Everbrook Academy

Regulation: 3270.113(a)(1)

Description: Staff assigned to specific children

Noncompliance Area: On 6/24/26 at approximately 8:20am in the Early Preschool Room, 4 staff and 14 children of mixed ages were observed. When the staff were asked to identify the individual children in their supervision group, Staff #1 identified a mixed group of 5 older toddlers and preschool aged children, Staff #2 identified 1 older toddler, Staff #3 identified 1 older toddler, and Staff #4 identified 6 older toddlers therefore, leaving one child unaccounted for. Also, at approximately 8:25am in the Preschool #1 Room, Staff #5 and Staff #6 were observed supervising 13 preschool age children. When staff were asked to identify the individual children in their supervision group, Staff #5 identified 7 children and Staff #6 was unable to identify the children in their group. Staff #6 explained that they do not typically work in the Preschool Room. When given a second opportunity to identify their supervision groups, Staff #5 identified 7 children and Staff #6 identified 5 children therefore, leaving one child unaccounted for.

Correction Required: TIERED IS: 1.) 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. 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 the training "Creating a Safe Environment with Active Supervision" training. 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. 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 the identification, implementation and evaluation of a tangible supervision identification system for each staff to identify the specific children in their respective supervisory groups. 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 5 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 shall be at within 5 months from the date the plan of correction is submitted. 4.) The legal entity will implement a tangible identification system for each staff to identify the specific children in their respective supervisory groups. The identification system must be submitted to the OCDEL-DHS representative by email for review. All staff will utilize the identification method appropriately at all times while supervising children foe a minimum of 3 months after the OCDEL-DHS representative review. The correction date for this portion of the plan shall be at minimum 3 months from the date the selected identification system is submitted to the OCDEL-DHS representative for review.

Regulation: 3270.51

Description: Similar Age Level

Noncompliance Area: Based on staff statements, on 6/23/26 in the Early Preschool Room, Staff #1 and Staff #7 were responsible for supervising 18 children of mixed ages; 6 older toddlers and 12 preschool age children. One of the staff was responsible for the 6 older toddlers and the other staff was responsible for the 12 preschool age children. The room was out of ratio for approximately one hour.

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.

Regulation: 3270.52

Description: Mixed Age Level

Noncompliance Area: On 6/24/26 at approximately 8:20am in the Early Preschool Room, 4 staff and 14 children of mixed ages were observed. When the staff were asked to identify the individual children in their supervision group, Staff #1 identified a mixed group of 5 older toddlers and preschool aged children, Staff #2 identified 1 older toddler, Staff #3 identified 1 older toddler, and Staff #4 identified 6 older toddlers. One child was not identified. When given a second opportunity to identify their supervision groups, Staff #1 identified a mixed group of 7 older toddlers and preschool aged children, Staff #2 identified 1 older toddler, Staff #3 identified 1 older toddler, and Staff #4 identified 6 older toddlers. Therefore, Staff #1 exceeded the child: staff ratio by one 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).

Regulation: 3270.20(a)(1)

Description: Inpatient hospitalization or ER treatment of child

Noncompliance Area: On 3.3.26, a child in care at the facility received emergency room treatment, but the regional office was not notified until 3.12.26, which was beyond the required 24 hours.

Correction Required: The operator shall immediately notify a child's parent and shall telephone notice to the appropriate regional office within 24 hours if a child in care at the facility is hospitalized or receives emergency room treatment.

Regulation: 3270.20(b)

Description: Mail or deliver written report to regional office within 72 hours

Noncompliance Area: On 3.3.26, a child in care at the facility received emergency room treatment, but a written report was not submitted to the regional office until 3.13.26, which was beyond the required 72 hours.

Correction Required: The operator shall mail or deliver a written report to the appropriate regional office within 72 hours after hospitalization of a child in care, emergency room treatment of a child in care, death of a child in care, a facility fire requiring the services of a fire department.

Regulation: 3270.123(a)(4)

Description: Arrival/departure times

Noncompliance Area: The Agreement in the files for Child #1, Child #2, Child #3, Child #4, Child #5, Child #6, Child #7, Child #8, Child #9, and Child #10 did not specify the child's arrival and departure times.

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

Regulation: 3270.123(a)(5)

Description: Designated release persons

Noncompliance Area: The Agreement, in the files for Child #1, Child #2, Child #3, Child #4, Child #5, Child #6, Child #7, Child #8, Child #9, and Child #10, did not specify the release person(s).

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

Regulation: 3270.124(b)(3)

Description: Parent home/work address, phone

Noncompliance Area: The Emergency Contact form, in the file for Child #2, did not include the work phone number of the enrolling parent. The Emergency Contact form, in the file for Child #5, did not include the work address or work phone number of the enrolling parent.

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

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

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

Noncompliance Area: The Emergency Contact form, in the files for Child #7 and Child #8, did not include 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)(5)

Description: Information re: special needs

Noncompliance Area: The Emergency Contact form, in the file for Child #2, did not include information on the child's special needs.

Correction Required: Emergency contact information must include information on the child's special needs, as specified by the child's parent, physician, physician's assistant or CRNP, which is needed in an emergency situation.

Regulation: 3270.124(b)(6)

Description: Insurance coverage information

Noncompliance Area: The Emergency Contact form, in the file for Child #8, did not include the health insurance policy number.

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

Regulation: 3270.124(f)/3270.181(c)

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

Noncompliance Area: The Emergency Contact form and the Financial Agreement, in the files for Child #1, Child #2, Child #3, Child #4, Child #5, Child #7, Child #8, Child #9, and Child #10, did not include documentation that the parent reviewed/updated the information at least once in a 6-month period.

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(b)(1)/3270.182(1)

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

Noncompliance Area: The Health Assessment, in the file for Child #6, an infant, was not updated within the required 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(b)(2)/3270.182(1)

Description: Toddler/preschool: updated health report every 12 months/Initial and subsequent health reports

Noncompliance Area: The Health Assessments, in the files for Child #1, Child #2, Child #3, Child #4, Child #5, Child #7, Child #9, and Child #10, were not updated within the required 12 months.

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. A child's record shall contain initial and subsequent health reports.

Regulation: 3270.133(5)

Description: Original label

Noncompliance Area: In Room 134, an Epi-Pen with an expiration date of 1/2026, was still stored at the facility for a preschool child.

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

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 #7 (see IS Code Sheet) did not contain documentation of a health assessment conducted within 12 months prior to providing initial service in a child care setting. The file for Staff #8 (see IS Code Sheet) did not contain documentation of a health assessment conducted within 12 months prior to providing initial service in a child care setting. The two (2) most recent Health Assessments in the file for Staff #13 exceeded the 24-month renewal requirement. The two (2) most recent Health Assessments in the file for Staff #22 exceeded the 24-month renewal requirement. The two (2) most recent Health Assessments in the file for Staff #25 exceeded the 24-month renewal requirement. The file for Staff #26 (see IS Code Sheet) did not contain documentation of a health assessment conducted within 12 months prior to providing initial service in a child care setting.

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

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

Description: Mantoux TB/Health assessment, TB test

Noncompliance Area: The file for Staff #7 (see IS Code Sheet) did not contain a tuberculosis test dated within 12 months of initial employment. The file for Staff #8 (see IS Code Sheet) did not contain a tuberculosis test dated within 12 months of initial employment. The file for Staff #25 (see IS Code Sheet) did not contain a tuberculosis test dated within 12 months of initial employment. The file for Staff #26 (see IS Code Sheet) did not contain a tuberculosis test dated within 12 months of 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. 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: 3270.182(5)

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

Noncompliance Area: Then Emergency Contact form, in the files for Child #6, Child #7, and Child #8, did not contain 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: 3270.192(2)(iv)

Description: Transcript, diploma and letters

Noncompliance Area: The file for Staff #7 did not contain evaluated proof of the foreign education, and therefore, the educational equivalency could not be determined.

Correction Required: A facility person's record shall include acceptable verification of experience, education or training is a transcript or a diploma or a letter signed by a representative of the experiential, educational or training entity.

Regulation: 3270.192(5)

Description: Two written references

Noncompliance Area: The file for Staff #1 contained one (1) nonfamily reference, which did not meet the requirement of two (2). The file for Staff #2 contained one (1) nonfamily reference, which did not meet the requirement of two (2). The file for Staff #4 did not contain any nonfamily references, which did not meet the requirement of two (2).

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(e)(4)(i)/3270.192(2)(iii)

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

Noncompliance Area: The file for Staff #10 contained documentation of Pediatric First-Aid/CPR which expired on 10.3.25, and it was not renewed until 11.17.25. The file for Staff #11 contained documentation of Pediatric First-Aid/CPR which expired on 10.3.25, and it was not renewed until 11.17.25. The file for Staff #12 contained documentation of Pediatric First-Aid/CPR which expired on 10.3.25, and it was not renewed until 11.17.25. The file for Staff #13 contained documentation of Pediatric First-Aid/CPR which expired on 10.3.25, and it was not renewed until 11.17.25. The file for Staff #18 contained documentation of Pediatric First-Aid/CPR which expired on 3.9.26, and it was not renewed. The file for Staff #21 contained documentation of Pediatric First-Aid/CPR which expired on 12.20.25, and it was not renewed until 2.3.26. The file for Staff #25 contained documentation of Pediatric First-Aid/CPR which expired on 6.21.25, and it was not renewed until 2.3.26. The file for Staff #27 contained documentation of Pediatric First-Aid/CPR which expired on 10.3.25, and it was not renewed until 2.3.26.

Correction Required: Competence is the completion of training by a professional in the field of first-aid and cardiopulmonary resuscitation (CPR). All staff persons shall renew their certification in pediatric first aid and pediatric cardiopulmonary resuscitation (CPR) on or before the expiration of the most current certification. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

Regulation: 3270.31(e)(4)(ii)/3270.192(2)(iii)

Description: Fire safety - 1 yr./Exp, educ., training at facility

Noncompliance Area: The file for Staff #11 contained documentation of Fire Safety Training on 11.20.25, but none in 2024. The file for Staff #15 contained documentation of Fire Safety Training on 6.13.24 and 7.22.25, which exceeded the annual requirement. The file for Staff #16 (see IS Code Sheet) contained documentation of Fire Safety Training on 7.24.26, which exceeded 1 year of hire. The file for Staff #17 contained documentation of Fire Safety Training on 12.6.24, but none in 2025. The file for Staff #21 contained documentation of Fire Safety Training on 1.2.25 and 2.3.26, which exceeded the annual requirement. The file for Staff #22 contained documentation of Fire Safety Training on 11.19.24 and 2.27.26, which exceeded the annual requirement. The file for Staff #24 contained documentation of Fire Safety Training on 12.9.24, but none in 2025. The file for Staff #25 contained documentation of Fire Safety Training on 11.26.24 and 2.3.26, which exceeded the annual requirement.

Correction Required: Staff persons shall participate, at least annually, in fire safety training conducted by a fire protection professional. Staff persons and volunteers shall receive training in maintenance of smoke detectors, the duties of facility persons during a fire drill and during a fire and the use of the facility's fire extinguishers, not including discharge of the fire suppressant agent. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

Regulation: 3270.31(f)(7)/3270.192(2)(iii)

Description: Health and Safety Training - Emergency preparedness/Exp, educ., training at facility

Noncompliance Area: The file for Staff #5 (see IS Code Sheet) contained documentation of Emergency Plan Training on 11.18.25, which exceeded the 90-day requirement. The file for Staff #6 (see IS Code Sheet) contained documentation of Emergency Plan Training on 11.18.25, which exceeded the 90-day requirement. The file for Staff #9 (see IS Code Sheet) contained documentation of Emergency Plan Training on 11.18.25, which exceeded the 90-day requirement. The file for Staff #11 contained documentation of Emergency Plan Training on 11.14.24, but none in 2025. The file for Staff #12 contained documentation of Emergency Plan Training on 11.14.24, but none in 2025. The file for Staff #14 contained documentation of Emergency Plan Training on 9.18.24 and 2.3.26, which exceeded the annual requirement. The file for Staff #15 contained documentation of Emergency Plan Training on 6.6.24, but none in 2025. The file for Staff #16 contained documentation of Emergency Plan Training on 6.10.24, but none in 2025. The file for Staff #18 contained documentation of Emergency Plan Training on 7.8.24, but none in 2025. The file for Staff #19 contained documentation of Emergency Plan Training on 8.26.24, but none in 2025. The file for Staff #20 contained documentation of Emergency Plan Training on 9.16.24 and 11.17.25, which exceeded the annual requirement. The file for Staff #23 contained documentation of Emergency Plan Training on 11.14.24, but none in 2025.

Correction Required: Staff persons shall complete professional development in the topic of emergency preparedness and response planning for emergencies resulting from a natural disaster or a man-caused event (such as violence at a child care facility) within the meaning of those terms under 602(a)(1) of the Robert T. Stafford Disaster Relief and Emergency Assistance Act (42 U.S.C.A. § 5195a(a)(1)) 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: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: The file for Staff #3 (see IS Code Sheet) contained a Child Abuse Clearance dated 1.14.26, an FBI Clearance dated 1.16.26, and an NSOR Certificated dated 1.28.26, which exceeded the first day caring for children. The file for Staff #15 (see IS Code Sheet) contained a Child Abuse Clearance dated 6.21.24, which exceeded the first day caring for children. The file for Staff #15 contained documentation of Mandated Reporter training on 9.10.20, and none thereafter, which exceeded the 60-month renewal requirement.

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

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The file for Staff #3 (see IS Code Sheet) contained a Disclosure Statement dated 3.2.26, which exceeded the first day caring for children. The file for Staff #5 (see IS Code Sheet) contained a Disclosure Statement dated 6.12.24, which exceeded the first day caring for children. The file for Staff #7 (see IS Code Sheet) contained a Disclosure Statement dated 3.2.26, which exceeded the first day caring for children. The file for Staff #8 (see IS Code Sheet) did not contain a Disclosure Statement. The file for Staff #21 (see IS Code Sheet) contained a Disclosure Statement dated 12.7.23, but did not contain a witness signature or date, making it invalid.

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 #8 and Staff #21 may not work in a child care position at the facility.

Regulation: 3270.34(a)(6)

Description: Staff evaluations

Noncompliance Area: The file for Staff #21 did not contain documentation of written evaluations in 2024 or 2025. The file for Staff #23 did not contain documentation of a written evaluation in 2025. The file for Staff #25 did not contain documentation of a written evaluation in 2024.

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: 3270.75(c)

Description: Has all items

Noncompliance Area: In Room 114, the first-aid kit did not contain tape. In Room 127, the first-aid kit did not contain nonporous gloves. In Room 140, the first-aid kit did not contain scissors, tweezers, or soap. In Room 141, the first-aid kit did not contain tweezers.

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.

Regulation: 3270.82(h)

Description: Handwashing signs

Noncompliance Area: In Room 120, a handwashing sign was not located at the toilet in the second restroom. In Room 122, a handwashing sign was not located at the toilet in the second restroom. In The Brook, a handwashing sign was not located in the restroom on the right, at the toilet.

Correction Required: A facility person and an able child shall wash his hands after toileting and before eating. A sign on which this requirement is written shall be posted at each toilet, training chair, diapering area and sink in the facility.

Regulation: 3270.113(a)

Description: Supervised at all times

Noncompliance Area: Child #1, a young toddler, was not supervised when Child #1 eloped from The Brook on 2.18.26, for over one (1) minute.

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)(1)

Description: Staff assigned to specific children

Noncompliance Area: Child #1, a young toddler, was not supervised when Child #1 eloped from The Brook on 2.18.26, for over one (1) minute. Staff #1 was not physically present and did not know the whereabouts of Child #1.

Correction Required: 1. 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. This portion of the plan shall have an immediate correction date. 2. The legal entity must arrange for all staff to complete Better Kid Care Training: Supervision: What's Required?. Training may count toward annual training requirement. Training certificates will be sent to the certification representative upon completion. The operator shall provide a date for when this training will be completed. 3. Following the completion of the Better Kid Care training and the installation of the alarms on the doors of The Brook, the provider will notify the certification representative of the completion. The certification representative will then conduct two (2) unannounced visits to ensure implementation of the plans. The provider shall provide a date for when the installation of the door alarms will be completed.

Regulation: 3270.106(f)

Description: 2 feet apart

Noncompliance Area: In Room 107, Infants #3, three (3) cribs which contained sleeping infants, were spaced as follows: 1 crib had 2' of space on one (1) side, with 1' of space on the other two (2) sides; 2 cribs had 2' of space on two (2) sides, with 1' space on the third side.

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: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: The file for Staff #2 (see IS Code Sheet), did not contain any documentation of Pediatric First-Aid/CPR training, which is required within 90 days of hire.

Correction Required: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10.

Regulation: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: The file for Staff #1 (see IS Code Sheet) did not contain an NSOR Certificate.

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

Regulation: 3270.51

Description: Similar Age Level

Noncompliance Area: On 9.30.25, Staff #1 was left alone with sixteen (16) preschool children, making the staff:child ratio 1:16.

Correction Required: 1. 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. 2. The legal entity must arrange for all staff to complete Better Kid Care Training: Big Emotions and Self-Regulation for Adults & Children. Training may count toward annual training requirement. 3. The legal entity must arrange for the Director(s) to participate in a minimum of three (3) in-person, technical assistance sessions with the ELRC #5 Quality Coach to address delegation of work, leadership, and the development of a policy for overwhelmed staff who need a short break.

Regulation: 3270.21

Description: General Health and Safety

Noncompliance Area: During family style breakfast Staff Person #1 placed a bowl of hard-boiled eggs cut into halves in front of Child #1 who is allergic to eggs. Child #1 took an egg from the bowl and took a bite; Staff #2 saw Child #1 ingest the egg and encouraged Child #1 to spit it out. Child #1 then had an allergic reaction to ingesting the egg, epi-pen was administered by the parents and Child #1 was transported to the hospital for further evaluation.

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

Regulation: 3270.106(a)

Description: Clean, age appropriate

Noncompliance Area: The cots in Rooms 109, 120, 122, 134, 140 and 141 were not labeled.

Correction Required: Individual, clean, age-appropriate rest equipment shall be provided for preschool, toddler and infant children as agreed between the child's parent and the operator. The rest equipment shall be labeled for the use of a specific child and used only by the specified child.

Regulation: 3270.106(f)

Description: 2 feet apart

Noncompliance Area: Observed less than 2 feet of space on 3 sides of two cribs in Room 107 and one crib in Room 108, where infants were napping.

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: 3270.123(a)(3)

Description: Services proceeded

Noncompliance Area: The most recent child service reports in the file for Child #5 exceeded six months between reports. The first child service report in the file for Child #6 was conducted more than six months after the child's first day in care.

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: The fee agreements in the files for Child #1, 2 and 3 were the original documents.

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: 3270.124(b)(7)

Description: Name/address/phone release person

Noncompliance Area: The emergency contact forms in the files for Child #7 and #8 did not include the addresses of the release persons.

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(c)

Description: Each child care space

Noncompliance Area: The emergency contact binder in Room 110 did not include an emergency contact form for Child #1, who was receiving care in that room.

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)/3270.182(1)

Description: Health information/Initial and subsequent health reports

Noncompliance Area: The file for Child #4, who has been enrolled for more than 60 days, did not include an initial health report.

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)(2)/3270.182(1)

Description: Toddler/preschool: updated health report every 12 months/Initial and subsequent health reports

Noncompliance Area: The file for Child #1, an older toddler, did not include an updated health report conducted within the past 12 months.

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. 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 most recent immunization record in the file for Child #1, an older toddler lacks the following immunizations according to the recommendations of the ACIP: 3rd Hep B, 4th DTAP, 4th Pneumococcal. The file for Child #4, who has been enrolled for more than 60 days, lacks an immunization record.

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 and #4 must be dismissed from care by close of business 4/23/25 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)/3270.192(3)

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

Noncompliance Area: The initial health assessment in the file for Staff Person #4 was conducted after the staff person's first day working in child care. (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. 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: 3270.181(c)

Description: Emergency info/agreement updated 6 mos

Noncompliance Area: The most recent parental updates for the emergency plans and fee agreements in the files for Child #1, 2, 3, 4, 5, 6 and 8 exceeded 6 months between updates.

Correction Required: 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: 3270.182(5)

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

Noncompliance Area: The emergency contact form in the file for Child #4 did not include 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: 3270.192(5)

Description: Two written references

Noncompliance Area: One of the reference letters in the file for Staff Person #5 was dated after the staff person's first day working in child care. (See LIS Code Sheet).

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: 3270.21

Description: General Health and Safety

Noncompliance Area: Observed adult scissors and a stapler, which were accessible to children, on a table in the PreK Room.

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

Regulation: 3270.27(c)

Description: Training regarding plan

Noncompliance Area: The most recent emergency plan trainings in the file for Staff Person #10 exceeded 12 months between trainings.

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

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

Description: Age and Training

Noncompliance Area: The most recent Pediatric First Aid/CPR Certification in the files for Staff Person #2 and #8 were conducted after the previous certifications had expired.

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

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The files for Staff Person #1, #3 and #7 do not contain out of state child abuse clearances for the states in which staff persons resided within the past five years. Staff Person #1: New York. Staff Person #3: West Virginia. Staff Person #7: Ohio. The required clearances for the following staff persons were conducted after the staff person's first day working in child care. Staff Person #4: Child Abuse. Staff Person #5: State Police, Child Abuse and FBI. Staff Person #9: State Police. Staff Person #10: State Police, Child Abuse, FBI, NSOR. Staff Person #11, 12 and 13: FBI, NSOR. (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, 3 and 7 may not work in a child care position at the facility.

Regulation: 3270.34(a)(6)

Description: Staff evaluations

Noncompliance Area: The first written evaluation in the file for Staff Person #1 was conducted more than 12 months after the staff person's first day working in child care. (See LIS Code Sheet).

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: 3270.36(b)(5)/3270.192(2)(ii)

Description: HS/GED + 2 yrs/Exp, educ., training prior to facility

Noncompliance Area: The files for Staff Person #4, #6 and #9 who work as Assistant Group Supervisors, lacked verification of two years child care experience.

Correction Required: An assistant group supervisor shall have a high school diploma or a general educational development certificate and 2 years experience with children. 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)/3270.66(d)

Description: Locked or inaccessible/Toxic plants not permitted

Noncompliance Area: Observed a golden pothos, which was accessible to children, in Room 140.

Correction Required: Cleaning materials and other toxic materials shall be kept in an area or container that is locked or made inaccessible to children. Toxic plants are not permitted in a child care space.

Regulation: 3270.75(c)

Description: Has all items

Noncompliance Area: The first aid kits in the facility lacked tape.

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.

Regulation: 3270.82(e)

Description: Toilet and sinks proper height

Noncompliance Area: Room 109, in which young toddlers who could stand on their own were in care, lacked a platform or steps for children to easily reach the sink to wash their hands.

Correction Required: Toilets and sinks shall be at proper heights for children using them or shall be easily approached by means of platforms or steps.

Regulation: 3270.124(b)(3)

Description: Parent home/work address, phone

Noncompliance Area: The Emergency Contact form, in the files for Child #1, Child #3, Child #7, and Child #9, did not include the enrolling parent's work phone number.

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

Regulation: 3270.124(b)(7)

Description: Name/address/phone release person

Noncompliance Area: The Emergency Contact form, in the file for Child #9, did not include the release person's address.

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(f)/3270.181(c)

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

Noncompliance Area: As confirmed by the operator and lack of documentation, the Emergency Contact forms and Financial Agreements were not reviewed/updated by a parent, within a 6-month period, for Child #2, Child #3, Child #4, Child #5, Child #6, Child #7, and Child #8.

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: 3270.133(5)

Description: Original label

Noncompliance Area: In Room 115, two bottles of medication were expired: Epi-Pen expired on 6/24, and Children's Cetrizine expired on 7/24.

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: The file for Staff #6 contained documentation of the 1-Hour Health & Safety Update training on 1.19.24, which was due by 12.30.22. The file for Staff #9 contained documentation of the 1-Hour Health & Safety Update training on 1.24.24, which was due by 12.30.22. The file for Staff #16 contained documentation of the 1-Hour Health & Safety Update training on 12.28.23, which was due by 12.30.22. The file for Staff #17 contained documentation of the 1-Hour Health & Safety Update training on 10.27.23, which was due by 12.30.22.

Correction Required: A facility shall be operated in conformity with applicable Federal and State laws and regulations. State agencies whose regulations may relate to the operation of a facility include the Department of Environmental Resources, the Department of Labor and Industry, the Department of Health, the Department of Education and the Department of Transportation. Conditions at the facility may not pose a threat to the health or safety of the children.

Regulation: 3270.151(a)

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

Noncompliance Area: * The most current Health Assessment in the file for Staff #2 was verified to contain a forged signature, as verified by the medical professional whose name appears on the form. Therefore, the Health Assessment is deemed forged and is therefore unacceptable.

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: 3270.151(a)

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

Noncompliance Area: ** The most current Health Assessment in the file for Staff #2 was verified to contain a forged signature, as verified by the medical professional whose name appears on the form. Therefore, the Health Assessment is deemed forged and is therefore unacceptable.

Correction Required: ** All staff, including the director, will obtain the training "Ethics: A Guide for Professional Behavior" from Better Kid Care. Training hours can be credited towards annual training requirements.

Regulation: 3270.151(a)

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

Noncompliance Area: *** The most current Health Assessment in the file for Staff #2 was verified to contain a forged signature, as verified by the medical professional whose name appears on the form. Therefore, the Health Assessment is deemed forged and is therefore unacceptable.

Correction Required: *** The director/LE will create and maintain a written policy addressing the accuracy and authenticity of all documents maintained in the facility, staff and children's files and outline consequences for individuals who create, present and/ or submit deceptive and/ or fraudulent documentation. The policy will be submitted to the Western Region office for review. The facility/staff handbook will then be updated to include this policy. All staff will confirm receipt and understanding of the policy in writing, to include any staff hired after acceptance of the POC. Review of this policy and topics addressed in the "Ethics" training will be discussed at staff meetings for three months after acceptance of the POC. Documentation of the receipt of policy by staff and staff meeting agendas will be available to Certification for review upon request.

Regulation: 3270.171(a)

Description: Pick-up and drop-off points

Noncompliance Area: No documentation was available that the operator notified the local traffic safety authorities in writing of 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: 3270.192(3)

Description: Health assessment, TB test

Noncompliance Area: The Health Assessment for Staff #2 was deemed invalid and therefore, the file lacked a current health assessment.

Correction Required: 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: 3270.27(c)/3270.192(2)(iii)

Description: Training regarding plan/Exp, educ., training at facility

Noncompliance Area: The Emergency Plan training in the file for Staff #5, was dated 8.1.23, and none thereafter, which exceeded the 12-month renewal requirement. The Emergency Plan training in the file for Staff #6, was dated 8/23, and none thereafter, which exceeded the 12-month renewal requirement. The Emergency Plan training in the file for Staff #7, was dated 8/23, and none thereafter, which exceeded the 12-month renewal requirement. The Emergency Plan training in the file for Staff #8, was dated 8/23, and none thereafter, which exceeded the 12-month renewal requirement. The Emergency Plan training in the file for Staff #9, was dated 8/23, and none thereafter, which exceeded the 12-month renewal requirement. The Emergency Plan training in the file for Staff #10, was dated 8/23, and none thereafter, which exceeded the 12-month renewal requirement. The Emergency Plan training in the file for Staff #11, was dated 8/23, and none thereafter, which exceeded the 12-month renewal requirement. The Emergency Plan training in the file for Staff #12, was dated 8/23, and none thereafter, which exceeded the 12-month renewal requirement. The Emergency Plan training in the file for Staff #13, was dated 8/23, and none thereafter, which exceeded the 12-month renewal requirement. The Emergency Plan training in the file for Staff #14, was dated 8/23, and none thereafter, which exceeded the 12-month renewal requirement. The Emergency Plan training in the file for Staff #15, was dated 4/23, and none thereafter, which exceeded the 12-month renewal requirement. The Emergency Plan training in the file for Staff #16, was dated 8/23, and none thereafter, which exceeded the 12-month renewal requirement. The Emergency Plan training in the file for Staff #18, was dated 8.1.23, and none thereafter, which exceeded the 12-month renewal requirement. The Emergency Plan training in the file for Staff #19, was dated 8.1.23, and none thereafter, which exceeded the 12-month renewal requirement. The Emergency Plan training in the file for Staff #20, was dated 8.14.23, and none thereafter, which exceeded the 12-month renewal requirement. The Emergency Plan training in the file for Staff #21, was dated 8/23, and none thereafter, which exceeded the 12-month renewal requirement. The Emergency Plan training in the file for Staff #22, was dated 8/23, and none thereafter, which exceeded the 12-month renewal requirement.

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. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

Regulation: 3270.27(e)

Description: Letter to parents

Noncompliance Area: No documentation was provided that a letter was provided to the parent of each enrolled child which explained the emergency procedures.

Correction Required: 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(f)

Description: Emergency plan

Noncompliance Area: No documentation was available that the Emergency Plan was sent to the local municipality and county emergency management agency.

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)(4)(i)/3270.192(2)(iii)

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

Noncompliance Area: The file for Staff #5 contained Pediatric First-Aid/CPR training which expired on 7.25.24, and it was not renewed until 10.3.24. The file for Staff #6 contained Pediatric First-Aid/CPR training which expired on 4.18.24, and it was not renewed until 5.28.24.

Correction Required: Competence is the completion of training by a professional in the field of first-aid and cardiopulmonary resuscitation (CPR). All staff persons shall renew their certification in pediatric first aid and pediatric cardiopulmonary resuscitation (CPR) on or before the expiration of the most current certification. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: The file for Staff #1 (see IS Code Sheet) did not contain documentation of the 10-hour Health & Safety training, which is beyond 90 days of hire.

Correction Required: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10.

Regulation: 3270.31(f)(10)

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

Noncompliance Area: The file for Staff #20 (see IS Code Sheet), contained documentation of Pediatric First-Aid/CPR training on 12.20.23, which exceeded 90 days of hire.

Correction Required: Staff persons shall complete professional development in pediatric first aid and pediatric cardiopulmonary resuscitation within 90 days of hire.

Regulation: 3270.31(f)(7)/3270.192(2)(iii)

Description: Health and Safety Training - Emergency preparedness/Exp, educ., training at facility

Noncompliance Area: The Emergency Plan training, in the file for Staff #4 (see IS Code Sheet), was dated 8.1.24, which exceeded 90 days of hire.

Correction Required: Staff persons shall complete professional development in emergency preparedness and response planning for emergencies resulting from a natural disaster or a man-caused event (such as violence at a child care facility) within the meaning of those terms under section 602(a)(1) of the Robert T. Stafford Disaster Relief and Emergency Assistance Act (42 U.S.C.A. § 5195a(a)(1)) 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: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: The file for Staff #1 (see IS Code Sheet) contained a Child Abuse Clearance dated 8.13.24, which was after the start date with children. The file for Staff #1 contained FBI Clearances dated 9.17.19 and 9.30.24, which exceeded the 60-month renewal requirement. The file Staff #4 contained documentation of Mandated Reporter training on 9.17.19 and 10.5.24, which exceeded the 60-month renewal requirement. The file for Staff #2 (see IS Code Sheet) contained a Child Abuse Clearance dated 4.9.24, which was after the start date with children. The file for Staff #6 contained documentation of Mandated Reporter training on 10.25.18 and 6.3.24, which exceeded the 60-month renewal requirement. The file for Staff #9 contained documentation of Mandated Reporter training on 2.28.18 and 2.2.24, which exceeded the 60-month renewal requirement. The file for Staff #14 (see IS Code Sheet), contained an FBI Clearance dated 3.17.23, with an Application dated 3.10.23, which was beyond the first date working with children.

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

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The file for Staff #3 did not contain a date on the Disclosure Statement. It could not be determined if the Disclosure Statement was obtained at the time of hire due to the missing date.

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

Regulation: 3270.34(a)(6)

Description: Staff evaluations

Noncompliance Area: The file for Staff #17 (see IS Code Sheet), contained documentation of a written evaluation on 7.1.24, which exceeded the 12-month requirement.

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: 3270.113(a)

Description: Supervised at all times

Noncompliance Area: *Previously cited on 2/7/24 SIN-00239502. Based on conversations with staff, on 3/12/24 at approximately 10:30 AM, Staff Person #1 was supervising Child #1 in the office. Child # 1 was sick and, in the office, to be picked up by parent. Staff Person #1 walked out of the office into the lobby and left Child #1 alone in the office alone and unsupervised.

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)

Description: Supervised at all times

Noncompliance Area: **Previously cited on 2/7/24 SIN-00239502. Based on conversations with staff, on 3/12/24 at approximately 10:30 AM, Staff Person #1 was supervising Child #1 in the office. Child # 1 was sick and, in the office, to be picked up by parent. Staff Person #1 walked out of the office into the lobby and left Child #1 alone in the office alone and unsupervised.

Correction Required: **Children must be supervised at all times. The legal entity must arrange for all childcare staff to complete two separate trainings. "Supervision: What's Required " and Supervision: Teamwork" both are available on Better Kid Care. Verification of completion of the supervision training will be submitted to DHS within 1 month of the approval of this plan of correction. The training may count towards the staff annual minimum of 12 clock hours of childcare training.

Regulation: 3270.113(a)(1)

Description: Staff assigned to specific children

Noncompliance Area: Previously cited on 2/7/24 SIN-00239502. Based on conversations with staff, on 3/12/24 at approximately 10:30 AM, Staff Person #1 was supervising Child #1 in the office. Child # 1 was sick and, in the office, to be picked up by parent. Staff Person #1 walked out of the office into the lobby and left Child #1 alone in the office alone and unsupervised.

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.

Regulation: 3270.51

Description: Similar Age Level

Noncompliance Area: Previously cited on 2/7/24 SIN-00239502. Based on conversations with staff, on 3/12/24 at approximately 10:30 AM, Staff Person #1 was supervising Child #1 in the office. Child # 1 was sick and, in the office, to be picked up by parent. Staff Person #1 walked out of the office into the lobby and left Child #1 alone in the office alone and unsupervised.

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.

Regulation: 3270.113(a)

Description: Supervised at all times

Noncompliance Area: According to Staff statements made to Cert Rep during an investigation on 2/7/24 it was disclosed that previously on 1/26/24 at approximately 4:00 PM a child was left alone in a classroom. Staff statements indicated that Staff #1 and Staff #2 were leaving the Gross Motor space and headed back to the classrooms to get the children's coats on to go outside. Upon getting the children's coats, Staff #1 left her classroom going next door to Staff #2's classroom and left Child #1 behind. Child #1 was left alone and unsupervised in the classroom where they could not be seen, heard, directed, or assessed. Staff#1 noticed the child was missing when the parent showed up to pick the child up from the facility.

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)(1)

Description: Staff assigned to specific children

Noncompliance Area: According to Staff statements made to Cert Rep during an investigation on 2/7/24 it was disclosed that previously on 1/26/24 at approximately 4:00 PM a child was left alone in a classroom. Staff statements indicated that Staff #1 and Staff #2 were leaving the Gross Motor space and headed back to the classrooms to get the children's coats on to go outside. Upon getting the children's coats, Staff #1 left her classroom going next door to Staff #2's classroom and left Child #1 behind. Child #1 was left alone and unsupervised in the classroom where they could not be seen, heard, directed, or assessed. Staff#1 noticed the child was missing when the parent showed up to pick the child up from the facility. Staff#1 was not physically present or know the whereabouts of all of the children in their assigned group.

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.

Regulation: 3270.113(b)

Description: No physical punishment

Noncompliance Area: On 2/1/24 at approximately 10:30 AM camera footage shows Staff #1 using their forearm to push Child #1 to the ground.

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

Regulation: 3270.51

Description: Similar Age Level

Noncompliance Area: According to Staff statements made to Cert Rep during an investigation on 2/7/24 it was disclosed that previously on 1/26/24 at approximately 4:00 PM a child was left alone in a classroom. Staff statements indicated that Staff #1 and Staff #2 were leaving the Gross Motor space and headed back to the classrooms to get the children's coats on to go outside. Upon getting the children's coats, Staff #1 left her classroom going next door to Staff #2's classroom and left Child #1 behind. Child #1 was left alone and unsupervised in the classroom where they could not be seen, heard, directed, or assessed. Staff#1 noticed the child was missing when the parent showed up to pick the child up from the facility. Therefore, ratio was 0:1.

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.

Regulation: 3270.111(b)

Description: Posted in group space

Noncompliance Area: The daily schedule was not posted in Room 110, Room 115, or Room 122.

Correction Required: The written plan of daily activities shall be posted in the group space.

Regulation: 3270.123(a)(1)

Description: Amount of fee

Noncompliance Area: The Agreement, in the file for Child #5, did not specify the fee amount.

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

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

Description: Admission date/Application, admission, withdrawal dates

Noncompliance Area: The Agreement, in the files for Child #4, Child #5, and Child #6, did not contain the date of admission.

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: 3270.124(b)(7)

Description: Name/address/phone release person

Noncompliance Area: The Emergency Contact form, in the files for Child #1, Child #5, Child #6, and Child #7, did not contain the release person's address.

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: The Emergency Transportation Plan was not posted in Room 110.

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

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

Noncompliance Area: The Health Assessment, in the file for Child #3, who is a young toddler, was dated more than 6 months ago.

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 Immunization Record, in the file for Child #2, Child #3, Child #4, Child #5, and Child #6, did not contain documentation of the influenza vaccination according to the ACIP recommendations.

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 #2, Child #3, Child #4, Child #5, and Child #6 must be dismissed from care by close of business on 10.20.23, and may only return to care when the immunization record is updated or when a parent provides a written, signed exemption letter.

Regulation: 3270.133(5)

Description: Original label

Noncompliance Area: The Epinephrine Injection Pen, for Child #8, in Room 140, contained an expiration date of 11/2022.

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: The files for Staff #11, Staff #12, Staff #13, Staff #14, Staff #15, Staff #16, Staff #17, Staff #18, Staff #19, Staff #20 and Staff #23 did not contain documentation of the Health and Safety, 1-hour Update training, which was required by December 30, 2022.

Correction Required: A facility shall be operated in conformity with applicable Federal and State laws and regulations.State agencies whose regulations may relate to the operation of a facility include the Department of Environmental Resources, the Department of Labor and Industry, the Department of Health, the Department of Education and the Department of Transportation. Conditions at the facility may not pose a threat to the health or safety of the children.

Regulation: 3270.151(a)/3270.192(3)

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

Noncompliance Area: The Health Assessments, in the file for Staff #5 and Staff #6 (see IS Code Sheets), were not conducted prior to providing initial service. The two (2) most recent Health Assessments, in the file for Staff #9, Staff #12, Staff #14, Staff #15, Staff #16, Staff #17, Staff #18, Staff #19, Staff #20, Staff #21, Staff #22, and Staff #23, exceeded the 24-month renewal requirement.

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: 3270.27(c)/3270.192(2)(iii)

Description: Training regarding plan/Exp, educ., training at facility

Noncompliance Area: The file for Staff #9 contained documentation of Emergency Plan training on 4.27.21 and 8.1.23, which exceeded the annual requirement. The file for Staff #13 contained documentation of Emergency Plan training on 9.12.22, and none thereafter, which exceeded the annual requirement. The file for Staff #15 contained documentation of Emergency Plan training on 8.8.21 and 8/2023, which exceeded the annual requirement. The file for Staff #16 contained documentation of Emergency Plan training on 8/2021 and 8/2023, which exceeded the annual requirement. The file for Staff #17 contained documentation of Emergency Plan training on 8.23.21 and 8/2023, which exceeded the annual requirement. The file for Staff #18 contained documentation of Emergency Plan training on 8.9.21 and 8/2023, which exceeded the annual requirement. The file for Staff #19 contained documentation of Emergency Plan training on 8.9.21, and none thereafter, which exceeded the annual requirement. The file for Staff #20 contained documentation of Emergency Plan training on 8/2021 and 8/2023, which exceeded the annual requirement. The file for Staff #21 contained documentation of Emergency Plan training on 5.10.21, and none thereafter, which exceeded the annual requirement. The file for Staff #22 contained documentation of Emergency Plan training on 7.6.21, and none thereafter, which exceeded the annual requirement.

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. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

Regulation: 3270.31(e)(4)(i)/3270.192(2)(iii)

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

Noncompliance Area: The file for Staff #9 contained documentation of Pediatric First-Aid/CPR training on 8.25.21 and 10.3.23, which exceeded the expiration date of the 2021 training. The file for Staff #11 contained documentation of Pediatric First-Aid/CPR training on 11.24.20, and none thereafter, which exceeded the expiration date of the 2020 training. The file for Staff #12 contained documentation of Pediatric First-Aid/CPR training on 8.25.21 and 10.3.23, which exceeded the expiration date of the 2021 training. The file for Staff #13 contained documentation of Pediatric First-Aid/CPR training on 8.22.21, and none thereafter, which exceeded the expiration date of the 2021 training. The file for Staff #14 contained documentation of Pediatric First-Aid/CPR training on 4.24.21, and none thereafter, which exceeded the expiration date of the 2021 training. The file for Staff #15 contained documentation of Pediatric First-Aid/CPR training on 8.25.21, and none thereafter, which exceeded the expiration date of the 2021 training. The file for Staff #16 contained documentation of Pediatric First-Aid/CPR training on 8.25.21, and none thereafter, which exceeded the expiration date of the 2021 training. The file for Staff #17 contained documentation of Pediatric First-Aid/CPR training on 6.4.20 and 10.3.23, which exceeded the expiration date of the 2020 training. The file for Staff #18 contained documentation of Pediatric First-Aid/CPR training on 8.25.21 and 10.3.23, which exceeded the expiration date of the 2021 training. The file for Staff #19 contained documentation of Pediatric First-Aid/CPR training on 8.25.21, and none thereafter, which exceeded the expiration date of the 2021 training. The file for Staff #21 contained documentation of Pediatric First-Aid/CPR training on 6.5.21, and none thereafter, which exceeded the expiration date of the 2021 training. The file for Staff #22 contained documentation of Pediatric First-Aid/CPR training on 2.19.20, and none thereafter, which exceeded the expiration date of the 2020 training. The file for Staff #23 contained documentation of Pediatric First-Aid/CPR training on 8.25.21 and 10.3.23, which exceeded the expiration date of the 2021 training.

Correction Required: Competence is the completion of training by a professional in the field of first-aid and cardiopulmonary resuscitation (CPR). All staff persons shall renew their certification in pediatric first aid and pediatric cardiopulmonary resuscitation (CPR) on or before the expiration of the most current certification. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

Regulation: 3270.31(e)(4)(ii)/3270.192(2)(iii)

Description: Fire safety - 1 yr./Exp, educ., training at facility

Noncompliance Area: The file for Staff #9 contained documentation of Fire Safety training on 4.30.21 and 12/2022, which exceeded the annual requirement. The file for Staff #10 contained documentation of Fire Safety training on 8.25.21 and 12/2022, which exceeded the annual requirement. The file for Staff #11 contained documentation of Fire Safety training on 1.11.22 and 12/2023, which exceeded the annual requirement. The file for Staff #12 contained documentation of Fire Safety training on 8.25.21 and 12/2022, which exceeded the annual requirement. The file for Staff #13 did not contain documentation of Fire Safety training, which was required by 9.15.22. The file for Staff #15 contained documentation of Fire Safety training on 8/2021 and 12/2022, which exceeded the annual requirement. The file for Staff #16 contained documentation of Fire Safety training on 8/2021 and 12/2022, which exceeded the annual requirement. The file for Staff #17 contained documentation of Fire Safety training on 8.25.21 and 12/2022, which exceeded the annual requirement. The file for Staff #18 contained documentation of Fire Safety training on 8.25.21 and 12/2022, which exceeded the annual requirement. The file for Staff #19 contained documentation of Fire Safety training on 8.25.21 and 12/2022, which exceeded the annual requirement. The file for Staff #20 contained documentation of Fire Safety training on 8/2021 and 12/2022, which exceeded the annual requirement. The file for Staff #21 contained documentation of Fire Safety training on 6.17.21 and 12/2022, which exceeded the annual requirement. The file for Staff #22 contained documentation of Fire Safety training on 6.1.21 and 12/2022, which exceeded the annual requirement. The file for Staff #23 contained documentation of Fire Safety training on 8.25.21 and 12/2022, which exceeded the annual requirement.

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. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: The file for Staff #4 (see IS Code Sheet) contained documentation of Health and Safety training, 10 hours, on 10.27.23, which was not within 90 days of hire. Staff #7 (see IS Code Sheet) has not completed the following required pre-service training within 90 days of the date of hire: Health & Safety - Revised, 10 hours.

Correction Required: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10. Staff #7 shall complete professional development in the topics of 3270.31(f)(1-10) within 90 days of hire. Staff #7 will have until 12.5.23 to complete the required training. Until such time as the required training has been completed, Staff #7 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 #7, Staff #7 may not work in a child care position at the facility.

Regulation: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: The file for Staff #1 (see IS Code Sheet) contained an FBI Clearance and application dated 3.17.23, which exceeded the initial start date. The file for Staff #2 (see IS Code Sheet) contained an FBI Clearance and application dated 7.7.23, which exceeded the initial start date. The file for Staff #3 (see IS Code Sheet) contained an FBI Clearance dated 9.18.23, and an application dated 9.13.23, which exceeded the initial start date. The file for Staff #6 (see IS Code Sheet) contained an FBI Clearance and application dated 8.18.23, which exceeded the initial start date. The file for Staff #7 (see IS Code Sheet) contained an FBI Clearance dated 5.16.23, and no application was available, which exceeded the initial start date. The file for Staff #7 (see IS Code Sheet) contained documentation of Mandated Reporter training on 8.18.23, which exceeded the 90-day requirement. The file for Staff #8 (see IS Code Sheet) contained an FBI Clearance dated 9.18.23, and an application dated 9.13.23, which exceeded the initial start date. The file for Staff #15 (see IS Code Sheet) contained an NSOR Certificate dated 10.7.21, and an application dated 9.30.21, which exceeded the initial start date. The file for Staff #20 contained documentation of Mandated Reporter training on 2.28.18, and none thereafter, which exceeded the 60-month renewal requirement. The file for Staff #23 (see IS Code Sheet) contained an FBI Clearance and application dated 8.26.21, which exceeded the initial start date. The file for Staff #23 (see IS Code Sheet) contained documentation of Mandated Reporter training on 4.15.22, which exceeded the 90-day requirement.

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