Bloomsburg Childrens Center I

Regulation: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: The inspector observed a Little Tikes Cozy Coupe ride on style toy in the toddler outdoor space to have rusted, and exposed bolts accessible to children. The inspector also observed a bench in the outdoor play area to be rusted, in poor repair, and accessible to children.

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: 3270.31(e)(4)(i)

Description: Age and Training

Noncompliance Area: Staff #2 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 1/2026 and a renewal pediatric first aid/CPR training dated 02/07/26.

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: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: Staff #1 did not obtain the required out-of-state SOR clearance until 3/20/26 and was working in direct care with children since hire (See LIS Code Sheet for DOH).

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). The CPSL was revised to include a requirement that all clearances be updated and on file at least every 60 months. As of 2/1/25 If staff are going to be hired under the 45-day provisional hire basis, the following conditions must be met; facility received the results of the applicant's PA Child Abuse History Clearance, NSOR Clearance, completed out-of-state clearances (if applicable), a signed disclosure statement, prior to employment and have received the result of the applicant's Pennsylvania State Police OR the FBI finger-print results prior to employment. Proof of submission must be on file for either the FBI or PA State Police Clearance. The employer, administrator, supervisor or other person responsible for employment decisions has no knowledge of information pertaining to the applicant which would disqualify him from employment based on CPSL.

Regulation: 3270.77(a)

Description: No peeling paint or plaster

Noncompliance Area: The inspector observed chipped paint on the half wall, in the preschool classroom, within reach of children.

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

Regulation: 3270.51

Description: Similar Age Level

Noncompliance Area: The inspector observed staff #1 in the preschool room with eleven preschool aged children present. Staff #1 named all eleven children and appeared surprised that she did not realize that there were eleven children present versus ten.

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 must arrange for staff #1 to receive a minimum of two hours of training regarding ratios. The director must receive approval from the DHS Northeast Regional Office regarding the training content prior to scheduling the training. The operator shall provide a date for when this training will be completed.

Regulation: 3270.95(a)/3270.95(b)

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

Noncompliance Area: During the unannounced inspection on 1/29/26 the inspector observed the fire drill/detection log and found that the facility did not conduct a manual test of the fire alarms every 30 calendar days. The inspector observed a manual test dated for 11/13/25 and the next having been dated for 12/17/25.

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: 3270.124(b)(3)

Description: Parent home/work address, phone

Noncompliance Area: During the unannounced renewal inspection, on 3/20/25 the inspector reviewed the child files and noted that child files #1 and #2 were missing the required work addresses and telephone numbers of the enrolling parent.

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

Regulation: 3270.135(a)(3)

Description: Disposable diapers

Noncompliance Area: Durning the unannounced renewal inspection on 3/20/25 the inspector found that the toddler room was not using a plastic-lined, hands-free covered can.

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

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: During the unannounced renewal inspection, on 3/20/25 the inspector reviewed the staff files and noted that staff #1did not complete 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.

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 #1 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 #1, staff person #1 may not work in a childcare position at the facility.

Regulation: 3270.113(b)/3270.113(d)

Description: No physical punishment /No harsh language

Noncompliance Area: On 9/25/24 the director of the facility (staff #2) made a self-report of noncompliance indicating that staff #1 was observed pinching child #1 and as a result staff #1 was immediately terminated from employment.

Correction Required: A facility person may not use any form of physical punishment, including spanking a child. A facility person may not use harsh, demeaning or abusive language in the presence of children.

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

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

Noncompliance Area: During the course of the investigation on 7/30/24 the inspector and staff #5 observed staff #1, #2, #3, and #4 outside in the fenced play space with twenty preschool aged children present. The four staff were talking in groups of two while two preschool aged children played in a sandbox and eighteen preschool aged children were unsupervised and congregated near the entry door to the outdoor play space. There was a Lil Tykes plastic playhouse near this door and several children were observed inside of the playhouse making this group of children unable to be seen. The staff assigned to the eighteen children did not have a clear line of sight to see, hear, access, and direct the children congregated near the entry door.

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. 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 director must submit documentation in a format approved by DHS proving that the facility procedure for the supervision of children in the outdoor play space is followed at all times e.g., a checklist. The director will conduct outdoor play space supervision checks for each age group each time they are in the outdoor play space daily for a period of not less than 30 days. The legal entity will confirm continuing compliance by sending weekly copies of the documentation to the Regional Office of Child Development and Early Learning on a weekly basis via email. The supervision checklist should be completed by the director and in their absence their direct administrator shall complete said outdoor play space supervision checks.

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

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

Noncompliance Area: During the course of the investigation on 7/30/24 the inspector and staff #5 observed staff #1, #2, #3, and #4 outside in the fenced play space with twenty preschool aged children present. The four staff were talking in groups of two while two preschool aged children played in a sandbox and eighteen preschool aged children were unsupervised and congregated near the entry door to the outdoor play space. There was a Lil Tykes plastic playhouse near this door and several children were observed inside of the playhouse making this group of children unable to be seen. The staff assigned to the eighteen children did not have a clear line of sight to see, hear, access, and direct the children congregated near the entry door.

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 legal entity must arrange for staff #1, #2, #3, #4, to receive a minimum of two hours of training regarding supervision of children. The training should consist of 1 hour of Supervision: Playground Supervision and 1 hour of Supervision: Positioning, Where Do I Stand, found on Better Kid Care or similar trainings. The legal entity must receive DHS approval of the trainings content prior to scheduling the trainings.

Regulation: 3270.69(c)/3270.69(d)

Description: Drinking water available/Provided every 1 hour outdoors

Noncompliance Area: During the course of the investigation on 7/30/24 the inspector learned that the children are not being provided with water throughout the day or when outside over an hour, during play. Children have to ask for water when outside and then are taken into the building as ratio allows for water. Further children are only provided with water after breakfast and following outdoor play, not throughout the day.

Correction Required: Safe drinking water shall be made available to children of all ages throughout the day. Drinking water shall be provided to children who are out-of-doors for a period exceeding 1 hour.

Regulation: 3270.102(a)/3270.104(a)

Description: Clean and good repair/Clean, good repair, proper size

Noncompliance Area: A renewal inspection occurred at the facility. A physical site review was conducted. A table and bench set was found in the outdoor play area and the cushions on two of the benches had broken zippers exposing the inside foam.

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

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

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. Staff #1 completed this training on 7/17/24.

Correction Required: Staff person(s) shall complete professional development in the topics of 3270.31(f)(1 -- 10).

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. Staff #1 did not review the emergency plan on an annual basis. Staff #1 previously reviewed the plan on 6/30/23 and again on 7/8/24.

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 participate in annual fire safety training. The following staff did not participate in annual fire safety training: Staff #1 (previous7/21/22, current 6/30/24) and Staff #2 (previous 8/30/22, current 3/25/24).

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: 3270.131(a)/3270.182(1)

Description: Health information/Initial and subsequent health reports

Noncompliance Area: An inspection occurred at the facility. A review of children's files was conducted. See the code sheet for the dates of enrollment. Regulation requires health reports on children to be on file no later than 60 days following the first day of attendance at the facility. The health report provided for Child #6 was dated 11/14/23, which was after the 60-day requirement.

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: 3270.27(c)

Description: Training regarding plan

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. Regulation requires that staff to review the emergency plan on an annual basis. The following staff did not review the emergency plan on an annual basis: Staff #1 and #6. Staff #1 reviewed the emergency plan on 6/27/22 and did not review the emergency plan again until 7/11/23. Staff #6 reviewed the emergency plan on 6/25/22 and did not review the emergency plan until 7/5/23.

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

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

Description: Fire safety - 1 yr.

Noncompliance Area: An inspection occurred at the facility. A review of staff files was conducted. Regulation requires fire safety training to be completed by staff at least annually. The following staff did not participate in fire safety training on an annual basis: Staff #3, #4 and #8. Staff #3 participated in fire safety training on 3/3/22 and did not participate in fire safety training again until 6/17/23. Staff #4 participated in fire safety training on 2/25/22 and did not participate in fire safety training again until 6/1/23. Staff #8 participated in fire safety training on 7/1/22 and did not participate in fire safety training again until 10/26/23.

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: 3270.34(a)(6)

Description: Staff evaluations

Noncompliance Area: An inspection occurred at the facility. A review of staff files was conducted. Regulation requires written evaluations of staff be completed on an annual basis. The following staff did not have an evaluation completed on an annual basis: Staff #1, #2, #4, #5, #6 #7 and #8. Staff #1 had an evaluation completed on 8/22/22 and did not have another evaluation completed until 9/19/23. Staff # 2 had an evaluation completed on 2/10/22 and did not have another evaluation completed until 4/6/23. Staff #4 had an evaluation completed on 8/29/22 and did not have another evaluation completed until 9/12/23. Staff #5 had an evaluation completed on 1/12/23 and did not have another evaluation completed until 2/7/24. Staff #6 had an evaluation completed on 8/17/22 and did not have an annual evaluation completed at the time of this inspection. Staff #7 had an evaluation completed on 12/27/22 and did not have another evaluation completed until 1/15/24. Staff #8 had an evaluation completed on 1/12/23 and did not have another evaluation completed until 2/7/24.

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

Regulation: 3270.51/3270.52

Description: Similar Age Level/Mixed Age Level

Noncompliance Area: An inspection occurred at the facility. Through staff interviews during this inspection, it was determined that the facility was not in compliance with staff: child ratios. On 2/19/24, a classroom contained 13 preschool aged children with Staff #9 for approximately 15-minutes in the morning. The ratio requirement for 13 preschool aged children would require 2 staff. On 2/20/24, a classroom contained 8 mixed-aged toddlers with Staff #10 for a period of time between 7-8a.m. The ratio requirement for 8 mixed-aged toddlers would require 2 staff.

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

Regulation: 3270.51/3270.52

Description: Similar Age Level/Mixed Age Level

Noncompliance Area: An inspection occurred at the facility. Through staff interviews during this inspection, it was determined that the facility was not in compliance with staff: child ratios. On 2/19/24, a classroom contained 13 preschool aged children with Staff #9 for approximately 15-minutes in the morning. The ratio requirement for 13 preschool aged children would require 2 staff. On 2/20/24, a classroom contained 8 mixed-aged toddlers with Staff #10 for a period of time between 7-8a.m. The ratio requirement for 8 mixed-aged toddlers would require 2 staff.

Correction Required: When children are grouped in similar age levels, the following maximum child group sizes and ratios of staff persons apply: Infants 1:4 with a maximum group size of 8; Young toddlers 1:5 with a maximum group size of 10; Older toddlers 1:6 with a maximum group size of 12; Preschool children 1:10 with a maximum group size of 20; Young school-age children 1:12 with a maximum group size of 24; Older school-age children 1:15 with a maximum group size of 30. When children are grouped in mixed age levels, the age of the youngest child in the group determines the staff:child ratio and maximum group size in accordance with the requirements in § 3270.51 (relating to similar age level). The legal entity must arrange for all facility staff to receive a minimum of three hours of PQAS-approved training, regarding supervision and appropriate ratios of children. The legal entity must receive DHS approval of the training content prior to scheduling the training.

Regulation: 3270.51/3270.52

Description: Similar Age Level/Mixed Age Level

Noncompliance Area: An inspection occurred at the facility. Through staff interviews during this inspection, it was determined that the facility was not in compliance with staff: child ratios. On 2/19/24, a classroom contained 13 preschool aged children with Staff #9 for approximately 15-minutes in the morning. The ratio requirement for 13 preschool aged children would require 2 staff. On 2/20/24, a classroom contained 8 mixed-aged toddlers with Staff #10 for a period of time between 7-8a.m. The ratio requirement for 8 mixed-aged toddlers would require 2 staff.

Correction Required: When children are grouped in similar age levels, the following maximum child group sizes and ratios of staff persons apply: Infants 1:4 with a maximum group size of 8; Young toddlers 1:5 with a maximum group size of 10; Older toddlers 1:6 with a maximum group size of 12; Preschool children 1:10 with a maximum group size of 20; Young school-age children 1:12 with a maximum group size of 24; Older school-age children 1:15 with a maximum group size of 30. When children are grouped in mixed age levels, the age of the youngest child in the group determines the staff:child ratio and maximum group size in accordance with the requirements in § 3270.51 (relating to similar age level). The legal entity must submit documentation in a format approved by DHS proving that the facility is maintaining the required staff:child ratios at all times. The legal entity will confirm continuing compliance by sending copies of the documentation to the Northeast Regional Office on a weekly basis for a period of three months after DHS approves the documentation format.

Regulation: 3270.72(c)

Description: Good repair

Noncompliance Area: An inspection occurred at the facility. A physical site review was conducted. Several window screens were observed damaged. These damaged screens were identified and discussed with the director at the time of the inspection.

Correction Required: Screens shall be in good repair.

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

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

Noncompliance Area: See SIN 00230322 9/6/23 and SIN 00232355 9/27/23.

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

Regulation: 3270.182(7)

Description: Reports of accidents, injuries and illnesses. Original report - parent same day Copy - facility accident file. Copy - child's file

Noncompliance Area: See SIN 00230322 9/6/23 and SIN 00232355 9/27/23.

Correction Required: A child's record shall contain reports of accidents, injuries and illnesses involving a child in care at the facility. The original report shall be given to the parent on the day of the incident. The second copy of the report shall be retained at the facility in an accident file. The third copy of the report shall be retained at the facility in the child's file.

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

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

Noncompliance Area: During an unannounced inspection, video footage was provided by the facility for review. On 9/5/23 at approximately 2:15 p.m., children were viewed being unsupervised on several occasions. Staff # 1 was observed to go into the hallway, leaving the children unsupervised in the classroom, and blocked by the cubbies. Several children were also viewed unlocking the half door, leaving the classroom, and walking down the hall to another classroom without supervision. At this time, Staff # 2 was observed in that classroom, unaware that the children were coming and going on their own. On the same day at 2:39p.m., an unexpected fire drill occurred. Staff # 1 was seen immediately standing at the exit door with children that were lining up. Staff # 1 exited the building with 6 preschool-aged children. Child # 2 was seen on video footage left in the room by Staff # 1, still sleeping on their cot. Shortly after, Staff #1 left, Child # 1 comes into view of the camera, also left in the building unsupervised. At 2:43p.m., Staff # 2 was viewed entering the classroom of Staff # 1 and finding Child # 1 and Child # 2. Staff # 2 realized after they got outside that they were missing Child #1. Staff # 1, never realized Child # 2 was unaccounted for until Staff # 2 found Child # 2 in the classroom.

Correction Required: Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Outdoor play space used by the facility is considered part of the facility premises. Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises. The legal entity must arrange for all facility staff to receive a minimum of three hours of PQAS-approved training, including technical assistance, regarding supervision and ratio of children. This training must be completed as a live training or in-person. The legal entity must receive DHS approval of the training content prior to scheduling the training.

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

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

Noncompliance Area: During an unannounced inspection, video footage was provided by the facility for review. On 9/5/23 at approximately 2:15 p.m., children were viewed being unsupervised on several occasions. Staff # 1 was observed to go into the hallway, leaving the children unsupervised in the classroom, and blocked by the cubbies. Several children were also viewed unlocking the half door, leaving the classroom, and walking down the hall to another classroom without supervision. At this time, Staff # 2 was observed in that classroom, unaware that the children were coming and going on their own. On the same day at 2:39p.m., an unexpected fire drill occurred. Staff # 1 was seen immediately standing at the exit door with children that were lining up. Staff # 1 exited the building with 6 preschool-aged children. Child # 2 was seen on video footage left in the room by Staff # 1, still sleeping on their cot. Shortly after, Staff #1 left, Child # 1 comes into view of the camera, also left in the building unsupervised. At 2:43p.m., Staff # 2 was viewed entering the classroom of Staff # 1 and finding Child # 1 and Child # 2. Staff # 2 realized after they got outside that they were missing Child #1. Staff # 1, never realized Child # 2 was unaccounted for until Staff # 2 found Child # 2 in the classroom.

Correction Required: Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Outdoor play space used by the facility is considered part of the facility premises. Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises. The Legal Entity / Director will revise their existing supervision policy. The policy will include how the facility will demonstrate their knowledge and ability to adequately supervise children while maintaining appropriate ratio at all times. The policy must focus on ensuring that each child is seen, heard, assessed and able to be directed at all times. The policy must include how the facility will ensure appropriate supervision and ratios during transition times and during times of emergency or fire drills. The policy must also include a plan for each staff to be assigned the responsibility for supervision of specific children, including the requirement that the staff person know the names and whereabouts of the children in their assigned group and be physically present with the children in their group on the facility premises and on facility excursions off the facility premises. This supervision and ratio policy must be submitted to the Department prior to implementation for approval. Once approved by the Department, the director will ensure that all current employees and any new hires are trained on this policy. Documentation of this training will be submitted to the Regional Office and maintained on file at the facility.

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

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

Noncompliance Area: During an unannounced inspection, video footage was provided by the facility for review. On 9/5/23 at approximately 2:15 p.m., children were viewed being unsupervised on several occasions. Staff # 1 was observed to go into the hallway, leaving the children unsupervised in the classroom, and blocked by the cubbies. Several children were also viewed unlocking the half door, leaving the classroom, and walking down the hall to another classroom without supervision. At this time, Staff # 2 was observed in that classroom, unaware that the children were coming and going on their own. On the same day at 2:39p.m., an unexpected fire drill occurred. Staff # 1 was seen immediately standing at the exit door with children that were lining up. Staff # 1 exited the building with 6 preschool-aged children. Child # 2 was seen on video footage left in the room by Staff # 1, still sleeping on their cot. Shortly after, Staff #1 left, Child # 1 comes into view of the camera, also left in the building unsupervised. At 2:43p.m., Staff # 2 was viewed entering the classroom of Staff # 1 and finding Child # 1 and Child # 2. Staff # 2 realized after they got outside that they were missing Child #1. Staff # 1, never realized Child # 2 was unaccounted for until Staff # 2 found Child # 2 in the classroom.

Correction Required: Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Outdoor play space used by the facility is considered part of the facility premises. 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: 3270.182(7)

Description: Reports of accidents, injuries and illnesses. Original report - parent same day Copy - facility accident file. Copy - child's file

Noncompliance Area: An unannounced inspection occurred at the facility. A review of the facility's accident/injury reports was conducted. Staff # 5 indicated that Child # 1 had fallen while at the facility and chipped a tooth and indicated that an incident report was written, and the parent was notified. Staff # 3 was unable to provide this incident report at the time of this inspection. A copy was not maintained in either the child's file or the facility file.

Correction Required: A child's record shall contain reports of accidents, injuries and illnesses involving a child in care at the facility. The original report shall be given to the parent on the day of the incident. The second copy of the report shall be retained at the facility in an accident file. The third copy of the report shall be retained at the facility in the child's file.

Regulation: 3270.51/3270.113(a)(2)

Description: Similar Age Level/Supervision on and facility premises

Noncompliance Area: During an unannounced inspection, video footage was provided by the facility for review. On 9/5/23 at 2:39p.m., an unexpected fire drill occurred. Staff # 2 was viewed exiting the building with 11 preschool-aged children. This number of children required 2 staff.

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: 3270.51/3270.113(a)(2)

Description: Similar Age Level/Supervision on and facility premises

Noncompliance Area: During an unannounced inspection, video footage was provided by the facility for review. On 9/5/23 at 2:39p.m., an unexpected fire drill occurred. Staff # 2 was viewed exiting the building with 11 preschool-aged children. This number of children required 2 staff.

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 legal entity must arrange for all facility staff to receive a minimum of three hours of PQAS-approved in-person training, including technical assistance, regarding supervision and ratio of children. This training must be completed as a live training or in-person. The legal entity must receive DHS approval of the training content prior to scheduling the training.

Regulation: 3270.94(a)(6)

Description: Remove all persons in one trip

Noncompliance Area: During an unannounced inspection, video footage was provided by the facility for review. On 9/5/23 at 2:39p.m., an unexpected fire drill occurred. Staff # 1 was seen immediately standing at the exit door with children that were lining up. Staff # 1 exited the building with 6 preschool-aged children. Child # 2 was seen on video footage left in the room by Staff # 1, still sleeping on their cot. Shortly after, Staff #1 left, Child # 1 comes into view of the camera, also left in the building unsupervised. At 2:43p.m., Staff # 2 was viewed entering the classroom of Staff # 1 and finding Child # 1 and Child # 2. Staff # 2 realized after they got outside that they were missing Child #1. Staff # 1, never realized Child # 2 was unaccounted for until Staff # 2 found Child # 2 in the classroom.

Correction Required: The Director or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that evacuation plans provide for the removal of all persons from the facility in a single trip.

Regulation: 3270.94(a)(6)

Description: Remove all persons in one trip

Noncompliance Area: During an unannounced inspection, video footage was provided by the facility for review. On 9/5/23 at 2:39p.m., an unexpected fire drill occurred. Staff # 1 was seen immediately standing at the exit door with children that were lining up. Staff # 1 exited the building with 6 preschool-aged children. Child # 2 was seen on video footage left in the room by Staff # 1, still sleeping on their cot. Shortly after, Staff #1 left, Child # 1 comes into view of the camera, also left in the building unsupervised. At 2:43p.m., Staff # 2 was viewed entering the classroom of Staff # 1 and finding Child # 1 and Child # 2. Staff # 2 realized after they got outside that they were missing Child #1. Staff # 1, never realized Child # 2 was unaccounted for until Staff # 2 found Child # 2 in the classroom.

Correction Required: The Director or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that evacuation plans provide for the removal of all persons from the facility in a single trip. The Legal Entity or Director will develop or revise the facility's fire drill plan and procedures. The fire drill policy and procedures must address the ability of all staff to remove all persons from the facility in a single trip. This policy must be sent to the Northeast Regional Office for review. Once approved this policy and procedure will be discussed with staff. Staff signatures will indicate their understanding of the facility's fire drill policy and procedure and their need to remove all persons from the facility in one trip.

Regulation: 3270.94(a)(6)

Description: Remove all persons in one trip

Noncompliance Area: During an unannounced inspection, video footage was provided by the facility for review. On 9/5/23 at 2:39p.m., an unexpected fire drill occurred. Staff # 1 was seen immediately standing at the exit door with children that were lining up. Staff # 1 exited the building with 6 preschool-aged children. Child # 2 was seen on video footage left in the room by Staff # 1, still sleeping on their cot. Shortly after, Staff #1 left, Child # 1 comes into view of the camera, also left in the building unsupervised. At 2:43p.m., Staff # 2 was viewed entering the classroom of Staff # 1 and finding Child # 1 and Child # 2. Staff # 2 realized after they got outside that they were missing Child #1. Staff # 1, never realized Child # 2 was unaccounted for until Staff # 2 found Child # 2 in the classroom.

Correction Required: The Director or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that evacuation plans provide for the removal of all persons from the facility in a single trip. Over the course of all fire drills conducted through February 29, 2024, the operator shall demonstrate that all children will be removed in one trip. For fire drills conducted through this date, the operator shall document who was on site prior to the drill, including staff and children, and complete a checklist upon evacuation showing that all children were accounted for in one trip. This checklist and documentation must be forwarded to the regional office after each conducted drill within 3 business days of conducting each drill.

Regulation: 3270.124(f)/3270.181(c)

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

Noncompliance Area: A renewal inspection occurred at the facility. A review of children's files was conducted. Emergency contact and agreement forms per regulation are to be updated at least every 6-month period. The following children's forms were not updated every 6-month period: Child # 2 emergency contact dated 5/7/22 not updated until 1/4/23 and agreement dated 3/25/22 and not updated until 10/5/22. Child # 3 emergency contact dated 5/2/22 and not updated until 11/4/22 and agreement dated 2/23/22 and not updated until 11/8/22. Child # 4 emergency contact dated 4/4/22 and not updated until 12/20/22. Child # 5 emergency contact dated 12/22/21 and not updated until 8/29/22 and agreement dated 3/21/22 and not updated until 10/4/22. Child # 6 agreement dated 3/16/22 and not updated until 10/21/22.

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

Regulation: 3270.95(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 conducted. Fire testing documented as occurring on the following dates lapsed occurring at least every 30 days as required by regulation: 4/11/22 5/17/22 7/8/22 8/12/22 9/19/22 11/10/22 12/21/22

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: 3270.32(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. The CPSL indicates that a Department of Education (DOE) FBI clearance could not be used for employment in a Department of Human Services (DHS) program after 9/24/18. Staff # 1 was hired and worked in a child care role using a DOE FBI clearance dated for 8/26/19.

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 indicates that a Department of Education FBI clearance could not be used for employment in a Department of Human Services program after 9/24/18.

Regulation: 3270.51

Description: Similar Age Level

Noncompliance Area: As reported by Staff # 12, the young school aged classroom was out of ratio on 9/29/21. Staff # 12 stated this was verified through interviews Staff # 12 had with staff and watching the facility's security camera. Staff # 12 stated in this school aged classroom, Staff # 4 was with 13 school aged children. The operator gave a plan of correction stating that "Staff to child ratios will be maintained at all times." Checklists showing compliance with ratios were required to be submitted to the regional office as part of a plan of correction. On 12/1/2021, the checklists show that the infant classroom contained 9 children with 2 staff from 12-1 p.m., which is a ratio that would require 3 staff. The operator admitted that the classroom was out of ratio, stating that she didn't realize the ratio was not different during naptime and one staff member was taking a break. There were other staff available in close proximity (by the kitchen area) but they were not in the classroom.

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: 3270.51

Description: Similar Age Level

Noncompliance Area: As reported by Staff # 12, the young school aged classroom was out of ratio on 9/29/21. Staff # 12 stated this was verified through interviews Staff # 12 had with staff and watching the facility's security camera. Staff # 12 stated in this school aged classroom, Staff # 4 was with 13 school aged children.

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

Regulation: 3270.51

Description: Similar Age Level

Noncompliance Area: As reported by Staff # 12, the young school aged classroom was out of ratio on 9/29/21. Staff # 12 stated this was verified through interviews Staff # 12 had with staff and watching the facility's security camera. Staff # 12 stated in this school aged classroom, Staff # 4 was with 13 school aged children.

Correction Required: When children are grouped in similar age levels, the following ratios of staff persons apply: Infants 1:4; Young toddlers 1:5; Older toddlers 1:6; Preschool children 1:10; Young school-age children 1:12; Older school-age children 1:15. The Legal Entity / Director will establish a supervision and ratio policy. The policy will include how the facility will demonstrate their knowledge and ability to adequately supervise children while maintaining appropriate ratio at all times. The policy must focus on ensuring that each child is seen, heard, assessed and able to be directed at all times. The policy must include the required staff:child ratios for each age group. The policy must include how the facility will ensure appropriate supervision and ratios during transition times and while in the outdoor play area. The policy must also include a plan for each staff to be assigned the responsibility for supervision of specific children, including the requirement that the staff person know the names and whereabouts of the children in his assigned group and be physically present with the children in his group on the facility premises and on facility excursions off the facility premises. The policy must also address how these groups will be transitioned from one staff person to another during staffing changes. This supervision and ratio policy must be submitted to the Department prior to implementation for approval. Once approved by the Department, the director will ensure that all current employees and any new hires are trained on this policy.

Regulation: 3270.51

Description: Similar Age Level

Noncompliance Area: As reported by Staff # 12, the young school aged classroom was out of ratio on 9/29/21. Staff # 12 stated this was verified through interviews Staff # 12 had with staff and watching the facility's security camera. Staff # 12 stated in this school aged classroom, Staff # 4 was with 13 school aged children.

Correction Required: When children are grouped in similar age levels, the following ratios of staff persons apply: Infants 1:4; Young toddlers 1:5; Older toddlers 1:6; Preschool children 1:10; Young school-age children 1:12; Older school-age children 1:15. The legal entity must submit documentation in a format approved by DHS proving that the facility procedure for counting children is followed at all times e.g., a checklist. The legal entity will confirm continuing compliance by sending copies of the documentation to the Regional Office of Child Development and Early Learning on a weekly basis for a period of three months after DHS approves the documentation format.

Regulation: 3270.51

Description: Similar Age Level

Noncompliance Area: As reported by Staff # 12, the young school aged classroom was out of ratio on 9/29/21. Staff # 12 stated this was verified through interviews Staff # 12 had with staff and watching the facility's security camera. Staff # 12 stated in this school aged classroom, Staff # 4 was with 13 school aged children.

Correction Required: When children are grouped in similar age levels, the following ratios of staff persons apply: Infants 1:4; Young toddlers 1:5; Older toddlers 1:6; Preschool children 1:10; Young school-age children 1:12; Older school-age children 1:15. The legal entity must arrange for all facility staff to receive a minimum of three hours of PQAS-approved in-person training, including technical assistance, regarding supervision of children and proper staff:child ratios. This training must be completed as a live training or in-person. The legal entity must receive DHS approval of the training content prior to scheduling the training.

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

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

Noncompliance Area: A complaint inspection occurred at the facility on 9/29/21. A review of the facility's camera system was conducted along with interviews with staff. A video recording from an incident on 9/24/21 from 3:28-3:32p.m. was viewed. Child # 1 and Child # 2, preschool children, were viewed in the outdoor play area, playing at the fence at the corner of E 5th St and Strawberry Ave. Child # 1 and Child # 2 were viewed climbing over the fence and leaving the outdoor play area at least 3 times during the time of the video. Child # 1 was viewed unable to climb back over the fence to get into the play area at roughly 3:32p.m. and a parent picking up their child at the facility was viewed lifting the child back over the fence. Child # 2 was unable to be identified due to the quality of the video. Staff # 1 and Staff # 2 were identified and confirmed that they were the staff responsible for this group of preschool children. During interviews, both staff stated they were a combined group and neither identified that Child #1 was in their group. Staff # 1 was seen in the video near the brick stairs tending to a child crying on the bench and later to a group fighting in the playhouse right next to the brick staircase. Staff # 2 indicated they were talking two children, putting 2 kids in timeout and going to the door to ask staff inside what needed to be done because it was time for Staff # 2 to leave for the day. Staff # 1 and Staff # 2 were unaware the children had been climbing over the fence and left the play area during this time. On 9/24/21, Staff # 3 began the day with Child # 1 in their supervision group. Staff # 4 then relieved Staff # 3 and stated it was assumed Child # 1 was in their group, but no appropriate discussion had taken place as to Child # 1 being in their group. Staff # 4 took Child # 1's group to the outdoor play area and this child's group was combined with Staff # 10 and Staff # 1's group. Again, no communication occurred indicating which staff was supervising which children. Staff # 10 was then relived for the day by Staff # 2. Again, no communication occurred indicating which staff was supervising which children. Appropriate supervision of Child # 1 and other children could not be established after staff transition times throughout the day. A follow up to the complaint inspection occurred at the facility on 10/22/21. Staff interviews were conducted regarding more information obtained on the original complaint. Through these interviews it was determined a lack of supervision occurred involving Child # 3. Staff # 11 had been doing rounds at the facility. Staff # 11 walked into the outdoor play area and was approached by several children. These children told Staff # 11 that Child # 3 was over the fence. A storage shed in the outdoor play area has a gap of about 5 feet between the shed and the fence near Strawberry Ave. where a small fence was added to both sides of the gap to prevent children from having access. Child # 3 was found in this section behind the shed, unable to be supervised by staff on the playground. Staff were not aware the child was in this area. Staff # 11 could not identify what staff were in the play area during this incident.

Correction Required: Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Outdoor play space used by the facility is considered part of the facility premises. Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises. The Legal Entity / Director will establish a supervision and ratio policy. The policy will include how the facility will demonstrate their knowledge and ability to adequately supervise children while maintaining appropriate ratio at all times. The policy must focus on ensuring that each child is seen, heard, assessed and able to be directed at all times. The policy must include the required staff:child ratios for each age group. The policy must include how the facility will ensure appropriate supervision and ratios during transition times and while in the outdoor play area. The policy must also include a plan for each staff to be assigned the responsibility for supervision of specific children, including the requirement that the staff person know the names and whereabouts of the children in his assigned group and be physically present with the children in his group on the facility premises and on facility excursions off the facility premises. The policy must also address how these groups will be transitioned from one staff person to another during staffing changes. This supervision and ratio policy must be submitted to the Department prior to implementation for approval. Once approved by the Department, the director will ensure that all current employees and any new hires are trained on this policy.

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

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

Noncompliance Area: A complaint inspection occurred at the facility on 9/29/21. A review of the facility's camera system was conducted along with interviews with staff. A video recording from an incident on 9/24/21 from 3:28-3:32p.m. was viewed. Child # 1 and Child # 2, preschool children, were viewed in the outdoor play area, playing at the fence at the corner of E 5th St and Strawberry Ave. Child # 1 and Child # 2 were viewed climbing over the fence and leaving the outdoor play area at least 3 times during the time of the video. Child # 1 was viewed unable to climb back over the fence to get into the play area at roughly 3:32p.m. and a parent picking up their child at the facility was viewed lifting the child back over the fence. Child # 2 was unable to be identified due to the quality of the video. Staff # 1 and Staff # 2 were identified and confirmed that they were the staff responsible for this group of preschool children. During interviews, both staff stated they were a combined group and neither identified that Child #1 was in their group. Staff # 1 was seen in the video near the brick stairs tending to a child crying on the bench and later to a group fighting in the playhouse right next to the brick staircase. Staff # 2 indicated they were talking two children, putting 2 kids in timeout and going to the door to ask staff inside what needed to be done because it was time for Staff # 2 to leave for the day. Staff # 1 and Staff # 2 were unaware the children had been climbing over the fence and left the play area during this time. On 9/24/21, Staff # 3 began the day with Child # 1 in their supervision group. Staff # 4 then relieved Staff # 3 and stated it was assumed Child # 1 was in their group, but no appropriate discussion had taken place as to Child # 1 being in their group. Staff # 4 took Child # 1's group to the outdoor play area and this child's group was combined with Staff # 10 and Staff # 1's group. Again, no communication occurred indicating which staff was supervising which children. Staff # 10 was then relived for the day by Staff # 2. Again, no communication occurred indicating which staff was supervising which children. Appropriate supervision of Child # 1 and other children could not be established after staff transition times throughout the day. A follow up to the complaint inspection occurred at the facility on 10/22/21. Staff interviews were conducted regarding more information obtained on the original complaint. Through these interviews it was determined a lack of supervision occurred involving Child # 3. Staff # 11 had been doing rounds at the facility. Staff # 11 walked into the outdoor play area and was approached by several children. These children told Staff # 11 that Child # 3 was over the fence. A storage shed in the outdoor play area has a gap of about 5 feet between the shed and the fence near Strawberry Ave. where a small fence was added to both sides of the gap to prevent children from having access. Child # 3 was found in this section behind the shed, unable to be supervised by staff on the playground. Staff were not aware the child was in this area. Staff # 11 could not identify what staff were in the play area during this incident.

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

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

Noncompliance Area: A complaint inspection occurred at the facility on 9/29/21. A review of the facility's camera system was conducted along with interviews with staff. A video recording from an incident on 9/24/21 from 3:28-3:32p.m. was viewed. Child # 1 and Child # 2, preschool children, were viewed in the outdoor play area, playing at the fence at the corner of E 5th St and Strawberry Ave. Child # 1 and Child # 2 were viewed climbing over the fence and leaving the outdoor play area at least 3 times during the time of the video. Child # 1 was viewed unable to climb back over the fence to get into the play area at roughly 3:32p.m. and a parent picking up their child at the facility was viewed lifting the child back over the fence. Child # 2 was unable to be identified due to the quality of the video. Staff # 1 and Staff # 2 were identified and confirmed that they were the staff responsible for this group of preschool children. During interviews, both staff stated they were a combined group and neither identified that Child #1 was in their group. Staff # 1 was seen in the video near the brick stairs tending to a child crying on the bench and later to a group fighting in the playhouse right next to the brick staircase. Staff # 2 indicated they were talking two children, putting 2 kids in timeout and going to the door to ask staff inside what needed to be done because it was time for Staff # 2 to leave for the day. Staff # 1 and Staff # 2 were unaware the children had been climbing over the fence and left the play area during this time. On 9/24/21, Staff # 3 began the day with Child # 1 in their supervision group. Staff # 4 then relieved Staff # 3 and stated it was assumed Child # 1 was in their group, but no appropriate discussion had taken place as to Child # 1 being in their group. Staff # 4 took Child # 1's group to the outdoor play area and this child's group was combined with Staff # 10 and Staff # 1's group. Again, no communication occurred indicating which staff was supervising which children. Staff # 10 was then relived for the day by Staff # 2. Again, no communication occurred indicating which staff was supervising which children. Appropriate supervision of Child # 1 and other children could not be established after staff transition times throughout the day. A follow up to the complaint inspection occurred at the facility on 10/22/21. Staff interviews were conducted regarding more information obtained on the original complaint. Through these interviews it was determined a lack of supervision occurred involving Child # 3. Staff # 11 had been doing rounds at the facility. Staff # 11 walked into the outdoor play area and was approached by several children. These children told Staff # 11 that Child # 3 was over the fence. A storage shed in the outdoor play area has a gap of about 5 feet between the shed and the fence near Strawberry Ave. where a small fence was added to both sides of the gap to prevent children from having access. Child # 3 was found in this section behind the shed, unable to be supervised by staff on the playground. Staff were not aware the child was in this area. Staff # 11 could not identify what staff were in the play area during this incident.

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

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

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

Noncompliance Area: A complaint inspection occurred at the facility on 9/29/21. A review of the facility's camera system was conducted along with interviews with staff. A video recording from an incident on 9/24/21 from 3:28-3:32p.m. was viewed. Child # 1 and Child # 2, preschool children, were viewed in the outdoor play area, playing at the fence at the corner of E 5th St and Strawberry Ave. Child # 1 and Child # 2 were viewed climbing over the fence and leaving the outdoor play area at least 3 times during the time of the video. Child # 1 was viewed unable to climb back over the fence to get into the play area at roughly 3:32p.m. and a parent picking up their child at the facility was viewed lifting the child back over the fence. Child # 2 was unable to be identified due to the quality of the video. Staff # 1 and Staff # 2 were identified and confirmed that they were the staff responsible for this group of preschool children. During interviews, both staff stated they were a combined group and neither identified that Child #1 was in their group. Staff # 1 was seen in the video near the brick stairs tending to a child crying on the bench and later to a group fighting in the playhouse right next to the brick staircase. Staff # 2 indicated they were talking two children, putting 2 kids in timeout and going to the door to ask staff inside what needed to be done because it was time for Staff # 2 to leave for the day. Staff # 1 and Staff # 2 were unaware the children had been climbing over the fence and left the play area during this time. On 9/24/21, Staff # 3 began the day with Child # 1 in their supervision group. Staff # 4 then relieved Staff # 3 and stated it was assumed Child # 1 was in their group, but no appropriate discussion had taken place as to Child # 1 being in their group. Staff # 4 took Child # 1's group to the outdoor play area and this child's group was combined with Staff # 10 and Staff # 1's group. Again, no communication occurred indicating which staff was supervising which children. Staff # 10 was then relived for the day by Staff # 2. Again, no communication occurred indicating which staff was supervising which children. Appropriate supervision of Child # 1 and other children could not be established after staff transition times throughout the day. A follow up to the complaint inspection occurred at the facility on 10/22/21. Staff interviews were conducted regarding more information obtained on the original complaint. Through these interviews it was determined a lack of supervision occurred involving Child # 3. Staff # 11 had been doing rounds at the facility. Staff # 11 walked into the outdoor play area and was approached by several children. These children told Staff # 11 that Child # 3 was over the fence. A storage shed in the outdoor play area has a gap of about 5 feet between the shed and the fence near Strawberry Ave. where a small fence was added to both sides of the gap to prevent children from having access. Child # 3 was found in this section behind the shed, unable to be supervised by staff on the playground. Staff were not aware the child was in this area. Staff # 11 could not identify what staff were in the play area during this incident.

Correction Required: Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Outdoor play space used by the facility is considered part of the facility premises. Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises. The legal entity must submit documentation in a format approved by DHS proving that the facility procedure for counting children is followed at all times e.g., a checklist. The legal entity will confirm continuing compliance by sending copies of the documentation to the Regional Office of Child Development and Early Learning on a weekly basis for a period of three months after DHS approves the documentation format.

Regulation: 3270.63/3270.76

Description: Unsafe Areas in Outdoor Space/Building Surfaces

Noncompliance Area: A complaint inspection occurred at the facility on 9/29/21. A review of the facility's camera system was conducted along with interviews with staff. A video recording from an incident on 9/24/21 from 3:28-3:32p.m. was viewed. Child # 1 and Child # 2, preschool children, were viewed in the outdoor play area, playing at the fence at the corner of E 5th St and Strawberry Ave. Child # 1 and Child # 2 were viewed climbing over the fence and leaving the outdoor play area at least 3 times during the time of the video. Child # 1 was viewed unable to climb back over the fence to get into the play area at roughly 3:32p.m. and a parent picking up their child at the facility was viewed lifting the child back over the fence. The fencing did not restrict the children from leaving the play area and entering a heavily traveled intersection. A follow up to the complaint inspection occurred at the facility on 10/22/21. Staff interviews were conducted regarding more information obtained on the original complaint. Through these interviews it was determined a lack of supervision occurred involving Child # 3. Staff # 11 had been doing rounds at the facility. Staff # 11 walked into the outdoor play area and was approached by several children. These children told Staff # 11 that Child # 3 was over the fence. A storage shed in the outdoor play area has a gap of about 5 feet between the shed and the fence near Strawberry Ave. where a small fence was added to both sides of the gap to prevent children from having access. Child # 3 was found in this section behind the shed, unable to be supervised by staff on the playground. Staff were not aware the child was in this area. Staff # 11 could not identify what staff were in the play area during this incident. The fencing in this area did not restrict the child from entering an area that was out of supervision of staff.

Correction Required: If unsafe areas or conditions are in or near an outdoor play space, fencing or natural barriers are required to restrict children from those unsafe areas or conditions.Floors, walls, ceilings and other surfaces, including the facility's outdoor play space surfaces shall be kept clean, in good repair and free from visible hazards.

Regulation: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: A renewal inspection occurred at the facility. A physical site review was conducted. In the outdoor play area, near the brick staircase was a playhouse. This play house was broken at the base of the door the children would use to get into the playhouse.

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: 3270.61(h)

Description: Exceeding Capacity

Noncompliance Area: A renewal inspection occurred at the facility and a physical site review was conducted on 10/6/21. The preschool room which is located to the right of the entrance and the third room at the end of the hall measures for 14 children. During this inspection, 17 children were observed in this classroom. Additionally, as reported by Staff # 12, the young school aged classroom was over capacity on 9/29/21. Staff #1 verified through interviews with staff and watching the facility's security footage that the school-aged classroom was over capacity by 3 children. One staff person was observed with 13 children, but this classroom only has a measured capacity for 10 children.

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

Regulation: 3270.66(a)

Description: Locked or inaccessible

Noncompliance Area: A renewal inspection occurred at the facility. A physical site review was conducted. In the preschool room located to the right of the entrance and is the third room at the end of the hall had a closet door that was unlocked. On the floor of this closet, accessible to children, was paint, resolve, and disinfectant solution. All of these items indicated that they needed to be out of reach of children.

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

Noncompliance Area: The director reported that on 7/27/20 facility persons #1, 2 and 3 were watching a group of 10 infants / young toddlers as one group and did not have specific children assigned to them at the time of a fire drill. Facility person #1 proceeded to pick up two infants and then allowed child #1, a young toddler, to walk outside in front of her barefoot onto the hot pavement. Child #1 was standing on the pavement for approximately 10 seconds before being picked up and the bottoms of his feet were burned and needed to be medically treated as a result.

Correction Required: The legal entity must arrange for all facility staff to receive a minimum of three hours in-person PQAS approved training regarding supervision of children. The legal entity must receive DHS approval of the training content prior to scheduling the training. The legal entity must submit documentation showing attendance by all staff.

Noncompliance Area: On 7/27/20 child #1 received burns on the bottom of his feet at approximately 3:30pm according to the incident report on file. The parent was not notified of the injury until the child was picked up at approximately 4:50pm. The parent did take child #1 to the emergency department to receive treatment for his injuries.

Correction Required: If emergency medical care is needed for a child, the parent shall be contacted as soon as practical in the best interest of the child. If the parent cannot be reached, the operator shall record in writing the reason emergency care was required and the attempts made to inform the parent.

Noncompliance Area: Facility person #1 told facility persons #2 and 3 that she had spanked child #1, an older toddler, in the bathroom, because he was not listening to her. Child #1 did not sustain any injuries.

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

Noncompliance Area: During renewal inspection on 9/13/19 Cert rep. observed two staff in the infant/toddler room supervising the children in the room. There is an adjoining nap room where two young toddlers were sleeping in their cribs. Staff can see the children through a glass window and the door was opened however a staff person was not physically present in the room to hear and assess the children as they were napping in their cribs.

Correction Required: Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises.

Noncompliance Area: There is a container of Tylenol that expired on 7/19 located in the medication box for child #1

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

Noncompliance Area: Facility person #1 was hired on 12/18 and has an FBI clearance on file that was received through the Department of Education. Facility person #1 will need an FBI clearance that was processed through the Department of Human Services in order to comply with current CPSL requirements.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). LACKING REQUIRED HIRING DOCUMENTS: Facility Person #1 may not work in a child care position at the facility until the FBI clearance processed through DHS is received.

Noncompliance Area: Some of the trash cans located in the bathrooms of the facility are not lidded

Correction Required: A toilet area, training chair area, diapering area and sink area shall be equipped with a clean, lidded waste receptacle.

Noncompliance Area: There are small areas of peeling blue paint on the wall near the door leading to the outdoor play yard in the middle preschool room

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

Noncompliance Area: The parent of child #1 did not receive an incident report on the same day that the child, an infant, was kicked in the head by another child

Correction Required: A child's record shall contain reports of accidents, injuries and illnesses involving a child in care at the facility. The original report shall be given to the parent on the day of the incident. The second copy of the report shall be retained at the facility in an accident file. The third copy of the report shall be retained at the facility in the child's file.

Noncompliance Area: OBSERVED AN EXPOSED BOLT ON THE LARGE PLAYGROUND EQUIPMENT ON THE YELLOW CIRCLE NEAR THE STEPS.

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

Noncompliance Area: OBSERVED 2 TUBES OF DIAPER CREAM IN THE DIAPER CHANGING AREA OT ROOM THAT ARE MARKED WITH CHILDREN'S NAMES BUT DO NOT HAVE CORRESPONDING MEDICATION LOGS.

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

Noncompliance Area: THE 1ST AID KIT IN THE OT ROOM DID NOT CONTAIN SCISSORS.

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

Noncompliance Area: THE TOILET SEAT & LID IN THE YT ROOM HAS A FINISN THAT IS WORN EXPOSING THE WOOD MAKING IT UNABLE TO BE PROPERLY SANITIZED.

Correction Required: Toilet areas and fixtures shall be cleaned daily and be in good repair.

Noncompliance Area: OBSERVED A RIP IN THE CLOTH COVERING OF A SOFT BLOCK IN THE INFANT/YOUNG TODDLER ROOM EXPOSING THE INNER FOAM.

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

Noncompliance Area: OBSERVED MEDICATION IN A STAFF PERSON'S PURSES IN UNLOCKED CLOSETS INTHE PRESCHOOL ROOM AND THE HEAD START ROOM. THE PURSES WERE ON THE FLOOR INSIDE THE UNLOCKED DOORS MAKING THEM CCESSIBLE TO CHILDREN.

Correction Required: Medication shall be stored in a locked area of the facility or in an area that is out of the reach of children.

Noncompliance Area: OBSERVED A MEDICATION LOG IN THE HEAD START ROOM THAT WAS SIGNED BY A PARENT AND CONTAINED A CHILD'S NAME BUT DID NOT CONTAIN A NAME OF MEDICATION OR ANY OTHER INFORMATION. THERE WAS A MEDICATION WITH THE SAME CHILD'S NAME INSIDE THE MED BOX.

Correction Required: A medication log shall include the name of the medication.

Noncompliance Area: STAFF PERSON #1, DOH 5/15/17, DOES NOT HAVE INITIAL EMERGENCY PLAN TRAINING ON FILE.

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.