Brightside Academy/north Versailles

Regulation: 3270.113(b)

Description: No physical punishment

Noncompliance Area: Based on staff statements, Staff Person #1 has pulled children by the arm to redirect them or to prevent them from leaving their rest mat. Based on staff statements, Staff Person #1 has picked up children who had left their rest mats and forcefully placed them back onto their mats.

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

Regulation: 3270.113(d)

Description: No harsh language

Noncompliance Area: Based on staff statements, Staff Person #1 has used harsh, demeaning, and abusive language when interacting with children. Staff Person #1 has screamed at children, making statements such as: "Go sit down somewhere away from me! Stop it! You need to stay on your mat!"

Correction Required: A facility person may not use harsh, demeaning or abusive language in the presence of children. TIERED LIS: 1. A facility person may not use harsh, demeaning or abusive language in the presence of children. This portion of the plan shall have an immediate correction date. 2. The legal entity will require all staff persons at the facility to complete a training regarding managing challenging behaviors in the classroom. The training must be offered by ELRC 5, in-person and a minimum of 2 hours. The training must be completed within 3 months of the approval of this plan of correction. The training must be approved by the Department prior to implementation. Upon completion of the training, staff training documentation will be provided to the OCDEL-DHS representative by email. The training may count towards the mandatory 12 training hours required by the Department. The operator shall provide a date for when this training will be complete. 3. The legal entity will require all leadership staff to participate in technical assistance visits provided by ELRC 5 regarding supporting staff who are managing challenging behaviors in the classroom. The legal entity will complete a minimum of 3, in-person technical assistance visits provided by ELRC 5. The technical assistance visits must be completed within 4 months of the approval of this plan of correction. Upon completion of the visits, documentation will be provided to the OCDEL-DHS representative by email. The correction date for this portion of the plan may be up to 4 months from the date the Regional Office approves this plan.

Regulation: 3270.113(d)

Description: No harsh language

Noncompliance Area: Based on interviews, it was verified that Staff Person #1 used harsh, demeaning language with children on multiple occasions in the infant room. Staff Person #1 was heard screaming "Shut up" and "Be quiet" to infants. Staff Person #1 was also heard saying, "I'm glad someone else is dealing with that mess," regarding a child with special needs.

Correction Required: A facility person may not use harsh, demeaning or abusive language in the presence of children.

Regulation: 3270.113(a)

Description: Supervised at all times

Noncompliance Area: At approximately 130pm it was observed that the lighting in the infant room was so dark that it was extremely difficult to see the 3 infants napping in their cribs or the 3 young toddlers on the ground. When staff were asked if they could see the children from their positions, one staff sitting in a chair and one staff holding an infant towards the opposite end of the room, they stated "well I can see them when I walk around to them."

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.

Regulation: 3270.106(f)

Description: 2 feet apart

Noncompliance Area: A crib in use by an infant lacked two feet of space on 3 sides. One side was blocked by an adult size rocking chair.

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: 3270.107

Description: Refrigerator

Noncompliance Area: The refrigerator in the kitchenette, containing condiments used for children's meals, lacked a thermometer. Hair and debris were observed in a sticky substance in the bottom of the same refrigerator.

Correction Required: A facility shall have an operable, clean refrigerator used to store potentially hazardous foods. The refrigerator shall be capable of maintaining food at 45° F or below. An operating thermometer shall be placed in the refrigerator.

Regulation: 3270.123(a)

Description: Signed

Noncompliance Area: The agreement for child #5 was not signed by the parent.

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

Regulation: 3270.123(a)(1)

Description: Amount of fee

Noncompliance Area: The agreement for child #4 did not specify the amount of the fee to be charged.

Correction Required: An agreement shall specify the amount of the fee to be charged per day or per week.

Regulation: 3270.123(a)(3)

Description: Services proceeded

Noncompliance Area: The files for children #1 and #3, enrolled for over 6 months, lacked documentation of a child service report shared with the parents.

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: 3270.124(b)(1)

Description: Child's name, birth date

Noncompliance Area: The emergency contact for child #5 included an incorrect date of birth.

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: The emergency contact information for child #2 did not include the address and telephone number of the child's physician or source of medical care.

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

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

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

Noncompliance Area: The emergency contact forms for children #1 and #5 included only the parents' initials and lacked signed parental consent for emergency medical care.

Correction Required: Emergency contact information must include the written consent signed by a parent for emergency medical care. A child's record shall contain signed parental consent for emergency medical care for the child. Written consent is required prior to admission.

Regulation: 3270.124(b)(7)

Description: Name/address/phone release person

Noncompliance Area: The emergency contact information for child #3 did not include the address of the individual designated by the parent to whom the child may be released.

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

Regulation: 3270.131(a)/3270.182(1)

Description: Health information/Initial and subsequent health reports

Noncompliance Area: The files for children #2 and #5, both enrolled over 60 days, did not include health reports. An invalid health report form was present in the file for child #5. The form was signed by the parent.

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

Description: Infant: updated health report every 6 months/Initial and subsequent health reports

Noncompliance Area: The file for child #1, an infant, lacked a health report conducted in the last 6 months.

Correction Required: The operator shall require the parent to provide an updated health report at least every 6 months for an infant or young toddler. A child's record shall contain initial and subsequent health reports.

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

Description: Immunization record/Dismissal policy

Noncompliance Area: The files for children #1 and #2, enrolled over 60 days, lacked vaccination records. Children #1 and #2 will be dismissed from care by close of business 12/16/25 until either the immunization record is updated or a parent provides a written, signed exemption letter.

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).

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: Staff person #3 has completed the health and safety course titled Get Started with Center-Based Care: Building Blocks for Quality (10 hours), but has not completed the required health and safety update course titled Pennsylvania Health and Safety Update 2022 (1 hour) training.

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 #3 must complete (PA Required Health and Safety for Centers-Group Child Care Parts 1 and 2/ PA Required Health and Safety for Family Child Care Parts 1 and 2).

Regulation: 3270.151(a)/3270.192(3)

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

Noncompliance Area: The file for staff #1 contained consecutive health assessments dated more than 24 months apart. The most recent health assessment on file is now current.

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

Regulation: 3270.171(a)

Description: Pick-up and drop-off points

Noncompliance Area: Written notification of the facility and the program's use of pedestrian and vehicular routes around the child care facility has not been sent annually. The most recent notification occurred 11/2024.

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: 3270.181(d)

Description: Dated signature affixed

Noncompliance Area: The emergency contact form and agreement for child #5 did not include a dated signature from the parent.

Correction Required: Following review, a parent shall attest to the accuracy of information in the emergency contact information and the financial agreement at each review by affixing a dated signature to the record.

Regulation: 3270.182(5)

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

Noncompliance Area: The records for children #1 and #5 included only the parents' initials and lacked signed parental consent for administration of minor first-aid procedures by facility staff

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

Regulation: 3270.21

Description: General Health and Safety

Noncompliance Area: The following sharp or hazardous items were accessible to preschool age children on the day of the inspection; A meat thermometer in an unlocked drawer in the kitchenette which connects to the school age room, unattended adult scissors and a stapler on a table in the school age room, and 2 jaw style staple removers in an unlocked cabinet in the rear PS room,

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

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The file for staff person #4 contained an invalid state police clearance. The clearance lacked a dissemination date. (SEE LIS CODE SHEET)

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

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

Noncompliance Area: The file for staff #3, designated as a Group Supervisor on the staff data sheet, did not contain documentation of the qualifications required for the position.

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: 3270.34(a)(6)

Description: Staff evaluations

Noncompliance Area: The files for staff #1and #2 lacked evaluations completed in the past 12 months.

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: 3270.51/3270.113(a)(1)

Description: Similar Age Level/Staff assigned to specific children

Noncompliance Area: Child #3, a preschooler, was observed in the restroom while Staff #1 supervised child #3 from the doorway of the school age room. Staff #1 was not in the same physical space with child #3. The restroom is located outside the rear door of the school age room.

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. 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: 3270.64

Description: Outside Walkways

Noncompliance Area: The facility's wooden walkway, used by children to access the facility's outdoor play space, was snow covered. Significant ice buildup was observed near the midway point of the walkway where runoff from the roof was accumulating. The entry to the walkway was marked with caution tape by the facility's custodial staff to prevent use.

Correction Required: Outside walkways shall be free from ice, snow, leaves, equipment and other hazards.

Regulation: 3270.65

Description: Protective Outlet Covers 5 yrs. or less

Noncompliance Area: An outlet on a string of holiday lights in the lobby lacked a protective cover. The lights were plugged in and accessible to children 5 years of age or younger. The lobby is used by children and staff to access the outdoor play space.

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

Regulation: 3270.66(a)

Description: Locked or inaccessible

Noncompliance Area: A Windex spray bottle, containing cleaning solution, was observed on the floor in the rear PS room.

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: 3270.75(b)

Description: Inaccessible to children

Noncompliance Area: The first aid kit in the school age room was accessible to children in care on the top of the cubbies. School age and preschool children were present in the room.

Correction Required: A first-aid kit must be inaccessible to children.

Regulation: 3270.76

Description: Building Surfaces

Noncompliance Area: Stained ceiling tiles were observed in the young toddler area and the infant room. Loose bunching carpet, which created a tripping hazard, was observed in the young toddler area. A broken handle was observed on a cabinet under the sink in the older toddler room. The broken area left a sharp screw exposed and accessible to children.

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: Peeling paint was observed in the older toddler area near the bookshelf. Peeling paint and crumbling plaster debris was observed in the rear preschool room on the floor near the bookshelf. A hole in the plaster/drywall was observed behind the gate in the same rear PS room.

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

Regulation: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: Stiff broken plastic was observed on the pockets of the wall calendar in PS Room 5. A broken corner was observed on a plastic toy bin in the YT room. Sharp protruding pieces of plastic were observed on a toy storage basket in the infant 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: 3270.119

Description: Infant sleep position

Noncompliance Area: Staff person #3 was observed placing child #1 to sleep on their stomach in a crib in the infant room. Child #1 is an infant.

Correction Required: Infants shall be placed in the sleeping position recommended by the American Academy of Pediatrics unless there is a medical reason an infant should not sleep in this position. The medical reason shall be documented in a statement signed by a physician, physician's assistant or CRNP and placed in the child's record at the facility.

Regulation: 3270.31(f)(10)/3270.192(2)(iii)

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

Noncompliance Area: Staff person #2 did not complete acceptable training in pediatric CPR and first aid within 90 days of hire. The file for staff #2 contained an unacceptable BLS training certificate dated 7/13/23. Approved training dated 6/04/24 is now on file.

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

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

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

Noncompliance Area: The file for staff #1, designated on the staff data sheet as an assistant group supervisor, did not contain documentation of the qualifications required for the position.

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: 3270.66(a)

Description: Locked or inaccessible

Noncompliance Area: AA batteries were accessible to children in a cubby in the school age room.

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

Description: Building Surfaces

Noncompliance Area: A broken hinge was observed on a cabinet door under the sink in the YT room. Rusted metal pieces were observed protruding from the cement wall along the ramp used by children to access the outdoor play space. Along the same ramp, a sharp screw was accessible on a piece of lattice used to cover a utility box mounted on the side of the building.

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: 3270.72(b)

Description: Screened

Noncompliance Area: Based on staff reports, the door leading from the school age classroom to the front parking area had been left open to allow for air circulation while the air conditioner was in disrepair. A screen was not in place during the times the door was open.

Correction Required: Windows or doors used for ventilation shall be screened when open.

Regulation: 3270.151(a)/3270.192(3)

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

Noncompliance Area: The file for staff #2 contained a health assessment dated after their first day providing initial service in a child care setting. A current health assessment is now on file.

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

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

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

Noncompliance Area: The files for staff #1 and #3, both designated as assistant group supervisors, did not include documentation of the qualifications required for the position. Both staff were observed caring for children alone.

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: 3270.37(c)

Description: Aides supervised all times

Noncompliance Area: Staff #1 was observed caring for children while unsupervised. Based on the contents of the staff file and a written designation in the file, staff #1 qualifies as an aide.

Correction Required: An aide or a combination of aides shall be supervised at all times by a staff person qualified at minimum as an assistant group supervisor.

Regulation: 3270.76

Description: Building Surfaces

Noncompliance Area: Splintering wood, broken rails, and exposed wood screws were observed on the ramp used by children to access the outdoor play space. Multiple protruding nail heads and tips were also observed on the rails and on a section of tape that was peeling away from the rails near the front corner. At the end of the ramp, a metal trim piece was detached on one end creating a tripping hazard. On the ground near the gate to the outdoor play space, two pieces of rebar were observed protruding several inches above the wooden landscaping pieces they were embedded in.

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(g)

Description: Clean and good repair

Noncompliance Area: The toilet in the school age room restroom was not fully attached to the floor and was observed to be unstable.

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

Regulation: 3270.95(a)/3270.95(b)

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

Noncompliance Area: Based on documentation at the facility, multiple consecutive tests of the fire alarm system were conducted at intervals greater than 30 days. A current test is not on record. The last documented test was dated 6/11/24. The documented test dates are as follows; 12/05/23 to 2/06/24=63 days, 2/06/24 to 3/14/24 = 37 days, 3/14/24 to 4/16/24 = 33 days.

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

Regulation: 3270.131(b)(1)

Description: Infant: updated health report every 6 months

Noncompliance Area: The file for Child #1, a young toddler, lacked a current health report that had been completed in the last 6 months. The last health report was dated 5.16.23.

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

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

Description: Immunization record/Dismissal policy

Noncompliance Area: The file for Child #1 lacked verification that the child had received the recommended 15-18 month DTAP vaccination. The file for Child #2 lacked verification that the child had received the recommended Varicella and MMR vaccinations. Written exemptions were not on file.

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 and #2 will be dismissed from care at the close of business on 12.5.23.

Regulation: 3270.161(d)

Description: Potentially hazardous food refrigerated

Noncompliance Area: A lunchbox containing a bento box with a cheese stick was observed in a child's cubby in the Main Room.

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

Regulation: 3270.69(b)

Description: 110º F or less

Noncompliance Area: The hot water in the single restroom in the Main Room was measured at 117.9° F. The hot water in the School Age Room was measured at 117° F.

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

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

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

Noncompliance Area: The file for Facility Person #1 lacked an initial health assessment that included a tuberculosis screening within 12 months prior to starting at the facility. The tuberculosis screening was dated 9 days after starting. The health assessment was dated 13 days after starting.

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

Regulation: 3270.192(2)(ii)

Description: Exp, educ., training prior to facility

Noncompliance Area: The file for Facility Person #2 lacked verification of 2500 hours to qualify them for the position they were observed to be performing. The file contained 2078.4 hours.

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

Regulation: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: The file for Facility Person #1 lacked proof that they had requested their NSOR certificate and that they had been fingerprinted for their FBI clearance prior to starting at the facility. The FBI clearance was on file 2 days after starting and the NSOR was on file 20 days after starting.

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

Regulation: 3270.82(i)

Description: Lidded waste receptacles

Noncompliance Area: A lidded can was missing from the one of the sinks in the Preschool area of the main classroom.

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

Regulation: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: The little tykes picnic table in the preschool outdoor play space was cracked posing pinch points for the children in care.

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

Regulation: 3270.102(g)

Description: Hazardous toys and equipment

Noncompliance Area: The Boppy located in the school age room was described as hazardous by the US Consumer Product Safety Commission and may not be on the premises at the facility.

Correction Required: Children's toys and equipment, including furniture and rest equipment, described as hazardous by the United States Consumer Product Safety Commission may not be used by children at the facility and may not be on the premises at the facility. At the time of inspection, the operator shall submit to the Department written affirmation on a form provided by the Department stating that the facility is in compliance with this requirement.

Regulation: 3270.66(e)

Description: Arts and crafts non-toxic

Noncompliance Area: There was Barbasol shaving cream labeled keep out of reach of children for use in the school age room.

Correction Required: Arts and crafts materials shall be nontoxic.

Regulation: 3270.113(e)

Description: Restraints prohibited

Noncompliance Area: **According to staff statements, Child #1, a preschool aged child, is very active and continually tries to climb shelves and furniture in the classroom, often attempts to run out of the classroom and refuses to stay on a cot at nap time. A backpack weighted with approximately 10 pounds of books was routinely placed on Child #1 to restrict the child from climbing furniture in the classroom and to keep the child seated on their cot at nap time. Due to the weight of the backpack, Child #1 was unable to stand while wearing the backpack and restricted to a seated position.

Correction Required: **The Legal Entity will arrange for all staff to attend a minimum of 2 hours of training on Managing Difficult Behaviors in the Classroom conducted by the ELRC. The training will be submitted to the regional office for approval prior to attendance. Proof of training will be submitted upon completion.

Regulation: 3270.113(e)

Description: Restraints prohibited

Noncompliance Area: *According to staff statements, Child #1, a preschool aged child, is very active and continually tries to climb shelves and furniture in the classroom, often attempts to run out of the classroom and refuses to stay on a cot at nap time. A backpack weighted with approximately 10 pounds of books was routinely placed on Child #1 to restrict the child from climbing furniture in the classroom and to keep the child seated on their cot at nap time. Due to the weight of the backpack, Child #1 was unable to stand while wearing the backpack and restricted to a seated position.

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.

Noncompliance Area: Based on interviews with staff members,on 9/15/20 Child #1 was observed with a mark on the child's forehead thought to be caused by a fall. The staff did not give a report to the parent on the day of the incident, but had an unsigned original report on file for the 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: Child file #1 lacked an updated vaccination for Influenza on the most recent health report according to the schedule of vaccinations recommended by the ACIP.

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

Noncompliance Area: The first aid kit in the preschool space lacked sterile gauze pads.

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.