Bloomsburg Area Ymca Day Care Center

Regulation: 3270.51

Description: Similar Age Level

Noncompliance Area: On 5/19/26 the inspector observed staff #1 alone with 13 preschool aged children in the outdoor pay area.

Correction Required: When children are grouped in similar age levels, the following maximum child group sizes and ratios of staff persons apply: Infants 1:4 with a maximum group size of 8; Young toddlers 1:5 with a maximum group size of 10; Older toddlers 1:6 with a maximum group size of 12; Preschool children 1:10 with a maximum group size of 20; Young school-age children 1:12 with a maximum group size of 24; Older school-age children 1:15 with a maximum group size of 30. TIERED LIS: 1. The required staff: child ratios must be maintained at all times. The correction date for this must be immediate. 2. The director shall post staff/child ratios in each childcare space. The correction for this shall allow for time to develop and post the required staff/child ratios.

Regulation: 3270.123(a)

Description: Signed

Noncompliance Area: Child files #1, #2, #3, #4, #5 and #6 were all missing the operator's signature on the agreement forms.

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

Regulation: 3270.123(a)(3)

Description: Services proceeded

Noncompliance Area: Child files #1, #2, #3, #4, #5, and #6 were all missing the services to be provided to the family and the child on the agreement forms.

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

Regulation: 3270.123(a)(4)

Description: Arrival/departure times

Noncompliance Area: Child files #1, #2, #3, #4, and #6 were all missing the child's arrival and departure times.

Correction Required: An agreement shall specify the child's arrival and departure times.

Regulation: 3270.124(b)(2)

Description: Physician name, address, phone

Noncompliance Area: Child file #1 was missing the required address and telephone number of the child's physician or source of medical care.

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)(6)

Description: Insurance coverage information

Noncompliance Area: The file for child #1 was missing the required health insurance coverage and policy number.

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

Regulation: 3270.131(a)

Description: Health information

Noncompliance Area: The file for child #6 has been enrolled over 60 days and does not have a health assessment on file (see LIS Code Sheet for DOA).

Correction Required: The operator shall require the parent of an enrolled child, including a child, a foster child and a relative of an operator or a facility person, to provide an initial health report no later than 60 days following the first day of attendance at the facility.

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

Description: Age and Training

Noncompliance Area: Staff #14 had an expired pediatric first aid/CPR training on file. This is evidenced by the previously documented pediatric first aid/CPR training on file which expired 4/2025 and a renewal pediatric first aid/CPR training dated 05/21/25.

Correction Required: Competence is the completion of training by a professional in the field of first-aid and cardiopulmonary resuscitation (CPR). All staff persons shall renew their certification in pediatric first aid and pediatric cardiopulmonary resuscitation (CPR) on or before the expiration of the most current certification.

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

Description: Fire safety - 1 yr.

Noncompliance Area: Staff #4 did not update their fire safety training annually as evidenced by a previous Fire Safety training dated 1/24/24 and an updated Fire Safety dated 8/3/25. Staff #5 did not update their fire safety training annually as evidenced by a previous Fire Safety training dated 9/19/24 and an updated Fire Safety dated 10/22/25. Staff #6 did not update their fire safety training annually as evidenced by a previous Fire Safety training dated 12/18/24 and an updated Fire Safety dated 2/2/26. Staff #12 did not update their fire safety training annually as evidenced by a previous Fire Safety training dated 5/08/24 and an updated Fire Safety dated 6/24/25. Staff #13 did not update their fire safety training annually as evidenced by a previous Fire Safety training dated 6/7/24 and no update on file. Staff #14 did not update their fire safety training annually as evidenced by a previous Fire Safety training dated 5/7/24 and no update on file.

Correction Required: Staff persons shall participate, at least annually, in fire safety training conducted by a fire protection professional. Staff persons and volunteers shall receive training in maintenance of smoke detectors, the duties of facility persons during a fire drill and during a fire and the use of the facility's fire extinguishers, not including discharge of the fire suppressant agent.

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: Staff person #8, #9, and #11, did not completed the following required pre- service training within 90 days of their date of hire (see LIS code sheet): Pediatric First Aid and CPR training from a PQAS approved trainer and a PQAS approved curriculum. Staff #2 and staff #7 did not have an acceptable Pediatric First Aid and CPR training from a PQAS approved trainer and a PQAS approved curriculum.

Correction Required: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10. Pediatric First Aid and CPR training from a PQAS approved trainer and a PQAS approved curriculum.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: Staff #1 and #6 did not have a NSOR on file prior to working in direct care with children. Staff #10 does not have a NSOR on file since hire. Staff #3 has a volunteer PA Child Abuse on file and not an employment PA Child Abuse as is required. Staff #6 also did not have a DHS FBI clearance on file since hire.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). As of 2/1/25 If staff are going to be hired under the 45-day provisional hire basis, the following conditions must be met; facility received the results of the applicant's PA Child Abuse History Clearance, NSOR Clearance, completed out-of-state clearances (if applicable), a signed disclosure statement, prior to employment and have received the result of the applicant's Pennsylvania State Police OR the FBI finger-print results prior to employment. Proof of submission must be on file for either the FBI or PA State Police Clearance. The employer, administrator, supervisor or other person responsible for employment decisions has no knowledge of information pertaining to the applicant which would disqualify him from employment based on CPSL. Facility Person #3, #6, and #10 may not work in a childcare position at the facility. TIERED LIS: 1. The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Staff #3, #6 and #10 must be removed from a childcare position with direct contact and routine interaction with children until all missing clearances are completed and on file at the facility. This portion of the plan requires an immediate date of correction. 2. The facility director and any other persons involved in the hiring of staff must register and attend an Existing Provider Orientation at a Regional Office. The provider must provide a correction date for when this portion of the plan will be completed. 3. In order to demonstrate compliance in this area, the director or legal entity representative will send completed staff files for all new hires for the next two months to the Northeast Regional Office for review. The staff files must include all clearance requests, completed clearances, (including out of state clearances and requests if necessary) signed and dated disclosure statement, health assessment and TB screening, two nonfamily references, proof of education and experience (officially translated if needed). The Northeast Regional Office will review the newly hired and completed staff files prior to hire within one week of receipt. The correction date for this portion of the plan must be two months from the acceptance of the plan by The Northeast Regional Office.

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

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

Noncompliance Area: While at the facility unannounced on 9/17/25interviews with staff #1 and #2 confirmed that staff #1 left two school aged children alone with an employee of the YMCA who is not a childcare employee on 8/28/25.

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

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

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

Noncompliance Area: While at the facility unannounced on 9/17/25 the inspector reviewed the file for staff #2 and found that this staff was working in direct care and did not have a health assessment and TB screening 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.

Regulation: 3270.192(2)(ii)

Description: Exp, educ., training prior to facility

Noncompliance Area: While at the facility unannounced on 9/17/25 the inspector reviewed the file for staff #2 and found that this staff was missing proof of education as is required.

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

Regulation: 3270.192(4)

Description: CPSL information

Noncompliance Area: While at the facility unannounced on 9/17/25 the inspector reviewed the file for staff #2 and found that this staff was missing a signed disclosure statement.

Correction Required: 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: 3270.192(5)

Description: Two written references

Noncompliance Area: While at the facility unannounced on 9/17/25 the inspector reviewed the file for staff #2 and found that this staff was missing two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person.

Correction Required: A facility person's record shall include two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person.

Regulation: 3270.52

Description: Mixed Age Level

Noncompliance Area: While at the facility unannounced on 9/17/25 interviews with staff #1 and #2 confirmed that staff #1 did, in fact, leave staff #2 alone with a group of 13 children, 12 older school aged children and 1 young school aged child on 8/28/25

Correction Required: When children are grouped in mixed age levels, the age of the youngest child in the group determines the staff: child ratio and maximum group size in accordance with the requirements in § 3270.51 (relating to similar age level). The required staff: child ratios must be maintained at all times. TIERED LIS: 1.The required staff: child ratios must be maintained at all times. The correction date for this portion of the plan must be immediate. 2. The legal entity must arrange for staff #1 and #2 to receive a minimum of two hours of training regarding Ratios. The legal entity must receive DHS approval of the training content prior to scheduling the training. The operator shall provide a date for when this training will be completed.

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

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

Noncompliance Area: While at the facility unannounced the inspector observed staff files and found that staff #1 had been working in direct care with children since hire (See LIS Code Sheet for DOH) and did not have a health assessment or TB screening as are required before working in direct care.

Correction Required: A facility person providing direct care who comes into contact with the children or who works with food preparation shall have a health assessment conducted within 12 months prior to providing initial service in a child care setting and every 24 months thereafter. A health assessment is valid for 24 months following the date of signature, if the person does not contract a communicable disease or develop a medical problem. An adult health assessment must include tuberculosis screening by the Mantoux method at initial employment. Subsequent tuberculosis screening is not required unless directed by a physician, physician's assistant, CRNP, the Department of Health or a local health department.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: While at the facility unannounced the inspector observed staff files and found that staff #1 had been working in direct care with children since hire (See LIS Code Sheet for DOH) and had a Pa Department of Education FBI on file versus the required DHS FBI.

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 # 1may not work in a childcare position at the facility with direct contact and routine interaction with children.

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: While at the facility unannounced for the renewal the inspector reviewed the emergency plan and found that it did not address continuity of operations as was required to be part of the emergency plan by 7/1/22." The OCDEL ANNOUNCEMENT C-22-04 requires facility emergency plans to include continuity of operations during and after an emergency that includes continuing daily 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.

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: 3270.27(a)(5)

Description: Emergency plan

Noncompliance Area: While at the facility unannounced for the renewal the inspector reviewed the emergency plan and found that it did not address accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions.

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

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

Description: Age and Training

Noncompliance Area: During the unannounced renewal inspection on 2/19/25 the inspector reviewed the staff files and noted that staff #1, did not renew their certification in pediatric first aid and pediatric cardiopulmonary resuscitation (CPR) on or before the expiration of the most current certification as evidenced by a previous certification expiration date of 4/24/22 and a renewal date of 8/4/24. Staff #3 did not renew their certification in pediatric first aid and pediatric cardiopulmonary resuscitation (CPR) on or before the expiration of the most current certification as evidenced by a previous certification expiration date of 6/24/22 and a renewal date of 11/7/24.

Correction Required: Competence is the completion of training by a professional in the field of first-aid and cardiopulmonary resuscitation (CPR). All staff persons shall renew their certification in pediatric first aid and pediatric cardiopulmonary resuscitation (CPR) on or before the expiration of the most current certification.

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: During the unannounced renewal inspection on 2/19/25 the inspector reviewed the staff files and noted that staff #2, did not completed the following required pre-service training within 90 days of their date of hire (see LIS Code Sheet) Pediatric First Aid and CPR from a PQAS approved trainer and a PQAS approved curriculum. Staff #4 did not complete the following required pre-service training within 90 days of their date of hire (see LIS Code Sheet), Health and Safety training, Pediatric First Aid and CPR. Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10. This training was not obtained until 1/12/25.

Correction Required: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10. Until such time as the required training is completed, staff person #2 must be supervised when interacting with children by an Assistant Group Supervisor who has completed the required training related to the citation. If there are no staff available to supervise staff person #2, staff person #2 may not work in a childcare position at the facility.

Regulation: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: During the course of the unannounced renewal inspection that occurred on 2/19/25 the inspector observed the file for staff #5 and found that this staff did not update their Pa Mandated Reporter training every 60 months as evidenced by a previous Pa Mandated Reporter training dated 8/31/19 and a current dated 9/19/24. The file for staff #6 was also observed and it was discovered this staff did not update their Pa Mandated Reporter training every 60 months as evidenced by a previous Pa Mandated Reporter training dated 8/28/19 and a current dated 9/19/24.

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

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: During the unannounced renewal inspection on 2/19/25 the inspector observed the file for staff #1 and found that this staff had been employed for over a year (see LIS Code Sheet for date of hire) and did not obtain an NSOR until 1/24/25. Staff file #6 had been employed for over a year (see LIS Code Sheet for date of hire) and did not obtain an NSOR until 2/26/24. Staff file #6 also did not update their clearances every 60 months as evidenced by a previous Pa State Police dated 2/24/19 and a current dated 5/23/24, a Pa Child Abuse previously dated 3/31/19 and a current dated 5/29/24. Staff #5 did not update their clearances every 60 months as evidenced by a previous Pa State Police dated 8/12/19 and a current dated 9/19/24, a Pa Child Abuse previously dated 8/13/19 and a current dated 9/19/24, a previous FBI dated 8/15/19 and a current dated 9/20/24.

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. If staff are going to be hired under the 45-day provisional hire basis, the following conditions must be met; facility received the results of the applicant's PA Child Abuse History Clearance prior to employment. and a signed disclosure statement, Facility received the result of the applicant's Pennsylvania State Police OR the FBI finger-print results prior to employment. The applicant has applied for the remaining required checks and the applicant provides a copy of the appropriate completed request forms to the employer, administrator, supervisor or other person responsible for employment decisions. The outstanding checks are: Pennsylvania State Police Criminal Record Check OR the FBI Criminal History Background Check, the National Sex Offender Registry (NSOR) check, and for an applicant who, in the past five years has resided outside of Pennsylvania, criminal history, child abuse, and sex offender registry checks from every state where the applicant lived within the past five years.

Regulation: 3270.95(a)/3270.95(b)

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

Noncompliance Area: Durning the course of the unannounced renewal inspection that occurred on 2/19/25 the inspector observed the fire drill/detection log and found that the facility last manually tested the main building's smoke detectors on 1/3/25, as evidenced on the log itself. This exceeds the every 30 calendar days requirement.

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)/3270.113(a)(1)

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

Noncompliance Area: During complaint investigation 7/26/24 through 8/8/2 the inspector observed 50 mixed aged children and six staff at the community pool. When asked how many children were present, staff #7 stated 51. The inspector asked that staff #7 to identify what children were assigned to each staff and staff #7 admitted to the inspector that all the staff supervise the children as a group with no children being specifically assigned or grouped by ages. It was also confirmed through investigation that the children go to the public bathrooms at the pool in groups of three without a staff accompanying them. Staff #7 admitted to leaving the pool on occasion leaving two staff with 43 mixed aged school aged children. The inspector also verified that staff #1 has also left the pool on occasion leaving staff #2 alone with up to 14 preschool aged children present. The inspector arrived unannounced on 7/30/24 to the facility to follow up on the complaint and found 43 mixed school aged children and five staff in the gymnastic room and in the outdoor fenced area. The inspector asked the staff present to name the group of children assigned to them and to identify the children by young school age and older school age. Staff #7 stated that the five staff present would not be able to do this as they are all supervising all the children as a group and do not have the children grouped by age or with a specific staff. The inspector observed children leaving the gymnastics room and walking through the open door into the outside fenced area, out of the gymnastics room and into the bathrooms unsupervised, and to and from the gym unsupervised while members of the public were present. While at the facility unannounced on 8/8/24 due to additional complaint allegations the inspector also verified that staff #6 and staff #7 were present in the outdoor play on 8/5/24 area with 30 mixed age school aged children present and none of the children were assigned to each staff. During this time staff #7 was standing at the gate releasing children with their back turned, making them unable to see, hear, access, and direct the children.

Correction Required: Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Outdoor play space used by the facility is considered part of the facility premises. Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises. Children must be supervised at all times. The facility will demonstrate their knowledge and ability to adequately supervise children at all times by developing and implementing a supervision policy that will focus on ensuring that each child is seen, heard, assessed and able to be directed at all times. This policy will cover supervision at the facility, while on trips, walks, excursions, and while at the pool. This supervision policy must be submitted to the Department of Human Services prior to implementation for approval. Once approved by the Department the director will ensure that all current employees have read, fully understand, and are able to follow the policy at all times. The director will ensure that all staff sign off on this policy as well as any new hires moving forward.

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

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

Noncompliance Area: During complaint investigation 7/26/24 through 8/8/2 the inspector observed 50 mixed aged children and six staff at the community pool. When asked how many children were present, staff #7 stated 51. The inspector asked that staff #7 to identify what children were assigned to each staff and staff #7 admitted to the inspector that all the staff supervise the children as a group with no children being specifically assigned or grouped by ages. It was also confirmed through investigation that the children go to the public bathrooms at the pool in groups of three without a staff accompanying them. Staff #7 admitted to leaving the pool on occasion leaving two staff with 43 mixed aged school aged children. The inspector also verified that staff #1 has also left the pool on occasion leaving staff #2 alone with up to 14 preschool aged children present. The inspector arrived unannounced on 7/30/24 to the facility to follow up on the complaint and found 43 mixed school aged children and five staff in the gymnastic room and in the outdoor fenced area. The inspector asked the staff present to name the group of children assigned to them and to identify the children by young school age and older school age. Staff #7 stated that the five staff present would not be able to do this as they are all supervising all the children as a group and do not have the children grouped by age or with a specific staff. The inspector observed children leaving the gymnastics room and walking through the open door into the outside fenced area, out of the gymnastics room and into the bathrooms unsupervised, and to and from the gym unsupervised while members of the public were present. While at the facility unannounced on 8/8/24 due to additional complaint allegations the inspector also verified that staff #6 and staff #7 were present in the outdoor play on 8/5/24 area with 30 mixed age school aged children present and none of the children were assigned to each staff. During this time staff #7 was standing at the gate releasing children with their back turned, making them unable to see, hear, access, and direct the children.

Correction Required: Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Outdoor play space used by the facility is considered part of the facility premises. Children must be supervised at all times. The legal entity must arrange for themself, all facility staff, including the director, to receive a minimum of three hours of in person PQAS approved training regarding supervision of children. This training does not have to be completed through the ELRC. The legal entity must receive DHS approval of the trainings content prior to scheduling the trainings.

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

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

Noncompliance Area: During complaint investigation 7/26/24 through 8/8/2 the inspector observed 50 mixed aged children and six staff at the community pool. When asked how many children were present, staff #7 stated 51. The inspector asked that staff #7 to identify what children were assigned to each staff and staff #7 admitted to the inspector that all the staff supervise the children as a group with no children being specifically assigned or grouped by ages. It was also confirmed through investigation that the children go to the public bathrooms at the pool in groups of three without a staff accompanying them. Staff #7 admitted to leaving the pool on occasion leaving two staff with 43 mixed aged school aged children. The inspector also verified that staff #1 has also left the pool on occasion leaving staff #2 alone with up to 14 preschool aged children present. The inspector arrived unannounced on 7/30/24 to the facility to follow up on the complaint and found 43 mixed school aged children and five staff in the gymnastic room and in the outdoor fenced area. The inspector asked the staff present to name the group of children assigned to them and to identify the children by young school age and older school age. Staff #7 stated that the five staff present would not be able to do this as they are all supervising all the children as a group and do not have the children grouped by age or with a specific staff. The inspector observed children leaving the gymnastics room and walking through the open door into the outside fenced area, out of the gymnastics room and into the bathrooms unsupervised, and to and from the gym unsupervised while members of the public were present. While at the facility unannounced on 8/8/24 due to additional complaint allegations the inspector also verified that staff #6 and staff #7 were present in the outdoor play on 8/5/24 area with 30 mixed age school aged children present and none of the children were assigned to each staff. During this time staff #7 was standing at the gate releasing children with their back turned, making them unable to see, hear, access, and direct the children.

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

Regulation: 3270.115(a)(5)/3270.115(a)(7)

Description: Staff:child ratios while swimming/Lifeguard not included in ratio

Noncompliance Area: During complaint investigation 7/26/24 through 8/8/2 the inspector observed the Bloomsburg YMCA walking into the pool and met with the program before they entered the pool area. The inspector observed 50 mixed aged children, six staff and one staff lifeguard present. When asked how many children were present, staff #7 (director) stated 51. The inspector asked that staff #7 place the 50 mixed age children into their swim groups, staff #7 and the five staff could not do so. Staff #7 then admitted to the inspector that all the staff supervise the children as a group with no children being specifically assigned or grouped by ages. None of the staff present knew the ages of the swimmers for required swim ratios. Staff #7 also admitted to utilizing the lifeguard as both a staff for ratio purposes and a lifeguard simultaneously.

Correction Required: The staff-child ratios while children are swimming are Infant 1:1; Young or older toddler 1:2; Preschool 1:5; Young school-age 1:6; Older school-age1:8. When children are swimming, the person certified in lifeguard training may not be included in the staff-child ratio.

Regulation: 3270.124(d)

Description: Excursions

Noncompliance Area: During complaint investigation 7/26/24 through 8/8/2, at the community pool. the director (staff #7) was asked to provide the inspector with the emergency contact information for each of the 50 children present and the director stated that they could not as they did not have this information with them for any of the 50 children present.

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

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

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

Noncompliance Area: During the unannounced inspections from 7/26/24- 8/8/24, stemming from the complaint investigation, the inspector observed the staff files and found that staff #3, #5 did not have a health assessment or a TB screening on file and were working in direct care with children. Staff #3 had a TB screening that was over 12 months old at the time of hire. Staff #2 had a health assessment and TB screening that was over 12 months old at the time of hire. Both staff #3 and staff #2 were also working in direct care with children.

Correction Required: A facility person providing direct care who comes into contact with the children or who works with food preparation shall have a health assessment conducted within 12 months prior to providing initial service in a child care setting and every 24 months thereafter. A health assessment is valid for 24 months following the date of signature, if the person does not contract a communicable disease or develop a medical problem. An adult health assessment must include tuberculosis screening by the Mantoux method at initial employment. Subsequent tuberculosis screening is not required unless directed by a physician, physician's assistant, CRNP, the Department of Health or a local health department.

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

Description: Water safety

Noncompliance Area: During the unannounced inspections from 7/26/24- 8/8/24, stemming from the complaint investigation, the inspector observed the staff files and found that staff #1, #2, #3, #4, and #5, had no proof of water safety training on file and all have been taking children to the community pool for swimming.

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

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: During complaint investigation 7/26/24 through 8/8/2 the inspector reviewed the staff files and found that staff #5 (see LIS Sheet for DOH) did not have proof of a FBI clearance, or a NSOR on file at the facility and was working in direct care with children. Staff #1 (see LIS Sheet for DOH) did not have proof of an NSOR on file at the facility and was working in direct care with children. The inspector returned on 8/7/24 to investigate additional allegations and staff #7 admitted that staff #1remained at the facility until 8/4/24 in direct care with children disregarding their required removal.

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 and staff # 5 may not work in a childcare position at the facility.

Regulation: 3270.33(a)/3270.36(b)(5)

Description: Each staff person meets quals/HS/GED + 2 yrs

Noncompliance Area: During the unannounced inspections from 7/26/24- 8/8/24, stemming from the complaint investigation, the inspector observed the staff files and found that staff #5 did not have any proof of education on file at the facility and was serving as an AGS.

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

Regulation: 3270.51/3270.52

Description: Similar Age Level/Mixed Age Level

Noncompliance Area: During complaint investigation 7/26/24 through 8/8/2 it was verified that staff #1 has left the pool leaving staff #2 alone with a group of up to 14 preschool aged children. Staff #7 also admitted to leaving the pool with another staff which resulted in two staff present with 45 mixed school aged children present. The inspector arrived unannounced on 7/30/24 to the facility to follow up on the complaint and found 43 mixed school aged children and five staff in the gymnastic room and in the attached outdoor fenced area. The inspector asked the staff present to name the group of children assigned to them and to identify the children by young school age and older school age. Staff #7 stated that the five staff present would not be able to do this as they are all supervising all the children as a group and do not have the children grouped by age or with a specific staff. While at the facility unannounced on 8/8/24 due to additional complaint allegations the inspector verified that staff #6 and staff #7 were present in the outdoor play on 8/5/24 area with 30 mixed age school aged children present via video and staff #7 admitted this as well.

Correction Required: When children are grouped in similar age levels, the following maximum child group sizes and ratios of staff persons apply: Infants 1:4 with a maximum group size of 8; Young toddlers 1:5 with a maximum group size of 10; Older toddlers 1:6 with a maximum group size of 12; Preschool children 1:10 with a maximum group size of 20; Young school-age children 1:12 with a maximum group size of 24; Older school-age children 1:15 with a maximum group size of 30. The required staff:child ratios must be maintained at all times.

Regulation: 3270.54(b)

Description: Two facility persons on excursions

Noncompliance Area: During complaint investigation 7/26/24 through 8/8/2 staff #7 acknowledged that they and another staff left the pool which resulted in one staff present with children.

Correction Required: At least two facility persons shall be present when children are on an excursion away from the facility. At a minimum, one of the facility persons shall be a staff person.

Regulation: 3270.61(f)

Description: No business simultaneous use

Noncompliance Area: During the unannounced inspections from 7/26/24- 8/8/24, stemming from the complaint investigation, the inspector observed that the gym being simultaneously used for YMCA members and the children receiving care.

Correction Required: Indoor space in which children are receiving care may not be used simultaneously for other business, commercial, social or another purpose unrelated to the child care being offered.

Regulation: 3270.61(h)

Description: Exceeding Capacity

Noncompliance Area: During the unannounced inspections from 7/26/24- 8/8/24, stemming from the complaint investigation, the inspector observed 43 children in the gymnastics room which is over the capacity for the room. This room is measured for 24 children. The inspector made the director aware of this capacity and asked that the children be separated into more accommodating spaces. While present unannounced on 8/8/24 the inspector observed the gymnastics room and found 44 children in the room. The daily activity log did not designate any times for the capacity to be increased.

Correction Required: The capacity established for an indoor space may not be exceeded.

Regulation: 3270.62(b)

Description: Play space - 65 square feet/child

Noncompliance Area: During the unannounced inspections from 7/26/24- 8/8/24, stemming from the complaint investigation, the inspector observed children playing in the outdoor fenced area just off the gymnastics room. This outdoor space is not measured space. The inspector made the director aware of this and asked that the children be removed from this unlicensed space.

Correction Required: Outdoor or indoor play space shall be measured at 65 square feet per child.

Regulation: 3270.71

Description: Heat Source

Noncompliance Area: During the unannounced inspections from 7/26/24- 8/8/24, stemming from the complaint investigation, the inspector observed that the kitchen door was propped open with a stove accessible to children. The kitchen door is located just outside the gymnastics room and bathrooms where the children were observed unsupervised by the inspector.

Correction Required: Hot water pipes and other sources of heat exceeding 110° F that are accessible to children shall be equipped with protective guards or shall be insulated to prevent direct contact.

Regulation: 3270.94(a)(1)/3270.94(a)(9)

Description: Every 60 days/Written record

Noncompliance Area: During the unannounced inspections from 7/26/24- 8/8/24, stemming from the complaint investigation, the inspector asked to view the fire drill/detection log. The director provided the inspector with the fire drill/detection log for the main building only. The inspector then asked to view the fire drill/detection log for the detached outer building as this building has a separate smoke detector system. The director informed the inspector that there was no fire drill/detection log for the outer building as there had been no manual testing of the smoke detector system nor any fire drills conducted although childcare children are receiving care in this building and were present on 7/30/24 and 8/6/24.

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

Regulation: 3270.95(a)/3270.95(b)

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

Noncompliance Area: During the unannounced inspections from 7/26/24- 8/8/24, stemming from the complaint investigation, the inspector asked to view the fire drill/detection log. The director provided the inspector with the fire drill/detection log for the main building only. The inspector then asked to view the fire drill/detection log for the detached outer building as this building has a separate smoke detector system. The director informed the inspector that there was no fire drill/detection log for the outer building as there had been no manual testing of the smoke detector system nor any fire drills conducted although childcare children are receiving care in this building and were present on 7/30/24 and 8/6/24.

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: 3270.95(a)/3270.95(b)

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

Noncompliance Area: A renewal inspection occurred at the facility. A review of the facility's fire system testing log was completed. Regulation requires the fire safety system to be tested at least once every 30 days. The following tests did not occur at least every 30 days: 1/17/24 - 2/26/24 4/8/24 - 5/21/24.

Correction Required: Fire detection devices or systems must be in compliance with standards established under section 1016(c) of the act (62 P.S. §  1016(c)). The Director or designated staff person who is responsible for compliance with this chapter shall ensure the requirements under subsection (a) are met.

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

Description: Mantoux TB/Health assessment, TB test

Noncompliance Area: A renewal inspection occurred at the facility, 1/17/24-1/23/24. A review of staff files was conducted. See the code sheet for the date of hire for the following staff. Regulation requires a tuberculosis screening at the time of initial hire. The following staff did not obtain a tuberculosis screening at the time of initial hire: Staff #3 and #9. Staff #3 obtained a tuberculosis screening on 9/26/23. Staff #9 was working in child care at the time of this inspection and the file did not contain a tuberculosis screening. An acceptable plan of correction was obtained on 2/22/24, indicating that the listed staff would obtain a tuberculosis screening. An unannounced inspection occurred at the facility on 3/7/24. At this inspection, Staff #9 did not have an appropriate tuberculosis screening on file.

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

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

Noncompliance Area: A renewal inspection occurred at the facility, 1/17/24-1/23/24. A review of staff files was conducted. At the time of the inspection, the facility was unable to provide documentation that the following staff completed all 12 hours of annual child care training: Staff #4, #7 and #10. An acceptable plan of correction was received on 2/22/24 that indicated staff would complete annual child care training hours. An unannounced inspection occurred on 3/7/24. At this inspection, the facility was unable to show documentation that, Staff #4, #7, and #10 had participated in a total of 12 hours of annual child care training.

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

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: A renewal inspection occurred at the facility, 1/17/24-1/23/24. A review of staff files was conducted. Staff persons #3, #4, #8 and #9 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 CPR. Staff persons #9 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): health and safety. An acceptable plan of correction was obtained on 2/22/24 and indicated staff would be supervised and would complete the required training by 2/14/24. An unannounced inspection occurred on 3/7/24 and at that time, Staff #3, #4, #8 and #9 still did not complete pediatric first aid and 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 persons #3, #4, #8 and #9 will have until 3/22/24 to complete the required training. Until such time as the required training has been completed, staff persons #3, #4, #8 and #9 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 persons #3, #4, #8 and #9, staff persons #3, #4, #8 and #9 may not work in a child-care position at the facility.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: A renewal inspection occurred at the facility, 1/17/24-1/23/24. A review of staff files was conducted. See the code sheet for the date of hire. Staff #9 was hired as a provisional hire. The file did not contain documentation that Staff #9 applied for the DHS FBI clearance. Staff #9 did not apply for the NSOR clearance at the time of initial hire but applied on 1/2/24. At the time of this inspection an NSOR and DHS FBI clearance were not in the staff's file. Staff #9 was working at the facility at the time of this inspection past their 45-day provisional hire period. Staff #9 was not hired correctly as a provisional hire per the CPSL. An acceptable plan of correction was obtained on 2/22/24 and indicated that the Legal Entity/Director would participate in the Existing Provider Orientation at the Northeast Regional Office on 2/20/24. An unannounced inspection occurred on 3/7/24. As of this inspection, the Director did not participate in the Existing Provider Orientation held on 2/20/24.

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 #9 may not work in a child care position at the facility. The Legal Entity/Director will call the Northeast Daycare Regional Office (800-222-2108) to schedule the legal entity, director and any one responsible for maintaining staff files to participate in the next Existing Provider Orientation. The Legal Entity, Director or any other appropriate staff will submit documentation to the Northeast Daycare Regional Office that they have attended the orientation. The next existing provider orientation being offered at the Northeast Daycare Regional Office is on 5/15/24.

Regulation: 3270.131(a)/3270.182(1)

Description: Health information/Initial and subsequent health reports

Noncompliance Area: A renewal inspection occurred at the facility. A review of children's files was conducted. See the code sheet for the date of enrollment of the children. Regulation requires children to have a health report in their file within 60 days of attendance. The following children did not have a health report in their file within 60 days of attendance: Child #1, #4 and #5. Child #1 obtained a health report on 12/1/23. No health report was in the file of Child #4. Child #5 obtained a health report on 10/26/23.

Correction Required: The operator shall require the parent of an enrolled child, including a child, a foster child and a relative of an operator or a facility person, to provide an initial health report no later than 60 days following the first day of attendance at the facility. A child's record shall contain initial and subsequent health reports.

Regulation: 3270.151(a)/3270.192(3)

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

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. See the code sheet for the date of hire for the following staff. Regulation requires health assessments at the time of initial hire. The following staff did not obtain a health assessment at the time of initial hire: Staff #3, #8 and #9. Staff #3 obtained a health assessment on 9/26/23. Staff #8 obtained a health assessment on 3/24/23. Staff #9 was working in child care at the time of this inspection and the file did not contain a health assessment. Regulation requires health assessments to be updated every 24 months. Staff #10 did not update their health assessment every 24 months. The previous health assessment on file for Staff #10 was dated 6/7/20 and an updated health assessment was not conducted until 1/2/23.

Correction Required: A facility person providing direct care who comes into contact with the children or who works with food preparation shall have a health assessment conducted within 12 months prior to providing initial service in a child care setting and every 24 months thereafter. A health assessment is valid for 24 months following the date of signature, if the person does not contract a communicable disease or develop a medical problem. A facility person's record shall include a written report of initial and subsequent health assessments, including the results of initial and subsequent tuberculin skin tests, x-rays or other medical documentation necessary to confirm freedom from communicable tuberculosis.

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

Description: Mantoux TB/Health assessment, TB test

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. See the code sheet for the date of hire for the following staff. Regulation requires a tuberculosis screening at the time of initial hire. The following staff did not obtain a tuberculosis screening at the time of initial hire: Staff #3 and #9. Staff #3 obtained a tuberculosis screening on 9/26/23. Staff #9 was working in child care at the time of this inspection and the file did not contain a tuberculosis screening.

Correction Required: An adult health assessment must include tuberculosis screening by the Mantoux method at initial employment. Subsequent tuberculosis screening is not required unless directed by a physician, physician's assistant, CRNP, the Department of Health or a local health department. A facility person's record shall include a written report of initial and subsequent health assessments, including the results of initial and subsequent tuberculin skin tests, x-rays or other medical documentation necessary to confirm freedom from communicable tuberculosis.

Regulation: 3270.192(5)

Description: Two written references

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. The file of Staff #9 did not contain two letters of written reference as required by regulation. Staff #9 was working in a child care position at the time of this inspection.

Correction Required: A facility person's record shall include two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person.

Regulation: 3270.27(c)

Description: Training regarding plan

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. Regulation requires staff to review the emergency plan on an annual basis. The following staff did not review the emergency plan on an annual basis: Staff #2, #6, #7 and # 10. Staff #2, # 6, #7 reviewed the plan on 8/18/22 and then on 9/11/23. Staff #10 reviewed the plan on 7/14/22 and then on 9/11/23. Regulation requires new staff to reviewing the emergency plan within 90 days of their hire date. See the code sheet for the hire date. The following staff did not review the emergency plan within 90 days of their hire date: #8 and #9. Staff # 8 reviewed the emergency plan on 9/11/23. At the time of this inspection, Staff #9 had not reviewed the emergency plan.

Correction Required: The operator shall assure that each facility person receives training regarding the emergency plan at the time of initial employment, on an annual basis and at the time of each plan update. The operator shall document the date of each training and the names of all facility persons who received the training and kept on file at the facility.

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

Description: Fire safety - 1 yr.

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. Regulation requires staff to patriciate in annual fire safety training. The following staff did not participate in annual fire safety training: Staff #1, #2, #4, #5, #6, #7 and #10. Staff #1 completed fire safety training on 1/27/22 and then on 4/11/23. Staff #2 completed fire safety training on 6/6/22 and then on 1/17/24. Staff #4 completed fire safety training on 8/9/22 and then on 1/17/24. Staff #5 completed fire safety training on9/1/22 and then on 1/17/24. Staff #6 completed fire safety training on 10/4/22 and then on 1/18/24. Staff #7 completed fire safety training on 10/6/22 and then on 11/14/23. Staff #10 completed fire safety training on 1/29/22 and then on 4/11/23.

Correction Required: Staff persons shall participate, at least annually, in firesafety training conducted by a fire protection professional. Staff persons and volunteers shall receive training in maintenance of smoke detectors, the duties of facility persons during a fire drill and during a fire and the use of the facility's fire extinguishers, not including discharge of the fire suppressant agent.

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

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

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. At the time of the inspection, the facility was unable to provide documentation that the following staff completed all 12 hours of annual child care training: Staff #4, #7 and #10.

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

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. Staff persons #3, #4, #8 and #9 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 CPR. Staff persons #9 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 person(s) shall complete professional development in the topics of 3270.31(f)(1 -- 10) within 90 days of hire. Staff persons #3, #4, #8 and #9 will have until 2/14/24 to complete the required training. Until such time as the required training has been completed, staff persons #3, #4, #8 and #9 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 persons #3, #4, #8 and #9, staff persons #3, #4, #8 and #9 may not work in a child-care position at the facility.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. See the code sheet for the date of hire. Staff #9 was hired as a provisional hire. The file did not contain documentation that Staff #9 applied for the DHS FBI clearance. Staff #9 did not apply for the NSOR clearance at the time of initial hire but applied on 1/2/24. At the time of this inspection an NSOR and DHS FBI clearance were not in the staff's file. Staff #9 was working at the facility at the time of this inspection past their 45-day provisional hire period. Staff #9 was not hired correctly as a provisional hire per the CPSL.

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 #9 may not work in a child care position at the facility.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. See the code sheet for the date of hire. Staff #9 was hired as a provisional hire. The file did not contain documentation that Staff #9 applied for the DHS FBI clearance. Staff #9 did not apply for the NSOR clearance at the time of initial hire but applied on 1/2/24. At the time of this inspection an NSOR and DHS FBI clearance were not in the staff's file. Staff #9 was working at the facility at the time of this inspection past their 45-day provisional hire period. Staff #9 was not hired correctly as a provisional hire per the CPSL.

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

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. See the code sheet for the date of hire. Staff #9 was hired as a provisional hire. The file did not contain documentation that Staff #9 applied for the DHS FBI clearance. Staff #9 did not apply for the NSOR clearance at the time of initial hire but applied on 1/2/24. At the time of this inspection an NSOR and DHS FBI clearance were not in the staff's file. Staff #9 was working at the facility at the time of this inspection past their 45-day provisional hire period. Staff #9 was not hired correctly as a provisional hire per the CPSL.

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 #9 may not work in a child care position at the facility. The Legal Entity/Director will call the Northeast Daycare Regional Office (800-222-2108) to schedule the legal entity, director and any one responsible for maintaining staff files to participate in the next Existing Provider Orientation. The Legal Entity, Director or any other appropriate staff will submit documentation to the Northeast Daycare Regional Office that they have attended the orientation. The next existing provider orientation being offered at the Northeast Daycare Regional Office is on 2/20/24.

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

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

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. At the time of the inspection, Staff #9 was working in child care. The file of Staff #9 did not contain proof of education. Staff #9 could not be appropriately qualified to work in a child care role at the facility.

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: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: A renewal inspection occurred at the facility. A physical site review was conducted. The outdoor play area contained a large metal climber/playset. This climber had a slide that was broken at each individual attachments of the enclosed slide. The steps and floor bases at the top of the climber was broken in areas and the plastic coating was coming off in areas. These areas of concern were addressed with the director at the time of the inspection.

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: 3270.151(a)/3270.192(3)

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

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. See the code sheet for the dates of hire of staff. Staff # 1 did not have a health assessment on file at the time of this inspection. Staff # 3 did not have a health assessment on file until 1/18/23. Staff # 6 did not have a health assessment or tuberculosis screening on file. At the time of this inspection, Staff # 6 was working in childcare. Staff # 7 did not have a health assessment or tuberculosis screening on file. At the time of this inspection, Staff # 7 was working in childcare. Staff # 8 did not have a health assessment and tuberculosis screening on file until 1/17/23.

Correction Required: A facility person providing direct care who comes into contact with the children or who works with food preparation shall have a health assessment conducted within 12 months prior to providing initial service in a child care setting and every 24 months thereafter. A health assessment is valid for 24 months following the date of signature, if the person does not contract a communicable disease or develop a medical problem. A facility person's record shall include a written report of initial and subsequent health assessments, including the results of initial and subsequent tuberculin skin tests, x-rays or other medical documentation necessary to confirm freedom from communicable tuberculosis.

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

Description: Mantoux TB/Health assessment, TB test

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. See the code sheet for the dates of hire of staff. Staff # 1 did not have a health assessment on file at the time of this inspection. Staff # 3 did not have a health assessment on file until 1/18/23. Staff # 6 did not have a health assessment or tuberculosis screening on file. At the time of this inspection, Staff # 6 was working in childcare. Staff # 7 did not have a health assessment or tuberculosis screening on file. At the time of this inspection, Staff # 7 was working in childcare. Staff # 8 did not have a health assessment and tuberculosis screening on file until 1/17/23.

Correction Required: An adult health assessment must include tuberculosis screening by the Mantoux method at initial employment. Subsequent tuberculosis screening is not required unless directed by a physician, physician's assistant, CRNP, the Department of Health or a local health department. A facility person's record shall include a written report of initial and subsequent health assessments, including the results of initial and subsequent tuberculin skin tests, x-rays or other medical documentation necessary to confirm freedom from communicable tuberculosis.

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. See the code sheet for the staff's date of hire. Staff person # 3 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): pediatric first aid/CPR.

Correction Required: Staff person(s) shall complete professional development in the topics of 3270.31(f)(1 -- 10) within 90 days of hire. Staff person # 3 will have until 2/15/23 to complete the required training. Until such time as the required training has been completed, staff person # 3 must be supervised, when interacting with children, by an AGS who has completed the required training related to this citation. If there are no staff available to supervise staff person # 3, staff person # 3 may not work in a child-care position at the facility.

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. Staff person #1 did not complete the required one-hour 2022 update to the health and safety training by 12/30/2022.

Correction Required: Staff person #1 shall complete the required one-hour 2022 update to the health and safety training by 2/15/22. Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. See the code sheet or the staff's dates of hire. Staff # 2 was hired incorrectly as a provisional hire. Staff # 2 did not apply for a state police clearance until 9/6/22 and a child abuse clearance until 9/8/22. Staff # 3 was hired incorrectly as a provisional hire. Staff # 3 did not apply for a state police clearance until 9/1/22. Staff # 4 was hired incorrectly as a provisional hire. Staff # 4 did not apply for an NSOR clearance until 11/9/22. Staff # 4 was hired also using a Department of Education FBI clearance dated 7/31/20. Staff # 5 was hired incorrectly as a provisional hire. Staff # 5 did not apply for an NSOR clearance until 9/6/22. Staff # 6 was hired incorrectly as a provisional hire. Staff # 6 was working at the facility past the 45-day provisional hire window and the file did not contain an NSOR clearance. Staff # 6 also did not apply for the NSOR clearance until 11/29/22. Staff # 7 was hired incorrectly as a provisional hire. Staff # 7 did not receive an NSOR clearance dated until 9/22/22.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Facility Person # 2, # 3, # 4, # 5, and # 6 may not work in a child care position at the facility.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: A renewal inspection occurred at the facility and a review of staff files was conducted. Staff # 1 had an FBI clearance dated for 3/20/17 and this clearance was not updated until 3/25/22. This clearance was not updated every 60 months as required by the CPSL.

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. The CPSL requires all clearances and mandated reporter training to be updated every 60 months.

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 renewal inspection occurred at the facility. A review of staff files was conducted. Staff # 3 has not had an updated health assessment completed since 9/13/19. Per regulation, health assessments are to be updated every 24 months. Staff # 5 had a date of hire of 8/23/21 and the file did not contain a health assessment or tuberculosis screening. Staff # 6 had a date of hire of 11/11/21 and the file did not contain a health assessment or tuberculosis screening. Staff # 10 had a date of hire of 9/11/21 and the file did not contain a health assessment or tuberculosis screening. Per regulation, staff are required to have a health assessment and tuberculosis screening conducted at initial employment. All listed staff have worked in child care without having an updated health assessment completed or an initial health assessment with tuberculosis screening completed. An acceptable plan of correction was received on 12/2/21. At a verification inspection on 12/17/21, the following staff have not yet participated in an updated health assessment: Staff # 3. The following staff have not yet participated in an initial health assessment and tuberculosis screening: Staff # 5, # 6, and # 10.

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: 3270.192(2)(ii)

Description: Exp, educ., training prior to facility

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was completed. Staff file # 5, # 8 and # 9 did not contain proof of education. These staff could not be appropriately qualified to work in a child care role at the facility. These staff have worked in a child care role without being appropriately qualified. An acceptable plan of correction was received on 12/2/21. At a verification inspection on 12/17/21, the following staff have not yet provided proof of education for their file: Staff # 5, # 8, and # 9.

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

Regulation: 3270.192(5)

Description: Two written references

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. The files of Staff # 4, # 5, # 6, # 8, # 9 and # 10 did not contain two letters of written reference. The listed staff have worked in child care without their files containing these letters of reference. An acceptable plan of correction was received 12/2/21. At a verification inspection on 12/17/21, the following staff have not yet provided two letters of written reference for their files: Staff # 4, # 5, # 6, # 8, # 9, # 10.

Correction Required: A facility person's record shall include two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person

Regulation: 3270.27(c)

Description: Training regarding plan

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. The files of staff # 1 and # 3 have not reviewed the facility's emergency plan since 2019. The file of staff # 2 has not reviewed the facility's emergency plan since 2020. These staff did not review the facility's emergency plan on an annual basis as required by regulation. The files of newly hired staff # 5, # 6, # 7, # 8, # 9, and # 10 did not contain documentation that these staff reviewed the facility's emergency plan at initial employment. These staff did not review the facility's emergency plan at the time of initial employment as required by regulation. All listed staff have worked in child care without having updated or initial training on the facility's emergency plan. An acceptable plan of correction was received on 12/2/21. During a verification inspection on 12/17/21 the following staff have not yet reviewed the facility's emergency plan: Staff # 1, # 2, # 3, # 5, # 6, # 7, # 8, # 9, and # 10.

Correction Required: The operator shall assure that each facility person receives training regarding the emergency plan at the time of initial employment, on an annual basis and at the time of each plan update. The operator shall document the date of each training and the names of all facility persons who received the training and kept on file at the facility.

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

Description: Fire safety - 1 yr.

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. The files of staff # 1 and # 3 did not contain documentation of fire safety training. Staff # 1 and Staff # 2 have not participated in fire safety training since 2019. The file of staff # 2 did not contain documentation of fire safety training since their employment date of 5/16/20. These staff did not participate in annual fire safety training as required by regulation. An acceptable plan of correction was received 12/2/21. During a verification inspection on 12/17/21, the following staff have not yet participated in annual fire safety training: Staff # 1, # 2, and # 3.

Correction Required: Staff persons shall participate, at least annually, in firesafety training conducted by a fire protection professional. Staff persons and volunteers shall receive training in maintenance of smoke detectors, the duties of facility persons during a fire drill and during a fire and the use of the facility's fire extinguishers, not including discharge of the fire suppressant agent.

Regulation: 3270.31(f)/3270.31(f)(10)

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

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. Staff # 5 had a date of hire of 8/23/21 and the file did not contain documentation of health and safety training topics or documentation of pediatric first aid and CPR training. Staff # 7 had a date of hire of 6/18/21 and the file did not contain documentation of pediatric first aid and CPR training. Staff # 9 had a date of hire of 6/7/21 and the file did not contain documentation of health and safety training topics or documentation of pediatric first aid and CPR training. These staff were required per regulation to participate in health and safety training topics and pediatric first aid and CPR within 90 days of the staff's hire date. All listed staff have worked in in child care without having completed the health and safety topics and pediatric first aid and CPR training. An acceptable plan of correction was received on 12/2/21. At a verification inspection on 12/17/21, the following staff have not yet completed pediatric first aid and CPR: Staff # 5, # 7, and # 9. The file of Staff # 9 also did not contain documentation of the health and safety training topics

Correction Required: Staff persons shall complete professional development in the following topics within 90 days of hire: 3270.31(f) Staff persons shall complete professional development in the following topics within 90 days of hire: (1) Prevention and control of infectious diseases (including immunization) and the establishment of a grace period that allows homeless children and children in foster care to receive services under this subchapter while their families (including foster families) are taking necessary action to comply with immunization and other health and safety requirements. (2) Prevention of Sudden Infant Death Syndrome and use of safe sleep practices. (3) Administration of medication, consistent with standards for parental consent. (4) Prevention of and response to emergencies due to food and allergic reactions. (5) Building and physical premises safety, including identification of and protection from hazards that can cause bodily injury such as electrical hazards, bodies of water and vehicular traffic. (6) Prevention of shaken baby syndrome and abusive head trauma. (7) Emergency preparedness and response planning for emergencies resulting from a natural disaster or a man-caused event (such as violence at a child care facility) within the meaning of those terms under section 602(a)(1) of the Robert T. Stafford Disaster Relief and Emergency Assistance Act (42 U.S.C.A. § 5195a(a)(1)). (8) Handling and storage of hazardous materials and appropriate disposal of biocontaminants. (9) Precautions when transporting children. (10) Pediatric first aid and pediatric cardiopulmonary resuscitation.

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 renewal inspection occurred at the facility. A review of staff files was conducted. Staff # 3 has not had an updated health assessment completed since 9/13/19. Per regulation, health assessments are to be updated every 24 months. Staff # 5 had a date of hire of 8/23/21 and the file did not contain a health assessment or tuberculosis screening. Staff # 6 had a date of hire of 11/11/21 and the file did not contain a health assessment or tuberculosis screening. Staff # 10 had a date of hire of 9/11/21 and the file did not contain a health assessment or tuberculosis screening. Per regulation, staff are required to have a health assessment and tuberculosis screening conducted at initial employment. All listed staff have worked in child care without having an updated health assessment completed or an initial health assessment with tuberculosis screening completed.

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: 3270.192(2)(ii)

Description: Exp, educ., training prior to facility

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was completed. Staff file # 5, # 8 and # 9 did not contain proof of education. These staff could not be appropriately qualified to work in a child care role at the facility. These staff have worked in a child care role without being appropriately qualified.

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

Regulation: 3270.192(5)

Description: Two written references

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. The files of Staff # 4, # 5, # 6, # 8, # 9 and # 10 did not contain two letters of written reference. The listed staff have worked in child care without their files containing these letters of reference.

Correction Required: A facility person's record shall include two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person

Regulation: 3270.27(c)

Description: Training regarding plan

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. The files of staff # 1 and # 3 have not reviewed the facility's emergency plan since 2019. The file of staff # 2 has not reviewed the facility's emergency plan since 2020. These staff did not review the facility's emergency plan on an annual basis as required by regulation. The files of newly hired staff # 5, # 6, # 7, # 8, # 9, and # 10 did not contain documentation that these staff reviewed the facility's emergency plan at initial employment. These staff did not review the facility's emergency plan at the time of initial employment as required by regulation. All listed staff have worked in child care without having updated or initial training on the facility's emergency plan.

Correction Required: The operator shall assure that each facility person receives training regarding the emergency plan at the time of initial employment, on an annual basis and at the time of each plan update. The operator shall document the date of each training and the names of all facility persons who received the training and kept on file at the facility.

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

Description: Fire safety - 1 yr.

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. The files of staff # 1 and # 3 did not contain documentation of fire safety training. Staff # 1 and Staff # 2 have not participated in fire safety training since 2019. The file of staff # 2 did not contain documentation of fire safety training since their employment date of 5/16/20. These staff did not participate in annual fire safety training as required by regulation.

Correction Required: Staff persons shall participate, at least annually, in fire safety training conducted by a fire protection professional. Staff persons and volunteers shall receive training in maintenance of smoke detectors, the duties of facility persons during a fire drill and during a fire and the use of the facility's fire extinguishers, not including discharge of the fire suppressant agent.

Regulation: 3270.31(f)/3270.31(f)(10)

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

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. Staff # 5 had a date of hire of 8/23/21 and the file did not contain documentation of health and safety training topics or documentation of pediatric first aid and CPR training. Staff # 7 had a date of hire of 6/18/21 and the file did not contain documentation of pediatric first aid and CPR training. Staff # 9 had a date of hire of 6/7/21 and the file did not contain documentation of health and safety training topics or documentation of pediatric first aid and CPR training. These staff were required per regulation to participate in health and safety training topics and pediatric first aid and CPR within 90 days of the staff's hire date. All listed staff have worked in in child care without having completed the health and safety topics and pediatric first aid and CPR training.

Correction Required: Staff persons shall complete professional development in the following topics within 90 days of hire: 3270.31(f) Staff persons shall complete professional development in the following topics within 90 days of hire: (1) Prevention and control of infectious diseases (including immunization) and the establishment of a grace period that allows homeless children and children in foster care to receive services under this subchapter while their families (including foster families) are taking necessary action to comply with immunization and other health and safety requirements. (2) Prevention of Sudden Infant Death Syndrome and use of safe sleep practices. (3) Administration of medication, consistent with standards for parental consent. (4) Prevention of and response to emergencies due to food and allergic reactions. (5) Building and physical premises safety, including identification of and protection from hazards that can cause bodily injury such as electrical hazards, bodies of water and vehicular traffic. (6) Prevention of shaken baby syndrome and abusive head trauma. (7) Emergency preparedness and response planning for emergencies resulting from a natural disaster or a man-caused event (such as violence at a child care facility) within the meaning of those terms under section 602(a)(1) of the Robert T. Stafford Disaster Relief and Emergency Assistance Act (42 U.S.C.A. § 5195a(a)(1)). (8) Handling and storage of hazardous materials and appropriate disposal of biocontaminants. (9) Precautions when transporting children. (10) Pediatric first aid and pediatric cardiopulmonary resuscitation.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. Staff # 1 had an FBI clearance dated for 2/1/16. This clearance was not updated every 60 months as required by the CPSL. Staff # 4 had a date of hire of 4/26/21 as a provisional hire and this staff was hired using a Department of Education FBI clearance dated 10/27/21. The CPSL states a Department of Education FBI clearance cannot be used for employment in a child care role in a child care setting. At the time of this inspection, Staff # 4's file did not contain documentation of an NSOR clearance. Staff could no longer be a provisional hire as the CPSL indicates a staff can only be provisionally hired for 45 days. Staff # 5 had a date of hire of 8/23/21 and at the time of this inspection, this file did not contain documentation that Staff # 5 participated in mandated reporter training. The CPSL requires all newly hired staff to participate in mandated reporter training within 90 days of the staff's hire date. Staff # 6 had a hire date of 11/11/21 as a provisional hire. The file of Staff # 6 did not contain documentation that they applied for the state police clearance, applied for / submitted their fingerprints for their FBI clearance, or applied or the NSOR clearance. Staff # 6 was not hired correctly as a provisional hire per the CPSL. Staff # 8 had a date of hire of 9/24/21 as a provisional hire. At the time of this inspection, Staff # 8 still did not received their FBI clearance. Staff could no longer be a provisional hire as the CPSL indicates a staff can only be provisionally hired for 45 days. Staff # 9 had a date of hire of 6/7/21 as a provisional hire. The file of Staff # 9 did not contain documentation that this staff applied for the state police clearance. Staff # 9 also presented a volunteer child abuse clearance dated for 10/14/19. The CPSL states volunteer clearances cannot be used for employment in a child care role at a facility. Staff could also no longer be a provisional hire as the CPSL indicates a staff can only be provisionally hired for 45 days. Staff # 10 had a date of hire of 9/11/21 as a provisional hire. The file did not contain documentation that staff # 10 applied for the NSOR clearance prior to working in child care. Staff # 10 was not hired correctly as a provisional hire. All listed staff have worked in child care without having appropriate clearances on file.

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, # 4, # 5, # 6, # 8, and # 9 may not work in a child care position at the facility. The CPSL requires all clearances to be updated every 60 months. The CPSL states as of 9/30/18 a Department of Education FBI clearance may not be used by a staff for hire in a child care setting, that a Department of Human Services FBI clearances is required for employment in a child care role at a child care facility. The CPSL indicates a staff can only be provisionally hired for 45 days. The CPSL requires all newly hired staff to participate in mandated reporter training within 90 days of a staff's date of hire. This Legal Entity has an approved provisional hire waiver. For this Legal Entity to hire staff provisionally, all staff must apply for all clearances including submitting their fingerprints for their FBI clearance to be hired as a supervised provisional hire. The CPSL states a volunteer clearance cannot be used as an appropriate clearance for employment in a child care role at a facility.

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

Description: Each staff person meets quals/Transcript, diploma and letters

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was completed. Staff file # 5, # 8 and # 9 did not contain proof of education. These staff could not be appropriately qualified to work in a child care role at the facility. These staff have worked in a child care role without being appropriately qualified.

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

Regulation: 3270.34(a)(6)

Description: Staff evaluations

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. Staff # 1 does not have documentation in the file of an annual evaluation since 2019. Staff # 2 has been employed with the facility more than an year and the file does not contain documentation of an annual evaluation. Staff # 3 does not have documentation in the file of an annual evaluation since 2019. Staff evaluations are required to be conducted on an annual basis per regulation.

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