Grace Trinity Academy

Regulation: 3270.21

Description: General Health and Safety

Noncompliance Area: During complaint investigation it was found staff #1 slammed the door of the Sunshine room causing the window glass on the door to shatter with a total of three young toddlers and one teacher present in the room.

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

Regulation: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: During the renewal inspection cert rep observed both of the sofa lining was observed ripped and peeled in the afterschool room and not in good repair.

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

Regulation: 3270.14/3270.176(a)

Description: Pertinent Laws & Regulations/Insured

Noncompliance Area: During the renewal inspection cert rep reviewed vehicle #1 insurance card and observed it was expired. Vehicle #2 registration was observed expired.

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. A vehicle shall be insured in accordance with the requirements of 75 Pa.C.S. § § 1701-1799.7 (relating to the Motor Vehicle Financial Responsibility Law).

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: Cert rep reviewed staff #1 and #2 record and observed staff did not sign disclosure statement at the time of initial employment.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). SAFETY PLAN: The operator is required to submit to the Children and Youth Agency a plan of supervision or alternate arrangement as required by the Child Protective Services Law. LACKING REQUIRED HIRING DOCUMENTS: Facility Person # -1 and #2 may not work in a child care position at the facility. PROVISIONAL HIRE UNSUPERVISED: A provisional employee may not be permitted to work alone with children and must work within the vicinity of a permanent employee. A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Facility Person #-1 and #2 may not work in a child care position at the facility.

Regulation: 3270.66(a)

Description: Locked or inaccessible

Noncompliance Area: During renewal inspection cert rep observed cleaning spray left out in the bathroom stall and not kept in an area or container that is locked or made inaccessible to 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: 3270.77(a)

Description: No peeling paint or plaster

Noncompliance Area: During the renewal inspection cert rep observed chipped paint in the left wall of the entrance to the afterschool room.

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

Regulation: 3270.94(a)(1)

Description: Every 60 days

Noncompliance Area: During the renewal inspection cert rep observed date of last documented fire drill was conducted on 6/19/25.

Correction Required: The Director or designated staff person who is responsible for compliance with this chapter ensure fire drills are conducted at least once every 60 days.

Regulation: 3270.95(a)/3270.95(b)

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

Noncompliance Area: During the renewal inspection cert rep reviewed fire drill log and observed last fire detection testing was on 4/22/25. At the time of the renewal inspection staff #3 could not manually operate fire alarm system.

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)(1)

Description: Staff assigned to specific children

Noncompliance Area: Certification rep observed staff #2 in the rainbow room with one child leaving staff #3 out of ratio with a total of 15 children, outside in the playground area, the youngest child was 3 years in age. Staff #2 was not able to provide the number of children in her 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: 3270.151(c)(2)

Description: Mantoux TB

Noncompliance Area: Certification rep reviewed staff #1 record and observed record did not 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.

Correction Required: An adult health assessment must include tuberculosis screening by the Mantoux method at initial employment. Subsequent tuberculosis screening is not required unless directed by a physician, physician's assistant, CRNP, the Department of Health or a local health department.

Regulation: 3270.27(c)

Description: Training regarding plan

Noncompliance Area: Certification rep reviewed staff #1 record and observed record did not include staff #1 receiving training regarding the emergency plan at the time of initial employment or on an annual basis and at the time of each plan update. updated emergency plan training was not in record.

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: Certification rep reviewed staff #1 record and observed staff #1 did not renew their certification in pediatric first aid and pediatric cardiopulmonary resuscitation (CPR) on or before the expiration of the most current certification; 12/31/23.

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)

Description: Comply with CPSL

Noncompliance Area: Certification rep reviewed staff #1 record and observed staff #1 Mandated Reporter Training in record expired: date of expiration 5/15/17.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). SAFETY PLAN: The operator is required to submit to the Children and Youth Agency a plan of supervision or alternate arrangement as required by the Child Protective Services Law. LACKING REQUIRED HIRING DOCUMENTS: Facility Person # -- may not work in a child care position at the facility. PROVISIONAL HIRE UNSUPERVISED: A provisional employee may not be permitted to work alone with children and must work within the vicinity of a permanent employee.

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

Description: Admission date/Application, admission, withdrawal dates

Noncompliance Area: Certification rep reviewed children #1, #2, #3, #4 and #5 record and observed date of children admission is not in record.

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: 3270.151(c)(2)

Description: Mantoux TB

Noncompliance Area: Certification rep reviewed staff #5 record and observed health assessment did not include tuberculosis screening by the Mantoux method at initial employment.

Correction Required: An adult health assessment must include tuberculosis screening by the Mantoux method at initial employment. Subsequent tuberculosis screening is not required unless directed by a physician, physician's assistant, CRNP, the Department of Health or a local health department.

Regulation: 3270.182(1)

Description: Initial and subsequent health reports

Noncompliance Area: Certification rep reviewed child #5 record and observed physical exam in record is expired: 11/22/23.

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

Regulation: 3270.182(4)

Description: Consent for administration of medications or special dietary needs

Noncompliance Area: Certification rep reviewed child #5 record and observed emergency contact from did not include signed parental consent for administration of medications or special dietary needs.

Correction Required: A child's record shall contain signed parental consent for administration of medications or special dietary needs.

Regulation: 3270.192(5)

Description: Two written references

Noncompliance Area: Certification rep reviewed staff #4 record did not include two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person.

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

Regulation: 3270.31(e)

Description: Age and Training

Noncompliance Area: Certification rep reviewed staff #2, and #3 record and observed staff did not obtain an annual minimum of 12 clock hours of childcare training.

Correction Required: A staff person shall obtain an annual minimum of 12 clock hours of child care training.

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

Description: Fire safety - 1 yr.

Noncompliance Area: Certification rep reviewed staff #1 record and observed fire safety training in record expired, date of expiration:11/30/24.

Correction Required: Staff persons shall participate, at least annually, in firesafety training conducted by a fire protection professional. Staff persons and volunteers shall receive training in maintenance of smoke detectors, the duties of facility persons during a fire drill and during a fire and the use of the facility's fire extinguishers, not including discharge of the fire suppressant agent.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: Certification rep reviewed staff #5 record and observed signed disclosure statement was not in record.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). SAFETY PLAN: The operator is required to submit to the Children and Youth Agency a plan of supervision or alternate arrangement as required by the Child Protective Services Law. LACKING REQUIRED HIRING DOCUMENTS: Facility Person # -- may not work in a child care position at the facility. PROVISIONAL HIRE UNSUPERVISED: A provisional employee may not be permitted to work alone with children and must work within the vicinity of a permanent employee. A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Facility Person #--- may not work in a child care position at the facility.

Regulation: 3270.162(b)

Description: Parents may provide

Noncompliance Area: Formula was not provided to child #1 as agreed upon by the parent and staff #1.

Correction Required: Meals and snacks may be provided by the parent, upon agreement between the parent and the operator.

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: On the day of incident, no incident report was written and given to the parent by staff #2.

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: 3270.123(a)(1)/3270.123(a)(2)

Description: Amount of fee/Date fee to be paid

Noncompliance Area: Certification rep reviewed child #6 record and observed amount of the fee to be charged per day or per week and date on which the fee is to be paid missing on agreement form.

Correction Required: An agreement shall specify the amount of the fee to be charged per day or per week. An agreement shall specify the date on which the fee is to be paid.

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

Description: Admission date/Application, admission, withdrawal dates

Noncompliance Area: Certification rep reviewed children #5 #7 and #9 record and observed admission date for facility children are not in their child record.

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)(2)/3270.124(b)(6)

Description: Physician name, address, phone/Insurance coverage information

Noncompliance Area: Certification rep reviewed child #3 record and observed child #3 is missing the name, address and telephone number of the child's physician or source of medical care in the emergency contact form. Certification rep observed Child #3 record and observed health insurance coverage and policy number for a child under a family policy or Medical Assistance benefits missing on the emergency contact form.

Correction Required: Emergency contact information must include the name, address and telephone number of the child's physician or source of medical care. 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(b)(4)/3270.182(3)

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

Noncompliance Area: Certification rep reviewed child #3 record and observed written consent signed by a parent for emergency medical care missing on the emergency contact form.

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)/3270.182(4)

Description: Information re: special needs/Consent for administration of medications or special dietary needs

Noncompliance Area: Certification rep reviewed children #2 and #3 record and observed 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 is missing on the emergency contact form. Certification rep reviewed children #2 #3 and #4 record and observed child #2 and #3 is missing signed parental consent for administration of medications or special dietary needs. Child #4 signed parental consent for administration of medications on the emergency contact form.

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. A child's record shall contain signed parental consent for administration of medications or special dietary needs.

Regulation: 3270.124(c)

Description: Each child care space

Noncompliance Area: During the renewal inspection certification rep observed the superstar's room had only 1 emergency contact form. The Rainbow room had 4 emergency contact forms out of 19 children enrolled in the classroom. In the Care Bears room there were 6 emergency contact forms out of 10 children enrolled. In the Sweet Peas room there were only 7 emergency contact forms out of 9 children enrolled.

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: 3270.124(f)/3270.181(c)

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

Noncompliance Area: Certification rep reviewed children #1, #4 and #5 record and observed financial fee agreement form in record was not updated within a - month period; child#1 date of agreement in record 6/23/22, child #2 9/26/22 and child #5 1/4/23. Emergency contacts for children #1, #2 and #3 were not reviewed and updated within a 6- month period, Child#1 date in record 1/23/22, child#2 9/6/22 and child #3 4/10/23. Child #2 did not have a financial agreement in record.

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)(2)

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

Noncompliance Area: Certification rep reviewed children #1, #3 and #4 record and observed children health reports in record was not updated within a 12-month period. Child #1 date of health report in record: 4/25/22, child #3: 5/26/22 and child #4: 9/2022.

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)

Description: Immunization record

Noncompliance Area: Certification rep reviewed children #1 #2 #3 #4 #5 #6 and #7 record and observed the facility children enrolled more than 60 days at the facility, did not contain current documentation of the flu vaccine based on the child's age as per the ACIP recommended schedule.

Correction Required: A health report shall include a review of the child's immunized status according to recommendations of the ACIP.

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: Certification rep reviewed emergency plan and observed "continuity of operations" section missing in the emergecny plan.

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(c)(2)/3270.192(3)

Description: Mantoux TB/Health assessment, TB test

Noncompliance Area: Certification rep reviewed staff #3 and #4 record and observed staff #3 Tb results of initial and subsequent tuberculin skin tests are pending: date of physical exam on record 8/28/2023. Staff #4 Physical Exam is expired date on record 1/18/2021 and results of initial and subsequent tuberculin skin tests, x-rays or other medical documentation necessary to confirm freedom from communicable tuberculosis are not in record.

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: 3270.171(a)

Description: Pick-up and drop-off points

Noncompliance Area: During the renewal inspection provider did not have on record an annual written notification to local traffic authority.

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

Regulation: 3270.182(5)/3270.182(6)

Description: Consent for administration of minor first-aid required prior to admission/Signed parental consent for transportation, walking excursions, swimming and wading

Noncompliance Area: Certification rep reviewed child #3 record and observed signed parental consent for transportation, walking excursions missing on emergency contact form.

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. A child's record shall contain signed parental consent for transportation, walking excursions, swimming and wading.

Regulation: 3270.191

Description: Individual Records

Noncompliance Area: Certification rep reviewed staff #3 record and observed staff #3 did not have a complete record date of hire: 8/28/2023.

Correction Required: An individual record is required for each facility person.

Regulation: 3270.192(2)(iv)

Description: Transcript, diploma and letters

Noncompliance Area: Certification rep reviewed Staff #1, #2, #3 and #4 record and observed verification of experience was not in record. Staff #3 did not have education or training is a transcript or a diploma or a letter signed by a representative of the experiential, educational or training entity. level of education in record.

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: Certification rep reviewed staff #3 record and observed the record did not include two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person.

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

Regulation: 3270.25(a)

Description: Availability of certificate of compliance and applicable regulations

Noncompliance Area: During the renewal inspection certification rep observed the operator did not 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 childcare office.

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 childcare office.

Regulation: 3270.27(a)(5)

Description: Emergency plan

Noncompliance Area: Certification rep reviewed emergecny plan and observed a plan that provides for accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions missing on the emergecny plan.

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

Regulation: 3270.27(a)(6)

Description: Emergency plan

Noncompliance Area: During the renewal inspection provider did not have in record a documented emergency drill log at the facility.

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

Regulation: 3270.27(f)

Description: Emergency plan

Noncompliance Area: During the renewal inspection emergency plan delivery document form was not in record with receipt that it was delivered to the local municipality and to the 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: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: Addendum from renewal inspection. During follow up visit on 2/15/24 certification rep received new information from staff data sheet. Certification rep reviewed staff #1 record and observed staff #1 did not have an NSOR clearance in record. Staff #5 did not have and NSOR certificate in record. staff #6 did not have an up-to-date FBI clearance on record, date of clearance in record 6/23/18. Staff #7 child abuse clearance in record expired, date of child abuse clearance in record 1/17/19.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). SAFETY PLAN: The operator is required to submit to the Children and Youth Agency a plan of supervision or alternate arrangement as required by the Child Protective Services Law. LACKING REQUIRED HIRING DOCUMENTS: Facility Person # -- may not work in a child care position at the facility. PROVISIONAL HIRE UNSUPERVISED: A provisional employee may not be permitted to work alone with children and must work within the vicinity of a permanent employee. A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Facility Person #--- may not work in a child care position at the facility.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: Certification rep reviewed staff #1 file and observed disclosure statement was not in record date of hire: 10/23/. Staff #3 did not obtain a Child Abuse clearance, State Police Clearance, FBI Clearance: date of hire 8/29/2023.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). SAFETY PLAN: The operator is required to submit to the Children and Youth Agency a plan of supervision or alternate arrangement as required by the Child Protective Services Law. LACKING REQUIRED HIRING DOCUMENTS: Facility Person # -- may not work in a child care position at the facility. PROVISIONAL HIRE UNSUPERVISED: A provisional employee may not be permitted to work alone with children and must work within the vicinity of a permanent employee. A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Facility Person #--- may not work in a child care position at the facility.

Regulation: 3270.65

Description: Protective Outlet Covers 5 yrs. or less

Noncompliance Area: During the renewal inspection certification rep observed outlet covers missing on the back wall of the classroom and above counter in the back sink area.

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

Regulation: 3270.69(b)

Description: 110º F or less

Noncompliance Area: During the renewal inspection certification rep read water temperature at 120 F in the girl's bathroom.

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

Regulation: 3270.75(c)

Description: Has all items

Noncompliance Area: During the renewal inspection certification rep observed the Supers Stars first aid kit did not contain a tweezer. The Sweet Peas first aid bag did not contain gauze tape and the afterschool room first aid bag did not contain bandages.

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: Durin the renewal inspection certification rep observed the girls and boy's bathroom did not have the proper handwashing sign above sink and toilets. In the care bears room bathroom sign above toilet was missing and, in the after, -school bathroom toilets.

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: 3270.91(a)

Description: Stairs, exits, etc. unobstructed

Noncompliance Area: During the renewal inspection certification rep observed the outside gate that serves as an emergency exit was locked.

Correction Required: Stairways, hallways, exits from rooms, exits from the facility and other means of egress serving as an exit shall be unobstructed.

Regulation: 3270.94(a)(9)

Description: Written record

Noncompliance Area: During the renewal inspection certification rep observed the Director or designated staff person who is responsible for compliance did not maintain on file at the facility indicating the specific time of day of the drill, the hypothetical location of the fire, the evacuation time, and the names of the facility persons and the number of children who participate in the fire drill.

Correction Required: The Director or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that a written record is maintained on file at the facility indicating the specific time of day of the drill, the hypothetical location of the fire, the evacuation time, and the names of the facility persons and the number of children who participate in the fire drill.

Regulation: 3270.70(a)

Description: 65º F minimum

Noncompliance Area: At the time of the complaint investigation, the temperature in Care Bears and Rainbow rooms were 56° F.

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

Regulation: 3270.111(a)

Description: Written plan

Noncompliance Area: At the time of renewal inspection, a written plan of daily activities and routines was not posted in Care Bares room.

Correction Required: A written plan of daily activities and routines, including a time for free play shall be established for each group. The plan shall be flexible to accommodate the needs of individual children and the dynamics of the group.

Regulation: 3270.124(b)(3)/3270.124(b)(7)

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

Noncompliance Area: At the time of renewal inspection, emergency contact form of child #3 did not include enrolling parent work address and phone number. Emergency contact from of child #1, #2, #3, #4, and #5 did not include release person's address.

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

Regulation: 3270.124(b)(6)

Description: Insurance coverage information

Noncompliance Area: At the time of renewal inspection, emergency contact form of child #2 and #5 did not include health insurance coverage and policy number for a child under a family policy or Medical Assistance benefits, if applicable.

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(e)

Description: Written emergency plan posted

Noncompliance Area: At the time of renewal inspection, a written plan identifying the means of transporting a child to emergency care and staffing provisions in the event of an emergency was not posted in Sweet Peas room.

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

Regulation: 3270.124(f)/3270.181(c)

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

Noncompliance Area: At the time of renewal inspection, emergency contact information of child #5 were not updated once in a 6-month period or as soon as there is a change in the information. Emergency contact form was reviewed by a parent on 1/19/22.

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

Regulation: 3270.131(b)(2)/3270.182(1)

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

Noncompliance Area: At the time of renewal inspection, a health report of child #6 was not updated at least every 12 months. A health report on file was from 7/6/21.

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)(2)(i)

Description: Immunization record/Exemption documentation from parent/guardian

Noncompliance Area: At the time of renewal inspection, immunization record of child #1 did not include MMR, Varicella and Hepatitis A immunization recommended by ACIP. Immunization record of child #3 did not include influenza immunization. Immunization record of child #5 did not include Hepatitis B, Hepatitis A, DTAP, HIB, Pneumococcal, Polio, Influenza, MMR, and Varicella immunization. A letter of exemption was not observed in the file of child #1, #3, and #5.

Correction Required: A health report shall include a review of the child's immunized status according to recommendations of the ACIP. Exemption from immunization for religious belief or strong personal objection equated to a religious belief shall be documented by a written, signed and dated statement from the child's parent or guardian. The statement shall be kept in the child's record.

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: At the time of renewal inspection, a policy and procedure to identify the potential signs and symptoms of baby shaken syndrome and abusive head trauma, strategies for coping with a crying, fussing, or distraught child, and the prevention and identification of child maltreatment was not observed.

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: At the time of renewal inspection, file of facility person #2 did not include an updated health assessment. A health assessment on file was from 8/12/20.

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(e)

Description: Emergency master file updated

Noncompliance Area: At the time of renewal inspection observed that some emergency contact forms were not updated in Sweet Peas, Superstars, Super Sonic, and The Magic School Bus rooms.

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

Regulation: 3270.31(f)/3270.31(g)

Description: Health and Safety Training/Professional development certificate

Noncompliance Area: At the time of renewal inspection, record of staff person #3 did not include verification that staff completed required pre-service Health and Safety training.

Correction Required: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10. Completion of professional development shall be documented by the signature and title of a representative of the professional development entity and include the date professional development was completed. Documentation shall be retained in the facility person's file or maintained in an electronic system as designated by the Department. Documentation of the completion of the professional development under subsection (f) taken from September 30, 2016, forward satisfies this requirement. Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10. Staff person #3 will have until 12/28/2022 to complete the required training. Until such time as the required training has been completed, staff person #3 must be supervised, when interacting with children, by a primary staff person who has completed the required training related to this citation. If there are no staff available to supervise staff person #3, staff person #3 may not work in a child-care position at the facility.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: At the time of renewal inspection, file of staff person #1 and #2 included FBI clearance required by DHS that was more than 60 month old and are not acceptable.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Facility Person #1, #2 may not work in a child care position at the facility.

Regulation: 3270.69(b)

Description: 110º F or less

Noncompliance Area: At the time of renewal inspection, hot water temperature accessible to children in Sweet Peas room was 118° F, in Superstars and The Magic School Bus rooms were 112° F.

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

Regulation: 3270.82(h)

Description: Handwashing signs

Noncompliance Area: At the time of renewal inspection, a handwashing sign that requires an able child and adult to wash hands after toileting and before eating was not posted at the sink in Superstars, Supersonics, girls and boys bathroom.

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(d)

Description: No harsh language

Noncompliance Area: At the time of the complaint investigation it was verified that staff person #1 was using harsh language in the presence of children while being overheard by two other staff members saying "They are getting on my nerves", "I have enough of these kids", "I am done with them".

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

Regulation: 3270.151(c)(5)

Description: Physician/CRNP assessment

Noncompliance Area: At the time of renewal inspection, a health assessment of staff person #4 did not include the physician's or CRNP's assessment of the person's suitability to provide child care.

Correction Required: An adult health assessment must include the physician's or CRNP's assessment of the person's suitability to provide child care.

Regulation: 3270.192(5)

Description: Two written references

Noncompliance Area: At the time of renewal inspection, file of staff person #1 and #3 did not include two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person.

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

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

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

Noncompliance Area: At the time of renewal inspection, file of staff person #3 hired on 8/23/21 and staff person #5 hired on 8/30/21 did not include verification of health and safety training completed within 90 days of hire.

Correction Required: Staff persons shall complete professional development in the following topics 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)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: At the time of renewal inspection, file of staff person #2 included FBI Clearance from 12/16/2016 which was more than 60 months old. File of staff person #5 hired on 8/30/21 did not include DHS required FBI clearance and NSOR Verification Certificate. Provisional hire period for staff person #5 ended on 10/14/21. In addition, file of staff person #5 did not contain verification of the required Mandated and Permissive Reporting in Pennsylvania training conducted within the 90 days of hire.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). LACKING REQUIRED HIRING DOCUMENTS: Facility Person # 5 may not work in a child care position at the facility. A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Staff Person #2 and #5 must be removed from child care position by close of business.

Regulation: 3270.34(a)(6)

Description: Staff evaluations

Noncompliance Area: At the time of renewal inspection, file of staff person #2 and #6 didn't contain proof of current written evaluation.

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: At the time of renewal inspection, file of staff person #1 and #5 did not include verification of 2 years experience with children required for the position of an assistant group supervisor.

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.

Noncompliance Area: During renewal inspection on 12/12/19 observed that a staff person did not ensure that a child's hands are washed after being diapered.

Correction Required: A staff person shall ensure that a child's hands are washed before meals and snacks, after toileting and after being diapered.

Noncompliance Area: During renewal inspection on 12/12/19, a health assessment of staff person #2 from 4/24/2017 was conducted more than 24 months ago.

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.

Noncompliance Area: During renewal inspection on 12/12/19, a health assessment of staff person #1did not include the physician's or CRNP's assessment of the person's suitability to provide child care.

Correction Required: An adult health assessment must include the physician's or CRNP's assessment of the person's suitability to provide child care.

Noncompliance Area: During renewal inspection on 12/12/19, safe routes were not posted by the operator and local traffic safety authorities were not notified annually in writing of the location of the facility and the program's use of pedestrian and vehicular routes around the day 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 day care facility. Written notification of safe routes shall be posted by the operator at a conspicuous location in the child care facility.

Noncompliance Area: During renewal inspection on 12/12/19, file of staff person #3 did not include two written nonfamily references from individuals attesting to the person's suitability to serve as a facility person, file of staff person #4 included only one written nonfamily reference.

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

Noncompliance Area: During renewal inspection on 12/12/19, the emergency plan was not reviewed at least annually. Last review was documented in writing on 1/2/18.

Correction Required: The operator shall review the emergency plan at least annually and update the plan as needed. The operator shall document in writing each review and update of the emergency plan and kept on file at the facility.

Noncompliance Area: During renewal inspection on 12/12/19, file of staff person #5 included the Pennsylvania State Police Criminal History Clearance for volunteer purpose, file of staff #6 and #7 did not include mandated reporter training. Staff #5, #6, and #7 were hired more than 90 days ago and are not "provisional employees" under CPSL.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). LACKING REQUIRED HIRING DOCUMENTS: Facility Person # 5 may not work in a child care position at the facility. 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.

Noncompliance Area: During renewal inspection on 12/12/19, written evaluation of staff person #1, #5, #8, and #9 was not conducted every 12 months.

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

Noncompliance Area: During renewal inspection on 12/12/19 observed staff #5, an aide, was working alone in Sunshine classroom without being supervised by an assistant group supervisor.

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

Noncompliance Area: During renewal inspection on 12/12/19, hot water temperature in areas accessible to children were 128 F in Stars room, 120 F in Sonics room, 118 F in Sunshine room, and 128 F in girls bathroom located on the main floor.

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

Noncompliance Area: During the complaint investigation on 8/19/19, it was verified that children were not supervised on the toddler playground by a staff #1, who was inside of the building. As a result, staff #1 was unaware that child #1 was pushed by another child and injured.

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.

Noncompliance Area: During allocated unannounced inspection on 8/19/19, emergency contact form of child #1 was not present in Care Bare 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.

Noncompliance Area: During allocated unannounced inspection on 8/19/19, observed a child's bottle in the young toddler room that was not labeled.

Correction Required: Disposable nursers and bottles shall be labeled with the child's name.

Noncompliance Area: During the complaint investigation on 8/19/19, child #1 record didn't contain a report of accident that happened on 8/9/19 at the facility.

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

Noncompliance Area: During the complaint investigation on 8/19/19, provider did not notify Southeast Regional Bureau of Certification within 24 hours that child #1 received emergency room treatment. Written report was not sent to Southeast Regional Bureau of Certification within 72 hours after emergency room treatment.

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.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

Noncompliance Area: During renewal inspection on 12/07/18, an agreement of child #3 was not signed by the parent.

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

Noncompliance Area: During renewal inspection on 12/07/18, an emergency contact form of child #2, 4, didn't include the address of the individual designated by the parent to whom the child may be released.

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

Noncompliance Area: During renewal inspection on 12/7/18, file of staff person #1 (date of hire 7/13/18) and #2 (date of hire 12/03/18) didn't contain verification of health assessment.

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.

Noncompliance Area: During renewal inspection on 12/07/18, an emergency contact form and agreement of child #1, 4, were not updated at least once in a 6 month period. Emergency information that was updated in the master file was not updated in classroom records.

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

Noncompliance Area: During renewal inspection on 12/07/18, file of staff person #3 didn't contain verification of annual fire safety training.

Correction Required: Staff persons shall participate, at least annually, in firesafety training conducted by a fire protection professional. Staff persons and volunteers shall receive training in maintenance of smoke detectors, the duties of facility persons during a fire drill and during a fire and the use of the facility's fire extinguishers, not including discharge of the fire suppressant agent.

Noncompliance Area: During renewal inspection on 12/07/18, file of staff person #1 didn't contain verification of mandated reporter training (date of hire 7/13/18).

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

Noncompliance Area: During renewal inspection on 12/07/18, file of staff person #3 and 4 didn't contain verification of yearly written staff evaluation.

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

Noncompliance Area: During renewal inspection on 12/07/18, file of staff person #2 didn't contain verification of experience that qualifies for the position of an assistant group supervisor.

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

Noncompliance Area: At the time of the unannounced inspection, staff #4 and #5 in the Care Bears room and staff #2 in the Sweet Peas room could not identify who were in their assigned groups.

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

Noncompliance Area: At the time of the unannounced inspection, the file of staff #2 had a health assessment and TB test that was not properly signed by a physician with his professional title.

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

Noncompliance Area: At the time of the unannounced inspection, the files of staff # 2 and #5 and #6 did not have verification of age.

Correction Required: A facility person's record shall include verification of age.