Chesterbrook Academy

Regulation: 3270.192(2)(ii)

Description: Exp, educ., training prior to facility

Noncompliance Area: Staff 1 did not have proof of education on file, prior to DOH. Please see LIS for DOH.

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

Regulation: 3270.192(5)

Description: Two written references

Noncompliance Area: Staff 1 and 2 only had one letter of reference on file.

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

Regulation: 3270.135(a)(3)

Description: Disposable diapers

Noncompliance Area: In the toddler room, the garbage can lid was not able to open by pressing the pedal. As a result, it was not hands free

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

Regulation: 3270.25(a)

Description: Availability of certificate of compliance and applicable regulations

Noncompliance Area: During the renewal inspection on 1/9/2025, the facility did not have the current certificate of compliance posted. The most recent one was from 4/15/2023-4/15/2024.

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)(5)

Description: Emergency plan

Noncompliance Area: The emergency plan did not have a section accommodating for infants and toddlers.

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: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: Staff 1, who does have a current child abuse clearance, did not obtain the child abuse clearance until five days after working with children. (See LIS for date of hire).

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: 3270.69(b)

Description: 110º F or less

Noncompliance Area: In the lower level of the annex building, the hot water temperature measured at 113 degrees.

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

Regulation: 3270.102(c)

Description: Outdoor equip.- protective surfacing

Noncompliance Area: On 11/13/2024, certification representative assessed embedded equipment on playground area and measured mulch that was under it. The mulch measured at approximately 1-2 inches which is under the required measurement of 9 inches, according to the Consumer Product Safety Commission.

Correction Required: Outdoor equipment that requires embedded mounting must be mounted over a loose-fill or unitary playground protective surface covering that meets the recommendations of the United States Consumer Product Safety Commission. The equipment must be anchored firmly and be in good repair. The embedded equipment cannot be used until the required 9 inches of mulch is obtained for the playground.

Regulation: 3270.123(a)(5)

Description: Designated release persons

Noncompliance Area: During renewal inspection conducted 1/24/2024, release persons were not written on child #2's fee agreement.

Correction Required: An agreement shall specify the persons designated by a parent to whom the child may be released.

Regulation: 3270.131(b)(1)

Description: Infant: updated health report every 6 months

Noncompliance Area: During renewal inspection conducted 1/24/2024, last health assessment on file for child #1 is dated 6/8/2023. Child #1 is a young toddler (see LIS code sheet).

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: 3270.134(a)/3270.134(d)

Description: Child's hands washed/Liquid or powdered soap

Noncompliance Area: During renewal inspection conducted 1/24/2024, a staff person was observed to not wash a child's hands with soap and water after diapering.

Correction Required: A staff person shall ensure that a child's hands are washed before meals and snacks, after toileting and after being diapered. Liquid or powdered soap shall be used for handwashing.

Regulation: 3270.151(c)(3)/3270.151(c)(5)

Description: Exam communicable disease/Physician/CRNP assessment

Noncompliance Area: During renewal inspection conducted 1/24/2024, health assessment on file for staff person #1 does not include an examination for communicable diseases and the results of that examination or the physician's assessment of the person's suitability to provide child care.

Correction Required: An adult health assessment must include an examination for communicable diseases and the results of that examination. An adult health assessment must include the physician's or CRNP's assessment of the person's suitability to provide child care.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: During renewal inspection conducted 1/24/2024, PSP clearances on file for staff person #2 are dated 9/4/2018 and 11/27/2023, which is past 60 months.

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: 3270.66(a)

Description: Locked or inaccessible

Noncompliance Area: During renewal inspection conducted 1/24/2024, child lock for the cabinet under the sink in the Toddler B room was broken. There were several cleaning products in the cabinet, including Clorox wipes, 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: 20.71(b)(5)

Description: Perpetrator in an indicated or founded report of child abuse

Noncompliance Area: Staff person #1 has been named as a perpetrator in an indicated report of child abuse.

Correction Required: A facility person who has been named as perpetrator in a founded/an indicated report of child abuse may not be present in the facility.

Regulation: 3270.113(b)

Description: No physical punishment

Noncompliance Area: Complaint investigation verified that staff person #1 grabbed and carried child #1 by the arm causing a dislocated elbow.

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

Regulation: 3270.113(b)

Description: No physical punishment

Noncompliance Area: Complaint investigation verified that staff person #1 grabbed and carried child #1 by the arm causing a dislocated elbow.

Correction Required: A facility person may not use any form of physical punishment, including spanking a child. Any staff hired during the next two (2) months must receive training on facility's discipline policy which shall be documented in the staff person's individual file at the facility. Any staff hired during the next two (2) months must also receive an additional training on discipline/positive guidance within the first two (2) weeks of hire. Training must be approved by Northeast Regional office prior to any staff receiving training.

Regulation: 3270.113(b)

Description: No physical punishment

Noncompliance Area: Complaint investigation verified that staff person #1 grabbed and carried child #1 by the arm causing a dislocated elbow.

Correction Required: A facility person may not use any form of physical punishment, including spanking a child. The legal entity must arrange for all staff to receive a minimum of two (2) hours of training regarding Behavior Management. 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.

Regulation: 3270.131(b)(2)

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

Noncompliance Area: During unannounced monitoring conducted 10/4/2023, last health assessment on file for child #1 is dated 9/2/2022. Child #1 is an older toddler. Last child health assessment on file for child #2 is dated 10/12/2020. Child #2 has several visit summaries on file following 10/12/2020. Child #2 is preschool-aged.

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

Description: Immunization record/Dismissal policy

Noncompliance Area: During complaint investigation conducted 10/4/2023, it was found that the following children were not immunized according to the recommendations of the ACIP. Child #1: no record of Hep A vaccine. There was no exemption on file. Child #1 is preschool aged (see LIS code sheet). Child #2: 1 of 2 doses of Hep A vaccine. There was no exemption on file. Child #2 is preschool aged (see LIS code sheet). Child #3: 1 of 2 doses of Hep A vaccine. There was no exemption on file. Child #3 is an older toddler (see LIS code sheet). Child #4: 3 of 4 doses each of the Pneumococcal, DTaP, and HIB vaccines and no record of Hep A vaccine. Child #4 is preschool aged (see LIS code sheet). Child #5: 1 of 2 doses of Hep A vaccine. There was no exemption on file. Child #5 is a young toddler (see LIS code sheet). Child #6: 1 of 2 doses of Hep A vaccine. There was no exemption on file. Child #6 is preschool aged (see LIS code sheet).

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). Child #1, child #2, child #3, child #4, child #5, and child #6 will be dismissed from care by close of business October 4, 2023 until either the immunization record is updated, or a parent provides a written, signed exemption letter.

Regulation: 3270.95(a)/3270.95(b)

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

Noncompliance Area: During unannounced monitoring conducted 10/4/2023, facility's smoke detectors were tested past 30 days on the following dates: 2/13/2023-3/22/2023; 5/3/2023-6/21/2023.

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

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

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

Noncompliance Area: During complaint investigation conducted 6/21/2023, Intermediate B group had 16 total preschool aged children. Staff person #1 initially identified 6 children as being in her group, then 7 children. Staff person #2 identified 7 children as being in her group. Certification representative advised them that 2 children were not named as being in groups, as their groups totaled 14 children. Certification representative conducted ratio/supervision checks in other rooms then came back to Intermediate B group. Staff person #1 identified 9 children as being in her group and staff person #2 identified 7 children as being in her group.

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

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

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

Noncompliance Area: During complaint investigation conducted 6/21/2023, Intermediate B group had 16 total preschool aged children. Staff person #1 initially identified 6 children as being in her group, then 7 children. Staff person #2 identified 7 children as being in her group. Certification representative advised them that 2 children were not named as being in groups, as their groups totaled 14 children. Certification representative conducted ratio/supervision checks in other rooms then came back to Intermediate B group. Staff person #1 identified 9 children as being in her group and staff person #2 identified 7 children as being in her group.

Correction Required: Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Outdoor play space used by the facility is considered part of the facility premises. Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises. Staff person #1 and staff person #2 shall register for and attend training titled "Supervision: Counting Children," which is located on the PD Registry.

Regulation: 3270.113(b)

Description: No physical punishment

Noncompliance Area: Complaint investigation verified that staff person #3 yanked child #1's arm and placed him down roughly.

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

Regulation: 3270.113(b)

Description: No physical punishment

Noncompliance Area: Complaint investigation verified that staff person #3 yanked child #1's arm and placed him down roughly.

Correction Required: A facility person may not use any form of physical punishment, including spanking a child. The legal entity shall create a discipline policy for the facility that will be submitted and approved by Northeast Regional Office. Discipline policy shall address both positive and forbidden discipline. After approval, the legal entity will review the policy with all current staff and new hires going forward who will sign and date an acknowledgement. Discipline policy is to be kept on file.

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 complaint investigation conducted 6/21/2023, an incident report dated 3/31/2023 in child #1's file was not signed by parent until 4/3/2023.

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: 3270.192(5)

Description: Two written references

Noncompliance Area: During unannounced monitoring conducted 6/21/2023, staff person #1's file did not contain two written, nonfamily references.

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: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: During unannounced monitoring conducted on 6/21/2023, staff person #2 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)1-10. Staff person #1 shall complete the required one-hour 2022 update to the health and safety training by July 11, 2023.

Regulation: 3270.95(a)/3270.95(b)

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

Noncompliance Area: During unannounced monitoring conducted 6/21/2022, facility's fire detection system testing log reflected that fire alarms were tested past 30 days on between 2/13/2023-3/22/2023. Additionally, log indicated that fire alarms were last tested on 5/3/2023 which is over 30 days ago.

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: 3270.123(a)(3)

Description: Services proceeded

Noncompliance Area: During renewal inspection conducted 1/3/2023, there last Child Service Reports on file the following children are as follows: Child #2: 11/16/2021 Child#3: 10/28/2021 Child #4: 12/1/2021

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: 3270.131(a)(3)/3270.131(d)(7)

Description: Initial health report for older toddler/preschool no more than 1 year/Free from contagious/communicable disease

Noncompliance Area: During renewal inspection conducted 1/3/2023, last health report on file for Child #2 is dated 10/27/2021. Child is an older toddler (see LIS code sheet). Health report is a visit summary, which does not state that child is able to participate in child care and is free from communicable diseases.

Correction Required: The initial health report for an older toddler or preschool child shall be dated no more than 1 year prior to the first day of attendance at the facility. 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.

Regulation: 3270.131(e)(1)

Description: Exemption documentation from parent/guardian

Noncompliance Area: During renewal inspection conducted 1/3/2023, the following children do not have verification of ongoing vaccines with schedule recommended by the ACIP. No exemptions are on file: Child #1: No flu vaccine. Child #2: 3 of 4 doses of DTAP and Rotavirus vaccines, no flu vaccine or Hepatitis A vaccine. Child #3: No flu vaccine.

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.

Regulation: 3270.161(d)

Description: Potentially hazardous food refrigerated

Noncompliance Area: During renewal inspection conducted 1/3/2023, a lunchbox containing cheese, fruit, and yogurt was observed in the cubby area of the Toddler B room.

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

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: During renewal inspection conducted 1/3/2023, Facility Person #1 has resided in New York and Arizona within the past 5 years and does not have out-of-state clearances on file or proof that they were properly requested at time of hire. Facility person #1 is past 45-day provisional period (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. Facility Person #1 may not work in a child care position at the facility until all out-of-state clearance results are on file.

Regulation: 3270.65

Description: Protective Outlet Covers 5 yrs. or less

Noncompliance Area: During renewal inspection conducted 1/3/2023, an electrical outlet was uncovered in the Pre-K room.

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: During renewal inspection conducted 1/3/2023, a cabinet under the sink in the Pre-K bathroom had a disarmed child lock, exposing several cleaning materials 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: 3270.74

Description: Emergency Numbers Posted

Noncompliance Area: During renewal inspection conducted 1/3/2023, emergency telephone numbers were not posted in the School-age room.

Correction Required: The telephone number of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted by each telephone in the facility.

Regulation: 3270.113(b)

Description: No physical punishment

Noncompliance Area: On complaint investigation conducted 8/11/2022, Certification Representative reviewed a video from an incident that took place in the facility on 8/1/2022 at approximately 10:45A-11:00A. In the video, Staff #1 is seen grabbing Child #1 by the right arm from behind and swinging her around to sit on her bottom. Staff #2 is seen picking up Child #2 and sitting him down roughly. There is no audio on the video. Neither child appears to be injured or upset during the video.

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

Regulation: 3270.113(b)

Description: No physical punishment

Noncompliance Area: On complaint investigation conducted 8/11/2022, Certification Representative reviewed a video from an incident that took place in the facility on 8/1/2022 at approximately 10:45A-11:00A. In the video, Staff #1 is seen grabbing Child #1 by the right arm from behind and swinging her around to sit on her bottom. Staff #2 is seen picking up Child #2 and sitting him down roughly. There is no audio on the video.

Correction Required: A facility person may not use any form of physical punishment, including spanking a child. The legal entity must arrange for Staff #1 and Staff #2 to receive a minimum of two hours of training regarding positive guidance. The legal entity must receive DHS approval of the training content prior to scheduling the training.

Regulation: 3270.113(b)

Description: No physical punishment

Noncompliance Area: On complaint investigation conducted 8/11/2022, Certification Representative reviewed a video from an incident that took place in the facility on 8/1/2022 at approximately 10:45A-11:00A. In the video, Staff #1 is seen grabbing Child #1 by the right arm from behind and swinging her around to sit on her bottom. Staff #2 is seen picking up Child #2 and sitting him down roughly. There is no audio on the video.

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

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

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

Noncompliance Area: On complaint investigation conducted 7/13/2022, two incidents of lack of supervision occurred at facility on 7/7/2022. Facility staff reported that a Child #1, who is an older toddler, left the building without staff supervision around pick-up time. Child #1 was outside alone for approximately one minute until a parent found him and brought him inside. Additionally, Child #2, who is preschool-age, was left inside while the rest of his class and Staff #1 went outside. Child #2 was inside for approximately one minute before another staff member noticed him and brought him outside. Facility showed certification representative video evidence of both incidents.

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

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

Noncompliance Area: On complaint investigation conducted 7/13/2022, two incidents of lack of supervision occurred at facility on 7/7/2022. Facility staff reported that a Child #1, who is an older toddler, left the building without staff supervision around pick-up time. Child #1 was outside alone for approximately one minute until a parent found him and brought him inside. Additionally, Child #2, who is preschool-age, was left inside while the rest of his class and Staff #1 went outside. Child #2 was inside for approximately one minute before another staff member noticed him and brought him outside. Facility showed certification representative video evidence of both incidents.

Correction Required: Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Outdoor play space used by the facility is considered part of the facility premises. Children must be supervised at all times. The operator must arrange for all staff to receive a minimum of 3 hours of PQAS approved, live training regarding Supervision & Ratio. It does not matter if the PQAS approved, live training is done through the ELRC. The operator must receive DHS approval of training content prior to scheduling the training. The training may not be conducted while children are in care.

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

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

Noncompliance Area: On complaint investigation conducted 7/13/2022, two incidents of lack of supervision occurred at facility on 7/7/2022. Facility staff reported that a Child #1, who is an older toddler, left the building without staff supervision around pick-up time. Child #1 was outside alone for approximately one minute until a parent found him and brought him inside. Additionally, Child #2, who is preschool-age, was left inside while the rest of his class and Staff #1 went outside. Child #2 was inside for approximately one minute before another staff member noticed him and brought him outside. Facility showed certification representative video evidence of both incidents.

Correction Required: Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Outdoor play space used by the facility is considered part of the facility premises. Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises. The Legal Entity must submit a supervision policy and procedures that must include specifics related to maintaining supervision during transition times. The policy & procedures must also address 3270.113(a-e). The policy & procedures must be submitted to the NE Regional Office for approval and then all current staff and new hires must sign an acknowledgement that they have been trained and understand this policy. The acknowledgement will be kept on file at facility.

Regulation: 3270.131(a)

Description: Health information

Noncompliance Area: On unannounced monitoring conducted 8/11/2022, file for Child #2 only contained immunization record and did not contain a health assessment. Child was enrolled at the facility for more than 60 days (see LIS code sheet).

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)(1)/3270.131(e)(1)

Description: Infant: updated health report every 6 months/Exemption documentation from parent/guardian

Noncompliance Area: On unannounced monitoring conducted 8/11/2022, last health assessment on file for Child #1 is dated 12/21/2021. Immunization record indicates that child received 3 of 4 doses of DTaP, HIB, and pneumococcal vaccines. Child is a young toddler (see LIS code sheet).

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

Regulation: 3270.151(a)

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

Noncompliance Area: On unannounced monitoring conducted 7/13/2022, the following staff members have not completed health assessments within the past 24 months: Staff #4: last health assessment is dated 6/9/2020. Staff #7: last health assessment is dated 6/11/2020. Staff#9: last health assessment is dated 7/8/2020.

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: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: On unannounced monitoring conducted 7/13/2022, Staff #4 had expired Child Abuse clearance dated 5/11/17 on file.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Staff #4 may not work in a child care position at the facility until Child Abuse clearance results are on file.

Regulation: 3270.65

Description: Protective Outlet Covers 5 yrs. or less

Noncompliance Area: On unannounced monitoring conducted on 7/13/2022, an outlet in the Pre-K room in Building 2 was observed to not have protective receptacle cover.

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

Regulation: 3270.95(a)/3270.95(b)

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

Noncompliance Area: On unannounced monitoring conducted 8/11/2022, facility's fire detection log indicated that alarms were tested on 6/20/2022 and on 7/29/2022, which is past 30 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: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: During review of several staff files on 1/5/22 cert rep observed that STAFF # 1 (start date 11/12/21 & provisional hire end date 12/26/21) did not have the NSOR verification letter in file. NSOR application was sent 11/11/21.

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

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

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

Noncompliance Area: During a complaint investigation visit that was conducted on 10/7/21 Cert rep. was shown video from the facility security camera for 9/30/21 which shows facility person #1 motioning to two preschool children join facility person #2's assigned supervision group as they were leaving the outdoor play space. Facility person #1 admits she did not verbally tell facility person #2 she had the children line up with the school-age group and facility person #2 said she did not realize child #1 and #2 were in line with her group until she walked to the front of the building. Facility person #1 admitted to an incident over the summer where she was reported to the director by another staff person for being in the preschool bathroom with the door partially open when she was the only staff person in the room supervising the children.

Correction Required: The legal entity must arrange for facility person #1 to receive a minimum of two hours of PQAS approved training regarding supervision of children. It does not matter if the PQAS approved training is done through the ELRC. The legal entity must receive DHS approval of the training content prior to scheduling the training. This training may be live online or in-person. Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Outdoor play space used by the facility is considered part of the facility premises. Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises.

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

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

Noncompliance Area: During a complaint investigation visit that was conducted on 10/7/21 Cert rep. was shown video from the facility security camera for 9/30/21 which shows facility person #1 motioning to two preschool children to join facility person #2's assigned supervision group as they were leaving the outdoor play space. Facility person #1 admits she did not verbally tell facility person #2 she had the children line up with the school-age group and facility person #2 said she did not realize child #1 and #2 were in line with her group until she walked to the front of the building. Facility person #1 admitted to an incident over the summer where she was reported to the director by another staff person for being in the preschool bathroom with the door partially open when she was the only staff person in the room supervising the children.

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

Regulation: 3270.113(d)

Description: No harsh language

Noncompliance Area: During a complaint investigation visit that was conducted on 10/7/21 facility person #1 did admit to Cert rep. that she did use an obscene phrase when speaking to facility person #3 while supervising a group of preschool children

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

Regulation: 3270.52

Description: Mixed Age Level

Noncompliance Area: During an unannounced complaint visit to facility on 10/7/21, facility person #1 admitted that she had a group of 8 preschool children assigned to her on 9/30/21 and that she allowed child #1 and #2 to join facility person #2's group of 12 school-age children as they were leaving the outdoor play space. This left facility person #2 with 2 preschool children and 12 school-age children. Facility person #2 was out of ratio for a few minutes until the children were returned to the preschool group.

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).

Noncompliance Area: The cove base to the left of the stairs in the annex building is loose, and there is mold visible under the cove base

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

Noncompliance Area: During a complaint investigation that was conducted on 9/13/19, it was determined that on 9/11/19, Child #1, a preschool aged child, was left on the outdoor play space by Staff person #1 & Staff person #2 . Child #1 was alone on the outdoor play space for between 3 - 5 minutes when the child was found by another staff member. Staff person #1 & staff person #2 were unaware that Child #1 was left outside for approximately 3-5 minutes

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

Noncompliance Area: During complaint investigation conducted on 8/19/19 & on 9/6/19, it was determined that the annex building stairway and the Pre-K room flood when it rains. During the complaint visit conducted on 9/6/19, cert rep observed water stains around the ceiling vent in the Pre-K room and it was determined that when the School Age toilet upstairs overflows, the water comes through the ceiling vent in the Pre-K room.

Correction Required: Conditions at the facility may not pose a threat to the health or safety of the children.Floors, walls, ceilings and other surfaces, including the facility's outdoor play space surfaces shall be kept clean, in good repair and free from visible hazards.

Noncompliance Area: During a complaint investigation conducted on 8/19/19, cert rep observed staff member #1 with 12 children, including one preschool child.

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).

Noncompliance Area: A complaint investigation was conducted at the facility on 4/16/19. During the investigation, staff person #1 admitted that the infant room is out of ratio each afternoon. Staff person #1 said that there is one staff member with four infants and one toddler for between two to ten minutes each afternoon at approximately 3PM.

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.

Noncompliance Area: There is a water stained ceiling tile in the two year old 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.