Staff #1 was supervising a group of 5 preschool children while they swimming in the facility indoor pool. Facility Person #2 was identified as the lifeguard on 4/23/2019. As of 5/6/2019, the facility has not provided records to the department to show that Staff #1 has completed annual water safety training within the past year, and also has not provided current lifeguard certification for Facility Person #2.

Correction Required: When children are swimming, supervision shall include one person certified in lifeguard training, as described in 3270.31(e)(4)(iii) (relating to age and training). A facility person who is counted in the staff-child swimming ratio shall annually complete water safety instruction.

Noncompliance Area: On 4/23/2019, Staff #3 only had one written, nonfamily reference 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

Noncompliance Area: On 4/23/2019, the director was unable to provide record files for Staff #1 and Facility Person #2. As of 5/6/2019, these records still have not yet been provided to the department.

Correction Required: A staff person shall provide to agents of the Department immediate access to the facility, the children and the files and records. An individual record is required for each facility person.

Noncompliance Area: On the morning of 4/23/2019, the hot water temperature for the sink that is used for child hand washing in the infant room measured 135 F. The hot water temperature was turned down, but it still measured 115 F early in the afternoon on 4/23/2019.

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

Noncompliance Area: On 4/23/2019, the following was observed: Drywall coming out of the bulletin board in the gym that is used by the children, and a Tikes tree house with a crack on the bottom leaving sharp edges exposed and broken fencing by the gate on the outdoor playground.

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. 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.

Noncompliance Area: On 12/3/2018, the Early Childhood Education Consultant reported that they had completed their time with the Bethlehem YMCA. ECE Consultant wrote that they checked the goal as "unmet" because some of the teachers were still not able to meet the minimum standards for supervision.

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. 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. All staff will receive 4 additional hours of technical assistance with supervision of children. In addition, the director will receive 2 hours of technical assistance with rewriting the facility supervision policy. The updated supervision policy will be sent to regional OCDEL when it is complete.

Noncompliance Area: During the renewal inspection on 11/28/2018, several bolts were exposed on the fencing of the outdoor playground.

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.

Noncompliance Area: During the renewal inspection on 11/28/2018, the refrigerator in the school age classroom did not have a thermometer in it.

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.

Noncompliance Area: Child files were reviewed during the renewal inspection on 11/28/2018. Child service reports for Child #1 and Child #6 had not been completed within the past 6 months.

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

Noncompliance Area: Child files were reviewed during the renewal inspection on 11/28/2018. The agreements for Child #2, #4 and #5 did not specify date of the child's admission.

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

Noncompliance Area: Child files were reviewed during the renewal inspection on 11/28/2018. The emergency contact information for Child #2 and Child #5 did not list complete health insurance information.

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

Noncompliance Area: The health report that was on file for Child #4 on 11/28/2018 did not contain a signature from a physician, physician's assistant or a CRNP.

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.

Noncompliance Area: During the renewal inspection on 11/28/2018, an inhaler with an expiration date of 09/2018 was seen in the Pre-K Counts 4B classroom.

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

Noncompliance Area: Staff files were reviewed during the renewal inspection on 11/28/2018. The health assessments for Staff #3 and Staff #5 did not have a signature by a physician, physician's assistant or CRNP. The health assessment for Staff #7 did not include tuberculosis screening by the Mantoux method initial employment.

Correction Required: A health assessment shall be conducted and a report shall be written and signed by a physician, physician's assistant or CRNP. The signature must include the individual's professional title. 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.

Noncompliance Area: Child files were reviewed during the renewal inspection on 11/28/2018. The emergency contact information and financial agreement for Child #3 and Child #4 had not been updated during the previous 6 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.

Noncompliance Area: Staff files were reviewed during the renewal inspection on 11/28/2018. Staff #2 did not have proof of education file. Staff #6 did not have proof of child care experience prior to working at the facility on fie.

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

Noncompliance Area: Staff files were reviewed during the renewal inspection on 11/28/2018. Staff #2 and Staff #7 did not have any written, nonfamily 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

Noncompliance Area: During the renewal inspection on 11/28/2018, one of the ceiling covers for the glass light bulbs in the school age classroom was missing. An object would only need to be tossed approximately 10 feet upwards to hit the glass light bulbs.

Correction Required: Conditions at the facility may not pose a threat to the health or safety of the children.

Noncompliance Area: Staff files were reviewed during the renewal inspection on 11/28/2018. The following staff did not proof of emergency plan training at initial employment on file: Staff #1, #2, #4, #5, #6 and #8.

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.

Noncompliance Area: Staff files were reviewed during the renewal inspection on 11/28/2018. Staff #9 and Staff #10 did not have proof of the annual minimum of 6 clock hours of child care training on file.

Correction Required: A staff person shall obtain an annual minimum of 6 clock hours of child care training.

Noncompliance Area: During the renewal inspection on 11/28/2018, Staff #11, a permanent employee, did not have a completed FBI clearance on file. Only proof of being fingerprinted was on file.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Facility Person # 11 may not work in a child care position at the facility. A provisional employee may not be permitted to work alone with children and must work within the vicinity of a permanent employee. 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 #11 may not work in a child care position at the facility.

Noncompliance Area: During the renewal inspection on 11/28/2018, Staff #4 and Staff #5 were both identified as assistant group supervisors. Neither Staff #4 or Staff #5 had proof of child care experience on file showing that they qualify as an assistant group supervisor.

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

Noncompliance Area: During the renewal inspection on 11/28/2018, one of the electrical outlets by the sink in the Kindergarten Readiness room was missing an outlet cover.

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

Noncompliance Area: During the renewal inspection on 11/28/2018, a small hole in the wall about the size of a nickel was seen in the older toddler 1 classroom near where the phone line was. Rust was also seen on the stalls in the boys bathroom on the main floor.

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.

Noncompliance Area: Child #1, age 14 months, was alone in the hallway standing by the door to the classroom when his mother arrived to pick him up on the afternoon of 8/9/2018. The two staff in the classroom, Staff #2 and Staff #3, did not realize that the child had left the classroom until mother went into the classroom and asked where her child was. This was verified by written statements from Staff #2 and Staff #3 that were obtained by Staff #1. It is unknown how long the child was alone in the hallway for. Staff # 1 estimates that Child #1 was alone in the hallway for at least 3 to 5 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. Outdoor play space used by the facility is considered part of the facility premises. Children must be supervised 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. The legal entity must arrange for all facility staff to receive a minimum of 2 hours of approved In-Person training regarding supervision of children. The legal entity must receive DHS approval of the training content prior to scheduling the training. These hours will not be counted towards the 6 hours of required annual training hours.

Noncompliance Area: During a complaint inspection on 5/11/2018 the financial agreement on file for Child #1 was incomplete and was not signed by the operator or the parent.

Correction Required: An agreement shall be signed by the operator and the parent.

Noncompliance Area: During a complaint inspection on 5/11/2018, the emergency contact information on file for Child #1 was incomplete and did not reference who shall be contacted in an emergency.

Correction Required: Emergency contact information is required for each enrolled child. Emergency contact information must reference who shall be contacted in an emergency.

Noncompliance Area: During a complaint inspection on 5/11/2018, the emergency contact information on file for Child #1 was incomplete. The emergency contact information did not include written consent signed by the parent for emergency medical care for the child and did not include signed parental consent for administration of minor first-aid procedures by facility staff.

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 administration of minor first-aid procedures by facility staff. Written consent is required prior to admission.

Noncompliance Area: During a complaint inspection on 5/11/2018, the emergency contact information on file for Child #1 was incomplete. , The emergency contact information did not include the health insurance coverage information and policy number for the child.

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.

Noncompliance Area: During a complaint inspection on 5/11/2018, the file for Staff #1, a new hire was requested for review. Staff #2 stated that she was unable to access the file for Staff #1 because the file was still with their Human Resources Department. The file for Staff #1 was not sent to the department for review until 5/29/2018.

Correction Required: A staff person shall provide to agents of the Department immediate access to the facility, the children and the files and records

Noncompliance Area: During the Renewal Inspection on the dates of 11/8/2017 and 11/17/2017, the following was observed: Staff #2 did not have verification of child care experience prior to working at the facility on file, Staff #3 did not have verification of child care experience prior to working at the facility and also did not have any written, nonfamily references on file, Staff #7 did not have verification of child care experience prior to working at the facility and also did not have any have any written, nonfamily references on file. During a verification visit on 12/22/2017, the information listed above was still not on file. Staff #1 and Staff #4 agreed to send this information to this Certification Representative as soon as possible. Staff #1 emailed information to this Certification Rep. on 1/19/2018, but the information did not include the needed information for Staff #2, Staff #3 and Staff #7. This Certification Rep. replied to Staff #1 about the information that was still needed on 1/22/2018. Rep. emailed Staff #1and Staff #4 on 1/29/2018 when this information for Staff #2, Staff #3 and Staff #7 still had not been received. This Certification Rep. also reminded Staff #1 and Staff #4 in this email of the expiration date of February 7, 2018 on the current certificate of compliance. Staff #1 emailed information to this Certification Rep. on 1/29/2018, but the child care experience and reference information for Staff #2, Staff #3 and Staff #7 still was not included.

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

Noncompliance Area: The most recent health report on file for Child #1, an infant is dated 2/15/2017. The most recent health report on file for Child #2, a young toddler is dated 3/8/2017. The most recent health report on file for Child #3, a young toddler is dated 3/11/2016.

Correction Required: The operator shall require the parent to provide an updated health report at least every 6 months for an infant or young toddler.

Noncompliance Area: Staff #4 began employment on 6/12/2017, but did not have an initial health assessment conducted until 7/11/2017. Staff #5 began employment on 10/3/2016, but does not have an initial health assessment and tuberculosis screening by the Mantoux method at initial employment on file. Staff #7 has been employed since February 2017, but does not have an initial health assessment and tuberculosis screening by the Mantoux method at initial employment on file. Staff #8 began employment on 5/8/2017, but did not have an initial health assessment conducted until 6/30/2017.

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.

Noncompliance Area: Staff #2 does not verification of child care experience prior to working at the facility on file. Staff #3 does not verification of child care experience prior to working at the facility and also does not have any written, nonfamily references on file. Staff #6 does not verification of child care experience prior to working at the facility and also only has one written nonfamily reference on file. Staff #7 does not verification of child care experience prior to working at the facility and also does not have any have any written, nonfamily references on file.

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

Noncompliance Area: Facility person #1 was observed volunteering at the facility in a classroom with children on 11/8/2017. Facility person does not have a volunteer state police clearance on file. In addition, the child abuse clearance on file for facility person #1 is from 9/28/2011. Staff person #2 began employment on 2/13/2017, but did not complete the mandated reporter training until 10/22/2017. Staff person # 3 began employment on 5/16/2017. The state police clearance on file Staff person #3 is a volunteer clearance. The FBI clearance is dated 6/9/2017. There is no proof on file that this clearance was requested on or before 5/16/2017. Staff person #3 did not complete the mandated reporter training until 10/10/2017. Staff person #4 began employment on 6/12/2017. The FBI Clearance for Staff person #4 is dated 7/3/2017 and the child abuse clearance is dated 6/20/2017. There is no proof on file that these clearances were requested on or before 6/12/2017. Staff person #6 has been employed since 4/27/2017. Staff person #6 does not have proof of completion of the mandated reporter training on file. Staff person #7 began employment in February 2017, but did not complete the mandated reporter training until 8/2/2017. Staff person #8 began employment on 5/8/2017, but did not complete the mandated reporter training until 9/25/2017.

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 # 1 may not volunteer at the facility until updated volunteer state police and child abuse clearances are both completed and on file.

Noncompliance Area: The following was observed: Rust on the stalls in the Preschool bathroom, a crack on the bottom of the wooden door in the Toddler 1 classroom, peeling paint on the wall by the cots in the Toddler 1 classroom, a bar sticking out of a vent in the Young School Age classroom and peeling paint in the back of the Older School classroom.

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

Noncompliance Area: The facility fire drill log was current at the time of inspection, but the log showed that a fire drill was held on 4/11/2017 and not again until 6/21/2017, and then not again until 8/28/2017.

Correction Required: A fire drill shall be held at least every 60 days. Facility persons and children in attendance shall participate in the fire drill. Facility persons and children shall exit the building, weather permitting.