Brecknock Academy

Regulation: 3270.123(a)(3)

Description: Services proceeded

Noncompliance Area: During a renewal inspection on 12/15/25 Child 2 did not have a Child service report. Child 2 has been enrolled for more than 6 months(see LIS code sheet for Date of enrollment).

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)/3270.123(a)(1)

Description: Signed /Amount of fee

Noncompliance Area: During a renewal inspection on 12/15/25 Children 1 and 4's fee agreements were not signed by the operator. Child 4's fee agreement also did not list the fee amount.

Correction Required: An agreement shall be signed by the operator and the parent. An agreement shall specify the amount of the fee to be charged per day or per week.

Regulation: 3270.124(b)(1)

Description: Child's name, birth date

Noncompliance Area: During a renewal inspection on 12/15/25 Child 5's emergency contact form did not include the child's name and birth date. The provider identified this emergency contact form was for Child 5, and it was present in Child 5's file.

Correction Required: Emergency contact information must include the name and birth date of the child.

Regulation: 3270.124(b)(2)

Description: Physician name, address, phone

Noncompliance Area: During a renewal inspection on 12/15/25 emergency contact form for Child 4 did not include the name of the child's source of medical care, and emergency contact form for Child 5 did not list the address for the child's 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)(3)/3270.124(b)(7)

Description: Parent home/work address, phone/Name/address/phone release person

Noncompliance Area: During a renewal inspection on 12/15/25 emergency contact forms did not list parents work address(Child 1), and work phone number (Children 1, 3, and 5). Additionally Children 3 and 4 did not have the address for the release persons listed on their emergency contact forms.

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

Regulation: 3270.124(c)

Description: Each child care space

Noncompliance Area: During a renewal inspection on 12/15/25 Cert rep observed that Child 6 and Child 7's emergency contact information was not present with them in the rooms where they were receiving care, the young toddler room and infant room respectively.

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

Regulation: 3270.131(a)

Description: Health information

Noncompliance Area: During a renewal inspection on 12/15/25 Older toddler Child 2's initial health assessment was dated 11/20/25 which is beyond 60 days from child's date of enrollment. (See LIS code sheet for DOB and Date of enrollment).

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

Regulation: 3270.131(b)(2)

Description: Toddler/preschool: updated health report every 12 months

Noncompliance Area: During a renewal inspection on 12/15/25 preschool Child 1's most recent health assessment was dated 3/18/24, which is more than 12 month ago.

Correction Required: The operator shall require the parent to provide an updated health report at least every 12 months for an older toddler or preschool child.

Regulation: 3270.133(5)

Description: Original label

Noncompliance Area: During a renewal inspection on 12/15/25 Cert rep observed Benadryl cream (exp 4/2025) and Neosporin(3/2025) in the older toddler room first aid kit.

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

Regulation: 3270.161(d)

Description: Potentially hazardous food refrigerated

Noncompliance Area: During a renewal inspection on 12/15/25 Cert rep observed a cheese stick in a child's lunch box in the Preschool room. The cheese stick and lunch box were not refrigerated.

Correction Required: Potentially hazardous food brought from the child's home or provided by the facility shall be refrigerated.

Regulation: 3270.181(e)

Description: Emergency master file updated

Noncompliance Area: During a renewal inspection on 12/15/25 cert rep observed the emergency contact form for Child 4 had been updated in the children's files, but was not updated in the emergency contact form in the children's classroom. This was evident by information such as child's last name, child's date of birth, and parent's home and work information not being present on the emergency contact forms in the classroom but were present on the master copy in the children's file, as well as information such as child's address and health insurance information being updated on the master file, but not the copy in the classroom.

Correction Required: If emergency information is updated in a master file, it shall be updated accordingly in other facility records.

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: During a renewal inspection on 12/15/25 it was reported that a copy of the accident injury or illness reports are not retained in in a facility wide accident file. Staff reported that when accident injury or illness reports are completed, the parent is given the original, and a copy is kept in the child's 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: 3270.183(a)

Description: Locked cabinet

Noncompliance Area: During a renewal inspection on 12/15/25 it was observed the children's files were stored in an unlocked drawer, in a unlocked office. It was reported the drawer was not able to be locked.

Correction Required: Child records are confidential and shall be stored in a locked cabinet.

Regulation: 3270.27(a)(6)

Description: Emergency plan

Noncompliance Area: During a renewal inspection on 12/15/25 the most recent emergency drill took place on 11/3/25, however the facility did not have documentation of the previous emergency drill log available for review during the inspection. Previous documentation verified by the regional office noted the most recent previous emergency drill was 2/1/2024. This is more than 12 months between emergency drills.

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

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: During a renewal inspection on 12/15/25 the following violations of the CPSL were noted: Staff 1's NSOR clearance certificates were dated 1/15/20 and 1/30/25, Staff 2's PSP clearance certificates were dated 7/13/20 and 11/4/25, Staff 2's DHS FBI clearance certificates were dated 7/24/20 and 8/5/25 and Staff 2's NSOR clearance certificates were dated 1/14/20 and 4/4/25. These are more than 60 months between clearance certificates. It was reported Staff 1 worked as staff between 1/16/25-1/30/25, and Staff 2 worked as Staff 1/15/25-4/4/25, and 7/14/25-11/4/25.

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. TIERED LIS: 1. The operator shall comply with the CPSL and with Chapter 3490 (related to protective Services. This portion of the plan shall have an immediate correction date. 2. The legal entity must create a checklist for staff and facility persons files that addresses all necessary staff and facility persons file paperwork and time frames for renewals of paperwork as appropriate. The staff and facility persons file paperwork that must be addressed in this checklist includes but is not limited to PA clearances, Out of State clearances and trainings as required by the CPSL and all documents required for staff and facility persons to be hired. The checklist must be submitted to the Regional Office for approval. Once approved this checklist shall be used by the person responsible for hiring and maintaining facility persons records. The provider shall provide a date for when this portion of the plan shall be completed.

Regulation: 3270.76

Description: Building Surfaces

Noncompliance Area: During a renewal inspection on 12/15/25 Cert rep observed the trim on the bottom of the back left wall of the young toddler room was peeling up and was not in good repair. Cert rep also observed the power cord to a mounted tv was loose and would be accessible to children creating a falling/pulling hazard in the unused 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.

Regulation: 3270.82(i)

Description: Lidded waste receptacles

Noncompliance Area: During a renewal inspection on 12/15/25 Cert rep observed that the toilet area in the older toddler room, and the unused preschool room was not equipped with a clean, lidded waste receptacle.

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

Regulation: 3270.123(a)(6)/3270.182(2)

Description: Admission date/Application, admission, withdrawal dates

Noncompliance Area: During an unannounced inspection on 11/13/25 Child 1's fee agreement and child's file did not include the child's admission date. Child 1's file did not list the child's withdraw date. It was reported the child had been withdrawn from child care. (See LIS code sheet for Date of admission and withdrawal).

Correction Required: An agreement shall specify the date of the child's admission. A child's record shall contain the dates of application, admission and withdrawal of the child.

Regulation: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: During an unannounced inspection 11/13/25 Staff person 1 did not complete mandated reporter training within 60 months of the previous training date. This is evidenced by mandated reporter trainings on file being dated 4/3/20 and 11/4/25. It was reported Staff person 1 did work in a child care position between 4/3/25 and 11/4/25.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to Child Protective Services).

Regulation: 3270.52

Description: Mixed Age Level

Noncompliance Area: During an unannounced inspection 11/13/25 Cert rep observed the following around 9:05AM: Staff person 2 was present and alone in the infant classroom with 5 children(2 infants, and 3 young toddlers). Staff person 2 report all 5 children were in their assigned group. It was reported that the operator was contacted to provide additional staff at 8:11AM when the room was noticed to be out of ratio. Additional staff did not arrive until 9:35AM.

Correction Required: When children are grouped in mixed age levels, the age of the youngest child in the group determines the staff:child ratio and maximum group size in accordance with the requirements in § 3270.51 (relating to similar age level). TIERED LIS: 1. The required staff:child ratios must be maintained at all times. This portion of the plan shall have an immediate correction date. 2. The legal entity must arrange for the director, all regular staff and substitute staff who may work at this location to receive a minimum of three hours of training regarding Supervision and Ratios. The training must be PQAS approved, in-person, and outside of childcare hours. The legal entity must receive DHS approval of the training content prior to scheduling the training. The operator shall provide a correction date for when this training will be completed. 3. The legal entity must update their ratio policy in order to maintain proper compliance with 3270.51-3270.55 with regards to ratios. This policy shall address the specific ratios for children in similar and mixed age groups served at this location. . This policy must address the steps staff and the operator will take in order to maintain ratios. The legal entity must receive approval of the updated policy from the Regional Office. Once approved by the Regional Office, the legal entity must review the updated policy with all staff and have staff sign off that the understand and will follow the supervision and ratio policy. The operator shall provide a correction date for when this portion of the plan will be completed.

Regulation: 3270.151(a)

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

Noncompliance Area: During an unannounced inspection on 4/2/25 Cert rep noted Staff 1's health assessment was dated 2/23/24 This is more than 12 month before her date of hire.(See LIS Code sheet).

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

Regulation: 3270.76

Description: Building Surfaces

Noncompliance Area: During a unannounced inspection on 2/12/25 Cert rep observed the dishwasher had visible mold/mildew on both the top and bottom racks where dishes would be placed. Inside the dishwasher was three plastic kids trays that were observed to be the same type of trays staff reported are used for children's lunches.

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

Regulation: 3270.131(d)(7)/3270.131(d)(8)

Description: Free from contagious/communicable disease/Age appropriate screenings complete

Noncompliance Area: During a renewal inspection on 12/12/24 cert rep supervisor noted Child 1's health assessment did not state if the child is able to participate in child care and appears to be free from contagious or communicable disease. Child 1's health assessment did not include a statement that age-appropriate screenings recommended by the American Academy of Pediatrics were conducted. An acceptable plan of correction was received on 12/30/24 with a correction date of 1/15/25. During an unannounced verification visit on 2/5/25 cert rep observed Child 1's health assessment did not state if the child is able to participate in child care and appears to be free from contagious or communicable disease. Child 1's health assessment did note that recommended age-appropriate screenings were completed.

Correction Required: A health report shall include a statement that the child is able to participate in child care and appears to be free from contagious or communicable disease. A health report shall include a statement that age-appropriate screenings recommended by the American Academy of Pediatrics were conducted since the time of the previous health report required by this section.

Regulation: 3270.27(c)

Description: Training regarding plan

Noncompliance Area: During a renewal inspection on 12/12/24 and 12/18/24 emergency plan training for 2023 and 2024 for all staff was not available for certification rep review. An acceptable plan of correction was received on 12/30/24 with a correction date of 1/10/25. During a unannounced verification visit on 2/5/25 it was noted Staff 5 had not completed emergency plan training. it was noted all other staff not on medical leave completed emergency training in January 2025.

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: 3270.69(a)

Description: Running water/ safe drinking water

Noncompliance Area: During a renewal inspection on 12/12/24 and 12/18/24 the operator did not have a Department of Enviromental Protection PWS compliance letter available for review. Operator reported the letter had not yet been requested. An acceptable plan of correction was received on 12/30/24 with a correction date of 1/30/25. During an unnanouce verification visit on 2/5/25 it was noted the operator had the request form for the PWS compliance letter, but did not have a Department of Enviromental Protection PWS compliance letter at that time.

Correction Required: A facility shall provide running water and a safe and adequate supply of drinking water that complies with the standards established under the Pennsylvania Safe Drinking Water Act (35 P.S. §§721.1-721.17).

Regulation: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: During a renewal inspection on 12/12/24 cert rep observed the follow concerns: 1) Broken piece with a rough edge on the top of the yellow toy tool bench in the main room/school aged room 2) Cracked seat on a riding elephant in the toddler play space 3) Child 3's rest equipment had tears in equipment that would prevent proper sanitation. 4) Child 4's pack and play had a crack in the plastic corner of the top of the pack and play. 5) Rough edge on the broken plastic from a gate that is no longer used in the young toddler room.

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: 3270.103

Description: Small Toys and Objects

Noncompliance Area: During a renewal inspection on 12/12/24 cert rep observed plastic bags were being kept in a location that made them accessible to children who were being changed in the young toddler classroom. The plastic bags were kept in a cloth bag with an opening that rested on the changing table. Children in this classroom may still be placing objects in their mouths.

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

Regulation: 3270.121(b)

Description: Given parents in writing

Noncompliance Area: During a renewal inspection on 12/18/24 it was noted that parents were not being provided in writing information regarding the facility's supervision policy nor a daily schedule.

Correction Required: At the time of enrollment, a parent shall receive in writing the facility's general daily schedule, hours for which care is provided, fees, responsibilities for meals, clothing, health policies, supervision policies, night care policies, dismissal policies, transportation and pick-up arrangements.

Regulation: 3270.124(b)(7)

Description: Name/address/phone release person

Noncompliance Area: During a renewal inspection on 12/12/24 it was noted Child 2 did not have an address for the release persons on the emergency contact form.

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

Regulation: 3270.124(e)

Description: Written emergency plan posted

Noncompliance Area: During a renewal inspection on 12/12/24 cert rep observed the currently unused preschool classroom did not have an emergency medical transportation plan posted. This room is listed on the facility license as childcare space.

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

Regulation: 3270.124(f)/3270.181(c)

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

Noncompliance Area: During a renewal inspection on 12/12/24 Child 1's Emergency contact form and fee agreement was not reviewed and signed by the parent since 9/8/2023.

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

Regulation: 3270.131(c)

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

Noncompliance Area: During a renewal inspection on 12/12/24 cert rep supervisor noted Child 1's health assessment was not signed and dated by a physician, physician's assistant or a CRNP.

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

Regulation: 3270.131(d)(7)/3270.131(d)(8)

Description: Free from contagious/communicable disease/Age appropriate screenings complete

Noncompliance Area: During a renewal inspection on 12/12/24 cert rep supervisor noted Child 1's health assessment did not state if the child is able to participate in child care and appears to be free from contagious or communicable disease. Child 1's health assessment did not include a statement that age-appropriate screenings recommended by the American Academy of Pediatrics were conducted.

Correction Required: A health report shall include a statement that the child is able to participate in child care and appears to be free from contagious or communicable disease. A health report shall include a statement that age-appropriate screenings recommended by the American Academy of Pediatrics were conducted since the time of the previous health report required by this section.

Regulation: 3270.133(5)

Description: Original label

Noncompliance Area: During a renewal inspection on 12/12/24 cert rep observed the following expired creams and lotions: Child 5's Aquaphor (expiration 7/2019) and Child 5's Hand lotion (expiration 5/2024) in the infant classroom.

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

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: During a renewal inspection on 12/12/24 the facility's emergency plan did not address the facility's plan for continuity of operations after an emergency.

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. A Facility emergency plan must address the facility's plan for continuity of operations.

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

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

Noncompliance Area: During a renewal inspection on 12/12/24 and 12/18/24 Staff 1 and Staff 2 did not have an initial tuberculosis screening on file. Staff 2 had an initial health assessment dated 7/28/2023, which is more than one year before her date of hire. Staff 6 had an initial health assessment and tuberculosis screening dated 1/31/2023, which is more than one year before her date of hire. See code sheet for dates of hire.

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: 3270.165

Description: Menus

Noncompliance Area: During a renewal inspection on 12/12/24 cert rep observed the facility menu was not posted in a conspicuous location for the parents.

Correction Required: An operator shall conspicuously post the menu at least 1 week in advance or provide a menu to each family.

Regulation: 3270.171(a)

Description: Pick-up and drop-off points

Noncompliance Area: During a renewal inspection on 12/12/24 cert rep observed that the annual traffic letter sent to local traffic authorities did not have the facility's correct information regarding the location of the facility and the program's use of pedestrian and vehicular routes around the child care facility.

Correction Required: An operator shall notify local traffic safety authorities annually in writing of the location of the facility and the program's use of pedestrian and vehicular routes around the child care facility.

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: During a renewal inspection on 12/18/24 Staff reported that a copy of the accident injury or illness reports is not retained in the child's file. Staff reported that when accident injury or illness reports are completed, the parent is given the original, and a copy is kept in the facility book.

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: 3270.25(a)

Description: Availability of certificate of compliance and applicable regulations

Noncompliance Area: During a renewal inspection on 12/12/24 cert rep noted there was no information available for or provided to parents to access the 3270 regulations electronically.

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

Regulation: 3270.27(a)(3)

Description: Contact when arises

Noncompliance Area: During a renewal inspection on 12/12/24 cert rep noted the emergency plan did not address the method for facility persons to contact parents as soon as reasonably possible when an emergency situation arises.

Correction Required: The facility shall have an emergency plan that provides for a method for facility persons to contact parents as soon as reasonably possible when an emergency situation arises.

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

Description: Contact when ended/Letter to parents

Noncompliance Area: During a renewal inspection on 12/12/24 cert rep noted the emergency plan and letter to the parents regarding the emergency plan did not address the method for facility persons to inform parents that the emergency has ended and to provide instruction as to how parents can safely be reunited with their children.

Correction Required: The facility shall have an emergency plan that provides for a method for facility persons to inform parents that the emergency has ended and to provide instruction as to how parents can safely be reunited with their children. The operator shall provide to the parent of each enrolled child a letter explaining the emergency procedures. The operator shall also provide to the parent of each enrolled child a letter explaining any subsequent update to the plan.

Regulation: 3270.27(a)(5)

Description: Emergency plan

Noncompliance Area: During a renewal inspection on 12/12/24 cert rep noted the emergency plan did not address accommodations for infants, and toddlers. The emergency plan did address accommodations for children with disabilities, and children with chronic medical conditions.

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

Regulation: 3270.27(c)

Description: Training regarding plan

Noncompliance Area: During a renewal inspection on 12/12/24 and 12/18/24 emergency plan training for 2023 and 2024 for all staff was not available for certification rep review.

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: 3270.27(f)

Description: Emergency plan

Noncompliance Area: During a renewal inspection on 12/12/24 and 12/18/24 documentation a copy of the emergency plan was sent to the local municipality and to the county emergency management agency was not available for certification rep review.

Correction Required: The operator shall send a copy of the emergency plan and subsequent plan updates to the local municipality and to the county emergency management agency.

Regulation: 3270.31(e)

Description: Age and Training

Noncompliance Area: During a renewal inspection on 12/12/24 and 12/18/24 it was noted that Staff 1 had 1 hour of child care training during her training year (3/7/2023-3/7/24) and Staff 2 had 11.5 hours of child care training during her training year (9/28/2023-9/28/2024) This is less than the required 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.

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

Description: Fire safety - 1 yr.

Noncompliance Area: During a renewal inspection on 12/18/24 it was noted Staff 1 had fire safety training 6/10/23 and 11/7/24. This is more than 12 months between fire safety training.

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: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: During a renewal inspection on 12/18/24 cert rep noted Staff 2's NSOR clearance certificate was dated 12/17/19. This was expired at the time of inspection. Staff 5 and 6 had disclosure statements that were not dated.

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

Regulation: 3270.34(a)(6)

Description: Staff evaluations

Noncompliance Area: During a renewal inspection on 12/12/24 it was noted Staff 3 did not have an annual staff evaluation on file for review.

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: 3270.34(b)(1)

Description: Bachelor's + 1 yr

Noncompliance Area: During a renewal inspection on 12/12/24 it was noted that Staff 4 did not have 1 year of experience documented on file. Staff 4 has a bachelor's degree in human resource management.

Correction Required: A director shall have attained a bachelor's degree from an accredited college or university in early childhood education, child development, special education, elementary education or the human services field and 1 year of experience with children.

Regulation: 3270.36(b)(5)

Description: HS/GED + 2 yrs

Noncompliance Area: During a renewal inspection on 12/12/24 and 12/18/24 Staff 1 did not have a high school diploma/general educational development certificate or experience with children documented on file. Staff 1 reported having graduated high school. Staff 5 had a high school diploma but only had 1420 year of experience verified and documented on file. Both staff have been working as Assistant group supervisors.

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

Regulation: 3270.66(a)

Description: Locked or inaccessible

Noncompliance Area: During a renewal inspection on 12/12/24 white out was found in an unlocked accessible drawer in the currently unused preschool classroom. The white out was labeled "Keep 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.

Regulation: 3270.69(a)

Description: Running water/ safe drinking water

Noncompliance Area: During a renewal inspection on 12/1/224 and 12/18/24 the operator did not have a Department of Enviromental Protection PWS compliance letter available for review. Operator reported the letter had not yet been requested.

Correction Required: A facility shall provide running water and a safe and adequate supply of drinking water that complies with the standards established under the Pennsylvania Safe Drinking Water Act (35 P.S. §§721.1-721.17).

Regulation: 3270.70(a)

Description: 65º F minimum

Noncompliance Area: During a renewal inspection on 12/12/24 the following child care rooms had temperatures that were less than 65 degrees: Older toddler room, Pre- kindergarten room, Main Room/School aged room, and the currently unused preschool room.

Correction Required: The indoor temperature shall be at least 65° F.

Regulation: 3270.75(a)

Description: In child care spaces

Noncompliance Area: During a renewal inspection on 12/12/24 there was no first aid kit in the currently unused preschool room. This room is on the facility license as childcare space.

Correction Required: A first-aid kit shall be in a child care space.

Regulation: 3270.76

Description: Building Surfaces

Noncompliance Area: During a renewal inspection on 12/12/24 cert rep observed a chunk of wooden trim was broke off in the young toddler room under the alligator. What remained on the trim left splintered wood exposed.

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

Regulation: 3270.77(a)

Description: No peeling paint or plaster

Noncompliance Area: During a renewal inspection on 12/12/24 cert rep observed peeling paint in the following locations: Under the birthday board in the Young toddler room and on the bottom trim of the windows in currently unused preschool room.

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

Regulation: 3270.24(a)/3270.191

Description: Immediate access/Individual Records

Noncompliance Area: During and unannounced inspection on 11/21/24 Staff 1's file was not present at the facility for review by Cert Rep. Staff 1's file was being kept at a different facility that does not share the same legal entity as this facility.

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

Regulation: 3270.52

Description: Mixed Age Level

Noncompliance Area: During an unannounced inspection on 11/21/24 cert rep supervisor observed the staff were out of ratio in the young toddler room. The one staff had 1 young toddler and 5 older toddlers in her supervision group. Ratio for the mixed age group is 5 children.

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 director will create a ratio policy. All staff must sign and acknowledge the ratio policy. The record of the staff's signed acknowledgement policy will be kept in the Staff file.

Regulation: 3270.52

Description: Mixed Age Level

Noncompliance Area: During an unannounced inspection on 11/21/24 cert rep supervisor observed the staff were out of ratio in the young toddler room. One staff had 1 young toddler and 5 older toddlers in her supervision group and the other staff had 6 older toddlers in her supervision group. Ratio for the mixed age group is 5 children.

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).

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: During an unannounced inspection on 8/14/2024, staff person #1 was observed to be caring for children unsupervised. Staff person #1 had not completed mandated reporter training within the last 60 months. This was evidenced by the previously documented mandated reporter training on file being dated 6/10/2019.

Correction Required: A facility shall be operated in conformity with applicable Federal and State laws and regulations. State agencies whose regulations may relate to the operation of a facility include the Department of Environmental Resources, the Department of Labor and Industry, the Department of Health, the Department of Education and the Department of Transportation. Conditions at the facility may not pose a threat to the health or safety of the children. Until such time as the required training has been completed, staff person #1 must be supervised, when interacting with children, by an AGS who has completed the required training related to this citation. If there are no staff available to supervise staff person #1, then staff person #1 may not work in a childcare position at the facility.

Regulation: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: On 8/14/2024, staff person #1 had not completed mandated reporter training within the last 60 months. This was evidenced by the previously documented mandated reporter training on file being dated 6/10/2019.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Staff person #1 will have until 9/26/2024 to complete the mandated reporter training. Until such time as the required training has been completed, staff person #1 must be supervised, when interacting with children, by an AGS who has completed the required training related to this citation. If there are no staff person(s) available to supervise staff person #1, staff person #1 may not work in a childcare position at the facility.

Regulation: 3270.106(f)

Description: 2 feet apart

Noncompliance Area: During a complaint investigation on 5/24/24, there were several pack-n-plays containing sleeping children that did not have at least 2 feet of space on at least 3 sides of that rest equipment. The pack-n-plays were only inches apart from each other and lined up against the wall.

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

Regulation: 3270.111(a)/3270.112

Description: Written plan/Infant/Toddler Stimulation

Noncompliance Area: It was observed and stated in the toddler room that although a schedule was posted, that schedule is not being followed and regular routines are not established. The written schedule shows snack time from 9:30-9:50, 10-10:30 diapers, 9:50-11:15 fee play/art, 10:30-11:15 outside, and nothing listed on the schedule to show what the children would be doing between 11:15-11:30. From 9:30-10:55 it was observed and stated by staff that 8 toddler-aged children were left sitting at the high chair table once snack was completed. Staff stated that children were not going outside that morning because of the weather but weather was moderate and appropriate for outdoor play. Staff stated that children did not do an art project that day either. Staff stated that they checked diapers but this was not completed according to the time on the posted schedule. At 10:55, staff were observed to have the TV on and children having free play on the floor. Staff #4 and #5 were unable to soothe or redirect child #1. Child #1 was observed to be laying on the floor screaming by the door. Staff person #4 and #5 sat on the floor with the children in silence as the children watched TV and freely played with what was left out on the floor. At the time of inspection, no stimulation by being held, rocked, talked to or played with was observed from staff #4 and #5 with toddlers in this room.

Correction Required: A written plan of daily activities and routines, including a time for free play shall be established for each group. The plan shall be flexible to accommodate the needs of individual children and the dynamics of the group. Infants and toddlers shall be provided stimulation by being held, rocked, talked to, played with and carried.

Regulation: 3270.113(a)(1)/3270.113(a)(2)

Description: Staff assigned to specific children/Supervision on and facility premises

Noncompliance Area: During a complaint investigation on 5/24/24, it was observed and stated by staff person #1 that the infant room, which contained 7 infants, were not separated into care groups. Staff person #1 stated that staff person #2 did not have a care group assigned to them.

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. The requirement for supervision on and off the facility premises includes compliance with the staff:child ratio requirements in §§ 3270.51--3270.55.

Regulation: 3270.113(e)

Description: Restraints prohibited

Noncompliance Area: It was observed that staff are restraining toddler children in the one-year-old room stating they put the children in the highchair table at 9:30am for snack, but it was observed that all 8 children were still sitting within that highchair table at 10:40am. At 10:40am, approximately 6 out of the 8 children were siting there without food in front of them, and the last 2 children were not removed from those highchair seats until approximately 10:55am.

Correction Required: A facility person may not restrain a child by using bonds, ties or straps to restrict a child's movement or by enclosing the child in a confined space, closet or locked room. The prohibition against restraining a child does not apply to the use of adaptive equipment prescribed for a child with special needs.

Regulation: 3270.123(a)(3)

Description: Services proceeded

Noncompliance Area: Files for child #1-#4 did not contain child service reports dated within the last 6 months as required. Facility stated that they are behind on completing these reports for children and families.

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(b)/3270.182(8)

Description: Parent receives original/Copy of initial and subsequent agreements. Parent receives original.

Noncompliance Area: During a complaint investigation on 5/24/24, file for child #5 did not contain an agreement. There was no initial or subsequent agreement observed on file.

Correction Required: A parent shall receive the original agreement. The facility shall retain a copy of the agreement. A child's record shall contain a copy of the initial agreement and subsequent written agreements between the parent and the operator. The parent receives the original agreement.

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: During a complaint investigation on 5/24/24, Staff person #1 and #2 were observed to be caring for children unsupervised together. Staff person #4 was left unsupervised when staff person #5 walked out of the classroom to open the door at the front entrance of the facility. Staff person #1, #2, and #4, see code sheet for hire date, have not completed the following pre-service training required prior to caring for children unsupervised: pediatric first aid/CPR from a PQAS approved trainer and a PQAS approved curriculum.

Correction Required: A facility shall be operated in conformity with applicable Federal and State laws and regulations. State agencies whose regulations may relate to the operation of a facility include the Department of Environmental Resources, the Department of Labor and Industry, the Department of Health, the Department of Education and the Department of Transportation. Conditions at the facility may not pose a threat to the health or safety of the children. Until such time as the required pre-service trainings are completed, staff person #1, #2, and #4 must be supervised, when interacting with children, by an AGS or GS who has completed the required training related to this citation. If there are no staff person(s) available to supervise staff person #1, #2, and #4, then staff person #1, #2, and #4 may not work in a child-care position at the facility.

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: During a complaint investigation on 5/24/24, staff person #7 was observed to be caring for children unsupervised. Staff person #7 does not have current pediatric first-aid/CPR training. This is evidenced by the previously documented pediatric first-aid/CPR training expiration date of 3/2024.

Correction Required: A facility shall be operated in conformity with applicable Federal and State laws and regulations. State agencies whose regulations may relate to the operation of a facility include the Department of Environmental Resources, the Department of Labor and Industry, the Department of Health, the Department of Education and the Department of Transportation. Conditions at the facility may not pose a threat to the health or safety of the children. Staff person #7 will have until 7/2/24 to complete the required training. Until such time as the required training has been completed, staff person #7 must be supervised, when interacting with children, by an AGS or GS who has completed the required training related to this citation. If there are no staff available to supervise staff person #7, then staff person #7 may not work in a child-care position at the facility.

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

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

Noncompliance Area: During a complaint investigation on 5/24/24, file for staff person #2 did not contain a health assessment or written results of a TB screening. Staff person #2 was present and working with children the day of inspection.

Correction Required: A facility person providing direct care who comes into contact with the children or who works with food preparation shall have a health assessment conducted within 12 months prior to providing initial service in a child care setting and every 24 months thereafter. A health assessment is valid for 24 months following the date of signature, if the person does not contract a communicable disease or develop a medical problem. 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(5)

Description: Two written references

Noncompliance Area: During a complaint investigation on 5/24/24, file for staff person #2 and #4 did not contain 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: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: During a complaint investigation on 5/24/24, files for staff person #1, #2, and #6, see code sheet for hire dates, did not contain the acceptable signed, dated, and witnessed disclosure statements as required. Staff person #1 did not have a disclosure statement on file. Staff person #2 had an undated disclosure statement on file. Staff person #3 had the wrong and therefore unacceptable disclosure statement on file. Staff person #1 and #2 were paired together alone in the infant room. Staff person #1 was hired provisionally and staff person #2 was hired provisionally incorrectly. File for staff person #1 contained a completed state police clearance, completed child abuse clearance, completed NSOR verification certificate, and the fingerprint receipt dated 4/26/24 for their FBI clearance. However a completed FBI clearance was not found on file. File for staff person #2 contained only a completed child abuse clearance and the application for the NSOR verification certificate.

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 Director, Legal Entity Representative, or anyone at the facility responsible for the hiring of staff or maintaining staff files will be required to attend Existing Provider Orientation conducted by the Northeast Regional Office. The legal entity representative must contact the Regional Office at 1-800-222-2108 in order to schedule this training.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: During a complaint investigation on 5/24/24, files for staff person #1, #2, and #6, see code sheet for hire dates, did not contain the acceptable signed, dated, and witnessed disclosure statements as required. Staff person #1 did not have a disclosure statement on file. Staff person #2 had an undated disclosure statement on file. Staff person #3 had the wrong and therefore unacceptable disclosure statement on file. Staff person #1 and #2 were paired together alone in the infant room. Staff person #1 was hired provisionally and staff person #2 was hired provisionally incorrectly. File for staff person #1 contained a completed state police clearance, completed child abuse clearance, completed NSOR verification certificate, and the fingerprint receipt dated 4/26/24 for their FBI clearance. However a completed FBI clearance was not found on file. File for staff person #2 contained only a completed child abuse clearance and the application for the NSOR verification certificate.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). PROVISIONAL HIRE UNSUPERVISED: A provisional employee may not be permitted to work alone with children and must work within the vicinity of a permanent employee. A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Facility Person #1 may not work in a child care position at the facility unsupervised until their completed FBI clearance is placed on file. Facility Person #2 may not work in a child care position at the facility until their completed state police clearance, completed FBI clearance, and NSOR verification certificate is on file.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: During a complaint investigation on 5/24/24, files for staff person #1, #2, and #6, see code sheet for hire dates, did not contain the acceptable signed, dated, and witnessed disclosure statements as required. Staff person #1 did not have a disclosure statement on file. Staff person #2 had an undated disclosure statement on file. Staff person #3 had the wrong and therefore unacceptable disclosure statement on file. Staff person #1 and #2 were paired together alone in the infant room. Staff person #1 was hired provisionally and staff person #2 was hired provisionally incorrectly. File for staff person #1 contained a completed state police clearance, completed child abuse clearance, completed NSOR verification certificate, and the fingerprint receipt dated 4/26/24 for their FBI clearance. However a completed FBI clearance was not found on file. File for staff person #2 contained only a completed child abuse clearance and the application for the NSOR verification certificate.

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, #2, and #6 may not work in a child care position at the facility until the acceptable signed, dated, and witnessed disclosure statement is on file.

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

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

Noncompliance Area: It was observed that the files for staff person #1, #2, and #4 did not contain documentation to verify that those staff persons met the appliable qualifications to be working in the position in which they were hired. Staff person #1 was hired as an AGS and staff persons #2 and #4 were hired as aides. File for staff person #1 contained verification of a high school diploma but did not contain documentation of experience. File for staff person #2 did not contain any verification of education or experience. File for staff person #3 contained verification of completion up to an 8th grade education level but did not contain verification of experience.

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: 3270.52/3270.113(a)(1)

Description: Mixed Age Level/Staff assigned to specific children

Noncompliance Area: During a complaint investigation on 5/24/24, it was observed that staff person #5 left the toddler room and came to open the door for an agent of the department, leaving staff person #4 alone for approximately 1-2 minutes with 8 toddlers.

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. 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 develop a written supervision and ratio policy and procedure to be implemented at the facility. The written policy must address 3270.113(a)(1) and 3270.52 relating to staff both assigning care groups and being physically present with children in their care group along with the expectation of staff to adhere to staff:child ratio requirements. The legal entity will submit policy/procedure to the Northeast Regional Office for approval. Once approved, all existing staff and new hires must be trained on the approved policy and procedure and it must be documented in their files.

Regulation: 3270.52/3270.113(a)(1)

Description: Mixed Age Level/Staff assigned to specific children

Noncompliance Area: During a complaint investigation on 5/24/24, it was observed that staff person #5 left the toddler room and came to open the door for an agent of the department, leaving staff person #4 alone for approximately 1-2 minutes with 8 toddlers.

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. 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: 3270.151(c)(2)

Description: Mantoux TB

Noncompliance Area: On 12/13/2023, Staff #2 had a current health assessment on file, but the health assessment did not include tuberculosis screening by the Mantoux method required at initial employment.

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.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: During the Renewal Inspection on 12/13/2023, it was discovered that Staff #1 resided in the state of Virginia within the previous 5 years. Staff #1 did not have the required out of state clearances or the request for the clearances from Virginia on file.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Staff Person #1 may not work in a childcare position at the facility until all required clearances are on file. A provisional employee may not be permitted to work alone with children and must work within the vicinity of a permanent employee. A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Staff Person #1 may not work in a childcare position at the facility may not work in a childcare position at the facility until all required clearances are on file.

Regulation: 3270.66(a)

Description: Locked or inaccessible

Noncompliance Area: On 12/13/2023, Lysol cleaner and carpet cleaner was seen in an unlocked cabinet accessible to children in the preschool classroom. Both items were labeled keep 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.

Regulation: 3270.76/3270.77(a)

Description: Building Surfaces/No peeling paint or plaster

Noncompliance Area: During the Renewal Inspection on 12/13/2023, a broken drawer was seen in the pre-k classroom. Peeling paint was also seen on the building outside next to the door entering the pre-k classroom.

Correction Required: Floors, walls, ceilings and other surfaces, including the facility's outdoor play space surfaces shall be kept clean, in good repair and free from visible hazards. Peeled or damaged paint or damaged plaster is not permitted on indoor or outdoor surfaces in the childcare facility.

Regulation: 3270.51

Description: Similar Age Level

Noncompliance Area: During an unannounced inspection on 8/1/2023, two staff members reported and provided written statements about being out of ratio during the previous morning, 7/31/2023. One staff confirmed that they had 5 infants by themself in the infant room until 8:00 AM on 7/31/2023. The other staff confirmed that they had 8 older toddlers by themself at certain points from 9:00 AM-9:45 AM on 7/31/2023.

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: 3270.35(d)/3270.35(e)

Description: Director only 45 children enrolled/46 or more children- additional group sups

Noncompliance Area: On 7/6/2023, it was discovered that the previous director is no longer employed as of approximately two weeks prior. Staff #1 is now serving as the director. Staff #1 is now the only staff person employed that qualifies as a director or a group supervisor. There were 62 children in attendance on 7/6/2023.

Correction Required: A director may not function as a group supervisor in a facility in which more than 45 children are enrolled. In a facility in which more than 45 children are enrolled, a group supervisor is required for the first group of 45 enrolled children and for each group or partial group of 45 additional enrolled children.

Regulation: 3270.54(b)

Description: Two facility persons on excursions

Noncompliance Area: On 7/6/2023, Staff #1 and Staff #2, the owner both verified that Staff #1 took a group of school age children on a bowling excursion away from the facility earlier that morning without having another facility person present.

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: 3270.134(b)

Description: Towels labeled and laundered

Noncompliance Area: On 5/12/2023, it was observed that the young toddler and older toddler classrooms were using one hand towel in each classroom to dry the children's hands after handwashing.

Correction Required: Cloth towels and washcloths shall be labeled with the child's name, used by only the named child and laundered weekly. The director shall arrange a laundry schedule with the parent.

Regulation: 3270.52

Description: Mixed Age Level

Noncompliance Area: On 5/12/2023, at 7:45 a.m., Staff #1 and Staff #3 were observed in the middle room with a mixed-age group of 20 children, including 4 older toddlers, 6 preschool children, and 10 young and older school-age children. This amount of children would require at least 3 staff persons. During this visit, Staff #4 and Staff #5 were also observed in the infant room with a mixed-age group of 7 infants and 2 young toddlers. This amount of children would require at least 3 staff persons.

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.

Regulation: 3270.52

Description: Mixed Age Level

Noncompliance Area: On 5/12/2023, at 7:45 a.m., Staff #1 and Staff #3 were observed in the middle room with a mixed-age group of 20 children, including 4 older toddlers, 6 preschool children, and 10 young and older school-age children. This amount of children would require at least 3 staff persons. During this visit, Staff #4 and Staff #5 were also observed in the infant room with a mixed-age group of 7 infants and 2 young toddlers. This amount of children would require at least 3 staff persons.

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.

Regulation: 3270.51/3270.52

Description: Similar Age Level/Mixed Age Level

Noncompliance Area: On 5/3/2023 at 3:45 PM, Staff #2 was observed in the preschool classroom with 13 children for approximately 2 minutes. Two children were eventually moved to a different classroom, leaving Staff #2 with 11 preschool children. Both amounts of children require at least 2 staff in each situation. During this visit, Staff #1 was observed with a mixed-age group of 15 young and older school-age children. This amount of children requires at least two staff persons. On 5/12/2023, at 7:45 a.m., Staff #1 and Staff #3 were observed in the middle room with a mixed-age group of 20 children, including 4 older toddlers, 6 preschool children, and 10 young and older school-age children. This amount of children would require at least 3 staff persons. During this visit, Staff #4 and Staff #5 were also observed in the infant room with a mixed-age group of 7 infants and 2 young toddlers. This amount of children would require at least 3 staff persons.

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. 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. The legal entity must arrange for all facility staff, who are employed as of the date of the training, to schedule and receive a minimum of 3 hours of PQAS-approved training regarding training regarding supervision and 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: 3270.51/3270.52

Description: Similar Age Level/Mixed Age Level

Noncompliance Area: On 5/3/2023 at 3:45 PM, Staff #2 was observed in the preschool classroom with 13 children for approximately 2 minutes. Two children were eventually moved to a different classroom, leaving Staff #2 with 11 preschool children. Both amounts of children require at least 2 staff in each situation. During this visit, Staff #1 was observed with a mixed-age group of 15 young and older school-age children. This amount of children requires at least two staff persons. On 5/12/2023, at 7:45 a.m., Staff #1 and Staff #3 were observed in the middle room with a mixed-age group of 20 children, including 4 older toddlers, 6 preschool children, and 10 young and older school-age children. This amount of children would require at least 3 staff persons. During this visit, Staff #4 and Staff #5 were also observed in the infant room with a mixed-age group of 7 infants and 2 young toddlers. This amount of children would require at least 3 staff persons.

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. 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. The legal entity must develop written policies and procedures for supervision of children and maintaining the required staff-to-child ratios at all times to be implemented at the facility. The written policies must address procedures for maintaining staff-to-child ratios and include specific procedures to ensure that the staff-to-child ratios are maintained at all times in the following situations: Maintaining ratios when staff call out for their scheduled shift and procedures for when parents are dropping off their children without enough staff members present to maintain the staff-to-child ratios. The legal entity will submit policy/procedures to the Northeast Regional Office for approval. Once approved, all existing staff and any new hires must be trained on the approved policies and procedures and the documentation must be kept on file at the facility.

Regulation: 3270.51/3270.52

Description: Similar Age Level/Mixed Age Level

Noncompliance Area: On 5/3/2023 at 3:45 PM, Staff #2 was observed in the preschool classroom with 13 children for approximately 2 minutes. Two children were eventually moved to a different classroom, leaving Staff #2 with 11 preschool children. Both amounts of children require at least 2 staff in each situation. During this visit, Staff #1 was observed with a mixed-age group of 15 young and older school-age children. This amount of children requires at least two staff persons. On 5/12/2023, at 7:45 a.m., Staff #1 and Staff #3 were observed in the middle room with a mixed-age group of 20 children, including 4 older toddlers, 6 preschool children, and 10 young and older school-age children. This amount of children would require at least 3 staff persons. During this visit, Staff #4 and Staff #5 were also observed in the infant room with a mixed-age group of 7 infants and 2 young toddlers. This amount of children would require at least 3 staff persons.

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: On 5/3/2023 at 3:45 PM, Staff #2 was observed in the preschool classroom with 13 children for approximately 2 minutes. Two children were eventually moved to a different classroom, leaving Staff #2 with 11 preschool children. Both amounts of children require at least 2 staff in each situation. During this visit, Staff #1 was observed with a mixed-age group of 15 young and older school-age children. This amount of children requires at least two staff persons. On 5/12/2023, at 7:45 a.m., Staff #1 and Staff #3 were observed in the middle room with a mixed-age group of 20 children, including 4 older toddlers, 6 preschool children, and 10 young and older school-age children. This amount of children would require at least 3 staff persons. During this visit, Staff #4 and Staff #5 were also observed in the infant room with a mixed-age group of 7 infants and 2 young toddlers. This amount of children would require at least 3 staff persons.

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. 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. The operator must print and post the required staff:child ratios and the age-level breakdown of children under 3270.4 in each classroom.

Regulation: 3270.131(d)(5)/3270.131(e)(3)

Description: Immunization record/Dismissal policy

Noncompliance Area: On 3/2/2023, the updated health reports on file for Child #1, #2, #3, #4 and #5 did not have the up-to-date annual influenza immunization as recommended by the ACIP. The files for Child #1, #2, #3, #4 and #5 did not include an exemption from immunization for religious belief or strong personal objection equated to a religious belief written, signed and dated statement by the child's parent.

Correction Required: A health report shall include a review of the child's immunized status according to recommendations of the ACIP. The facility shall implement dismissal policies in accordance with the Department of Health regulation in 28 Pa. Code § 27.77 (relating to immunization requirements for children in child care group settings). Children #1, #2, #3, a#4 and #5 must be dismissed from care by close of business on 3/2/2023 and may only return to care when the immunization record is updated or when a parent provides a written, signed exemption letter.

Regulation: 3270.151(a)

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

Noncompliance Area: Staff #7 and #9 had current health assessments on file on 3/2/2023, dated 2/23/2023 for Staff #7 and 2/6/2023 for Staff #9. The previous health assessments on file were for 9/1/2020 for Staff #7 and 11/2/2020 Staff #9.

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

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: Staff persons #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16 and #17 did not complete the required one-hour 2022 update to the health and safety training by 12/30/2022.

Correction Required: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-9. Staff persons #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16 and #17 shall complete the required one-hour 2022 update to the health and safety training by 3/21/2023.

Regulation: 3270.95(a)/3270.95(b)

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

Noncompliance Area: During the Opening Inspection on 3/2/2023, the operator did not have proof of purchase/installation for the fire detection system on file.

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.