Heritage Out Of School Time

Regulation: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: Broken magnatiles were observed to be accessible in the Stargazers room, which could be harmful to children. Rest mats with torn vinyl corners and not in good repair were observed in the cubbies in the hallway.

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: 3270.121(b)

Description: Given parents in writing

Noncompliance Area: At the time of inspection, the facility lacked a policy regarding the transfer of care between the child care facility and the child's school. The policy shall be a written agreement which includes the parent's signature providing consent and placed in the child's file.

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

Regulation: 3270.124(b)(2)

Description: Physician name, address, phone

Noncompliance Area: The emergency contact forms for Child #1, Child #2, and Child #3 lacked the complete address and phone number of the child's physician or source of medical care.

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

Regulation: 3270.124(c)

Description: Each child care space

Noncompliance Area: At the time of inspection, Child #5 was receiving care in the Penguins room, and the Pirates room was observed in Room 17 (Steelers) without their emergency contact information being in the space where they were receiving care.

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

Description: Immunization record/Dismissal policy

Noncompliance Area: The immunization record for Child #4 (Preschool Age) lacked the following immunizations: 3 doses of Hepatitis B, 3 doses of DTAP, 3 doses of Hib, 4 doses of Pneumococcal, 3 doses of Polio, 1 dose of MMR, 1 dose of Varicella, and 2 doses of Hepatitis A without a Letter of Exemption in the file.

Correction Required: A health report shall include a review of the child's immunized status according to recommendations of the ACIP. The facility shall implement dismissal policies in accordance with the Department of Health regulation in 28 Pa. Code § 27.77 (relating to immunization requirements for children in child care group settings). Child #4 must be dismissed from care by close of business on 7/27/26 and may only return to care when the immunization record is updated or when a parent provides a written, signed exemption letter.

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: The facility's emergency plan lacked policies regarding volunteer emergency preparedness training, and continuity of operations, required as of 7/1/22, as per Announcement C-22-04. The facility's Continuity of Operations policy in the emergency plan lacked procedures on backing up or retrieving health and other key records/files and managing financial issues such as paying employees and bills during the aftermath of the disaster.

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 two most recent health assessments on file for Staff #2 (1/28/24 & 2/5/25), Staff #4 (2/21/24 & 5/20/26), Staff #6 (8/11/23 & 5/10/26), and Staff #7 (3/12/24 & 4/30/26) are dated more than 24 months apart.

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: 3270.161(d)

Description: Potentially hazardous food refrigerated

Noncompliance Area: Multiple lunchboxes containing potentially hazardous foods from home were observed in the cubbies in the hallway and were not refrigerated.

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

Regulation: 3270.21

Description: General Health and Safety

Noncompliance Area: A screwdriver was observed in a teacher caddy in the Panthers room and was accessible to children.

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

Regulation: 3270.27(d)

Description: Plan posted

Noncompliance Area: At the time of inspection, the emergency plan was not posted in a conspicuous location.

Correction Required: The operator shall post the emergency plan in the facility at a conspicuous location.

Regulation: 3270.31(e)

Description: Age and Training

Noncompliance Area: The file for Staff #4 contained 3 of 12 annual childcare training hours within the training timeframe of 12/2024-12/2025. The file for Staff Person #7 contained 11 of 12 annual childcare training hours within the training timeframe of 12/2024-12/2025.

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: The two most recent fire safety trainings on file for Staff #1 (5/29/25 & 7/16/26), Staff #3 (1/17/25 & 5/29/26), Staff #8 (6/19/25 & 7/15/26), and Staff #9 (5/28/25 & 6/2/26) are dated more than 12 months apart.

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.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The file for Staff #5 contained a Virginia Child Abuse clearance dated 4/6/26 and a Virginia Sex Offender clearance dated 6/22/26, which are required prior to the date of hire (SEE IS CODE SHEET). The file for Staff #10 contained a West Virginia Child Abuse clearance dated 5/1/26 and a West Virginia Sex Offender clearance dated 4/22/26, which are required prior to the date of hire (SEE IS CODE SHEET).

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

Regulation: 3270.76

Description: Building Surfaces

Noncompliance Area: The carpet in the Dazzlers room and a rectangular rug with butterflies in the Stargazers Room were observed to be darkened with dirt spots. Torn vinyl was observed on the corners of the mats on the walls in the Gym. A metal pipe at the bottom of the curtain in the Gym was observed with rough edges and was accessible to children.

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

Regulation: 3270.77(a)

Description: No peeling paint or plaster

Noncompliance Area: Peeling paint was observed on the wood panels around the window air conditioner units in the outdoor play space.

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)(4)

Description: Hypothetical locations

Noncompliance Area: The facility's fire drill log contained consecutive hypothetical locations for the fire used for the fire drill in April 2026 and May 2026.

Correction Required: The Director or designated staff person who is responsible for compliance with this chapter ensure the hypothetical locations of the fire are rotated around the facility for each drill such that the hypothetical location is never the same for consecutive drills.

Regulation: 3270.95(a)

Description: Devices must be compliant

Noncompliance Area: The fire alarm 30-day test log includes test dates 3/19/26-4/20/26, more than 30 days apart.

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)).

Regulation: 3270.113(a)

Description: Supervised at all times

Noncompliance Area: At approximately 10:15 AM, Child #1 was asleep and left alone in the Dreamers classroom for 10-15 minutes while Staff #1 and Staff #2 went to the Gym with the rest of the group.

Correction Required: Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Outdoor play space used by the facility is considered part of the facility premises.

Regulation: 3270.113(a)

Description: Supervised at all times

Noncompliance Area: At approximately 4:51 on 2/4/26, video footage taken in the facility shows a parent holding the door open to the Imagineers classroom while Child #1 exits into the hallway. Child #1 continues to walk alongside the family down the hallway and exits the building.

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. TIERED LIS: 1. 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. THIS PORTION OF THE PLAN SHALL HAVE AN IMMEDIATE CORRECTION DATE. 2. The legal entity shall ensure that all facility staff complete an in-person supervision and ratio training, coordinated through the ELRC, that include a component relating to supervision during times of transition. Training documentation must be retained on file that includes the date of the training and the names of the attendees. THE OPERATOR SHALL PROVIDE A DATE FOR WHEN THIS WILL BE COMPLETED. 3. The legal entity shall develop a written dismissal policy with procedures to include supervision regulations and center requirements, developed with the ELRC. The policy should also include clarification regarding staff placement during dismissal, relocating children to other rooms at the end of the day, and procedures for parents during dismissal. The written policy shall be forwarded to the Certification Representative for review. Following confirmation of the review, the dismissal policy shall be presented to all staff members at a staff meeting. Verification of completion will include copies of signed and dated acknowledgements for all staff, as well as the staff meeting agenda where the new policy was discussed. Documentation shall be forwarded to the certification representative upon completion and kept on file at the facility. THE OPERATOR SHALL PROVIDE A DATE FOR WHEN THIS WILL BE COMPLETED. 4. The legal entity shall ensure that all facility staff complete a technical assistance program regarding supervision of children coordinated through the ELRC, with an emphasis on supervision during transitions and appropriate supervision within the environment, including rest time. Documentation of completion of the TA shall be retained on file at the facility as well as submitted to certification representative upon completion. THE OPERATOR SHALL PROVIDE A DATE FOR WHEN THIS WILL BE COMPLETED. 5. The legal entity will develop a tool with which to complete daily supervision and ratio checks of all classrooms throughout the day to assess sightlines, staff positioning in the room, and supervision groups. The tool will include the classroom name, date and time of observation, staff person(s) present, the number of children and their age levels (Infant, YT, OT, PS, YSA, OSA) present. The tool will assess that a staff person is physically present with their group of children under their supervision. The tool will assess that the staff person can see, hear, direct and assess the activity of the children under their supervision. THE CORRECTION DATE FOR THIS PORTION OF THE PLAN WILL BE THE DAY THE ASSESSMENT TOOL IS SUBMITTED TO CERTIFICATION, PRIOR TO USE. 6. Random supervision and ratio checks will occur at least 3 times per week for the 4 months subsequent to training and after submission of the tool. Documentation of the checks will be made available to Certification upon request. THE CORRECTION DATE FOR THIS PORTION OF THE PLAN WILL BE AT A MINIMUM OF 4 MONTHS FROM DATE THE REGIONAL OFFICE APPROVES THE TOOL.

Regulation: 3270.113(a)(1)

Description: Staff assigned to specific children

Noncompliance Area: At approximately 10:15 AM, Child #1 was asleep and left alone in the Dreamers classroom for 10-15 minutes while Staff #1 and Staff #2 went to the Gym with the rest of the 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(a)(1)

Description: Staff assigned to specific children

Noncompliance Area: At approximately 4:51 on 2/4/26, video footage taken in the facility shows a parent holding the door open to the Imagineers classroom while Child #1 exits into the hallway. Child #1 continues to walk alongside the family down the hallway and exits the building.

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: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: The two most recent mandated reporter trainings on file for Staff #1 (8/17/20 &8/25/25) and Staff #2 (4/30/20 & 6/7/20) are dated more than 60 months apart.

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

Regulation: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: A green toy bin in the Voyagers classroom was observed to have a broken handle and not in good repair. Foam blocks with ripped pieces and teeth marks were observed in the Pirates room. Peeling vinyl was observed on the couch in the Dreamers classroom, on the brown couch in the Voyagers classroom, a bean bag in the Panthers classroom, and on the front and back wall mats in the Gym. Rest equipment with torn vinyl and exposed foam was observed in the Dreamers and Imagineers classrooms.

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: 3270.106(f)

Description: 2 feet apart

Noncompliance Area: Rest equipment in the Dreamers and Imagineers classrooms lacked two feet on three sides of the rest equipment while the equipment was in use.

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 report on file for Child #2 is dated 1/7/25, more than 6 months from the child's date of enrollment (SEE IS CODE SHEET). The two most recent child service reports on file for Child #8 are dated 12/1/23 & 2/10/25, more than 6 months apart.

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(3)

Description: Parent receives original/Consent for emergency medical care required prior to admission

Noncompliance Area: The file for Child #5, Child #7, Child #9, and Child #10 contained the original financial agreement when the parent is to receive the original agreement.

Correction Required: A parent shall receive the original agreement. The facility shall retain a copy of the agreement. 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)(2)

Description: Physician name, address, phone

Noncompliance Area: The emergency contact form on file for Child #7 and Child #8 lacked a complete address and phone number for the child's physician or source of medical care.

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

Regulation: 3270.124(b)(3)

Description: Parent home/work address, phone

Noncompliance Area: The emergency contact form on file for Child #1, Child #5, Child #6, and Child #7 lacked complete addresses for the enrolling parent's home and work address.

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 on file for Child #3 and Child #6 lacked the enrolling parent's signature giving the facility written consent to obtain 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)(6)

Description: Insurance coverage information

Noncompliance Area: The emergency contact form on file for Child #5 lacked the health insurance policy or medical assistance 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(b)(7)

Description: Name/address/phone release person

Noncompliance Area: The emergency contact form on file for Child #1 and Child #7 lacked complete addresses for all 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(f)/3270.181(c)

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

Noncompliance Area: The file for Child #2 contained an emergency contact form that was reviewed and updated by the parent dated 9/4/24 & 4/4/25, more than 6 months apart.

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(a)/3270.131(e)

Description: Health information/ACIP recommended immunization record

Noncompliance Area: The file for Child #6, enrolled more than 60 days, lacked an initial health report (See LIS Code Sheet).

Correction Required: The operator shall require the parent of an enrolled child, including a child, a foster child and a relative of an operator or a facility person, to provide an initial health report no later than 60 days following the first day of attendance at the facility. The facility may not accept or retain an infant 2 months of age or older, a toddler or a preschool child at the facility for more than 60 days following the first day of attendance at the facility unless the parent provides written verification from a physician, physician's assistant, CRNP, the Department of Health or a local health department of the dates (month, day and year) the child was administered immunizations in accordance with the recommendations of the ACIP.

Regulation: 3270.131(a)/3270.182(1)

Description: Health information/Initial and subsequent health reports

Noncompliance Area: The file for Child #3 contained an initial health assessment dated 1/17/25, more than 60 days beyond enrollment (SEE IS CODE SHEET).

Correction Required: The operator shall require the parent of an enrolled child, including a child, a foster child and a relative of an operator or a facility person, to provide an initial health report no later than 60 days following the first day of attendance at the facility. 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 two most recent health assessments on file for Child #1 (Preschool Age) are dated 3/14/24 and 4/4/25, more than 12 months apart.

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 immunization record for Child #4 (PSA) lacked the following immunizations: 2 doses of Rotavirus and 1 dose of Pneumococcal without a Letter of Exemption in the file. Child #4 must be dismissed from care by close of business on 7/16/25 and may only return to care when the immunization record is updated or when a parent provides a written, signed exemption letter.

Correction Required: A health report shall include a review of the child's immunized status according to recommendations of the ACIP. The facility shall implement dismissal policies in accordance with the Department of Health regulation in 28 Pa. Code § 27.77 (relating to immunization requirements for children in child care group settings).

Regulation: 3270.131(d)(7)

Description: Free from contagious/communicable disease

Noncompliance Area: The health assessment on file for Child #2 dated 9/24/24 does not indicate if the child is free from contagious disease and may participate in child care.

Correction Required: A health report shall include a statement that the child is able to participate in child care and appears to be free from contagious or communicable disease.

Regulation: 3270.131(e)(1)

Description: Exemption documentation from parent/guardian

Noncompliance Area: The file for Child #3 contained an immunization record dated 1/17/25, more than 60 days beyond enrollment (SEE IS CODE SHEET). The file for Child #6, enrolled more than 60 days, lacked an immunization record or letter of exemption from the parent (See LIS Code Sheet). Child #6 must be dismissed from care by close of business on 7/16/25 and may only return to care when the immunization record is provided or when a parent provides a written, signed exemption letter.

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

Regulation: 3270.151(a)/3270.192(3)

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

Noncompliance Area: The most recent health assessment on file for Staff #12 (5/5/23) and Staff #6 (4/26/23) are dated more than 24 months prior. The two most recent health assessments on file for Staff #14 (1/4/23 & 3/3/25) and Staff #11 (7/16/21 & 1/28/24) are dated more than 24 months apart.

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: 3270.161(d)

Description: Potentially hazardous food refrigerated

Noncompliance Area: In the Imagineers Room, a child's lunchbox containing potentially hazardous food from home was observed on a table and not refrigerated.

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

Regulation: 3270.181(c)

Description: Emergency info/agreement updated 6 mos

Noncompliance Area: The file for Child #3 contained a financial agreement form that was reviewed and updated by the parent dated 10/10/24 & 5/5/25, more than 6 months apart.

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 on file for Child #3 and Child #6 lacked the enrolling parent's signature giving the facility written consent to administer minor first aid.

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: The files for Staff #3, Staff #4, Staff #5, Staff #8, Staff #9, and Staff #11 lacked two written nonfamily reference letters.

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: Adult scissors were observed accessible on the teacher's desk in the Steelers and Penguins rooms.

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

Regulation: 3270.27(a)(6)

Description: Emergency plan

Noncompliance Area: The two most recent emergency drills are dated 2/20/24 and 6/5/25, more than 12 months apart.

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

Regulation: 3270.27(c)

Description: Training regarding plan

Noncompliance Area: The initial emergency plan training on file for Staff #7 is dated 7/2/25, more than 90 days beyond the facility person's date of hire (SEE IS CODE SHEET).

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

Regulation: 3270.27(e)

Description: Letter to parents

Noncompliance Area: The facility's emergency plan parent letter lacked accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions.

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: 3270.31(e)(4)(ii)

Description: Fire safety - 1 yr.

Noncompliance Area: The two most recent fire safety trainings on file for Staff #1 are dated 6/30/23 and 7/10/24, more than 12 months apart.

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)

Description: Comply with CPSL

Noncompliance Area: The two most recent mandated reporter trainings on file for Staff #1 (4/30/20 & 6/17/25), Staff #2 (4/20/20 & 7/11/25), and Staff #14 (4/27/20 & 6/4/25) are dated more than 60 months apart. Staff #3 and Staff #4 have not completed the mandated reporter training within 90 days of their date of hire (see LIS code sheet). Staff #7 did not complete the mandated reporter training within 90 days of their date of hire (see LIS code sheet). The training was completed on 7/13/25.

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 #10 contained an NSOR certificate dated 10/3/24, after date of hire, without a NSOR request on file at time of hire required for provisional hiring under the CPSL (SEE IS CODE SHEET).

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

Regulation: 3270.34(a)(6)

Description: Staff evaluations

Noncompliance Area: The two most recent staff evaluations on file for Staff #13 are dated 5/23/24 and 6/30/25, more than 12 months apart.

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: 3270.65

Description: Protective Outlet Covers 5 yrs. or less

Noncompliance Area: A protective receptacle cover was missing in an outlet in the Dreamers, Imagineers, and Voyagers rooms.

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

Regulation: 3270.66(a)

Description: Locked or inaccessible

Noncompliance Area: Hand sanitizer in the Penguins room and antibacterial wipes in the Pirates room, both labeled 'Keep Out of Reach of Children', were observed accessible 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: 3270.67(a)

Description: Trash removed once a day

Noncompliance Area: A trash can in the outside play space was observed with garbage from days prior.

Correction Required: Trash shall be removed from the facility at least once per day.

Regulation: 3270.67(d)

Description: Contaminated trash in closed plastic-lined receptacle

Noncompliance Area: In the Penguins and Panthers rooms, garbage cans containing napkins with human secretions lacked lids on the receptacles.

Correction Required: Trash that has been contaminated by human secretions or excrement shall be contained in closed, plastic-lined receptacles.

Regulation: 3270.76

Description: Building Surfaces

Noncompliance Area: In the Panthers Room, a piece of baseboard trim was missing on the cabinet in the corner and was not in good repair. Broken tiles with sharp edges located at the bottom of the walls and standing water on the floor and in a bucket were observed in the Boys Bathroom. Broken tiles with sharp edges located at the bottom of the walls and a leaking sink was observed in the Girls Bathroom. In the outside play space, standing water was observed in the toy bins and play tables.

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

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: Staff #1 was observed to be caring for children unsupervised. Staff #1 has not completed mandated reporter training within the last 60 months. This is evidenced by the previously documented mandated reporter training on file being dated 6/17/20.

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: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: Staff #3 and Staff #4 did not complete the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Pediatric First Aid/CPR training. Staff #3 completed the training on 6/5/25. Staff #4 completed the training on 6/15/25.

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: Staff #1 and Staff #2 have not completed mandated reporter training within the last 60 months. This is evidenced by the previously documented mandated reporter training on file being dated: Staff 1: 6/17/20 & Staff #2: 4/7/20.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Until such time as the required training has been completed, Staff #1 and Staff #2 must be supervised, when interacting with children, by an AGS who has completed the required training related to this citation. If there are no staff person(s) available to supervise Staff #1 and Staff #2, Staff #1 and Staff #2 may not work in a child-care position at the facility.

Regulation: 3270.32(a)/3270.192(2)(iii)

Description: Comply with CPSL/Exp, educ., training at facility

Noncompliance Area: The two most recent mandated reporter trainings on file for Staff #5 (4/17/20 & 6/13/25), Staff #6 (4/30/20 & 6/5/25), and Staff #7 (4/30/20 & 6/14/25) are dated more than 60 months apart.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

Regulation: 3270.95(a)/3270.95(b)

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

Noncompliance Area: The fire alarm 30-day test log includes test dates 12/17/24-1/28/25, 4/2/25-5/12/25 and 5/12/25-6/24/25, more than 30 days apart.

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)

Description: Supervised at all times

Noncompliance Area: Based on the self-reported noncompliance and staff interviews, Child #1 was left along in the Gym for approximately 2 minutes on 12/20/24 between 8:25 AM - 8:30 AM before bus dismissal while Staff #1 and Staff #2 were outside waiting for the buses with the rest of the supervision group.

Correction Required: Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Outdoor play space used by the facility is considered part of the facility premises.

Regulation: 3270.113(a)

Description: Supervised at all times

Noncompliance Area: Based on the self-reported noncompliance and staff interviews, Child #1 was left along in the Gym for approximately 2 minutes on 12/20/24 between 8:25 AM - 8:30 AM before bus dismissal while Staff #1 and Staff #2 were outside waiting for the buses with the rest of the supervision group.

Correction Required: *The legal entity must arrange for all facility staff to receive a minimum of two hours of training regarding supervision of children. The legal entity must receive DHS approval of the training content prior to scheduling the training.

Regulation: 3270.113(a)(1)

Description: Staff assigned to specific children

Noncompliance Area: Based on the self-reported noncompliance and staff interviews, Child #1 was left along in the Gym for approximately 2 minutes on 12/20/24 between 8:25 AM - 8:30 AM before bus dismissal while Staff #1 and Staff #2 were outside waiting for the buses with the rest of the supervision 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: 3270.51

Description: Similar Age Level

Noncompliance Area: Based on the self-reported noncompliance and staff interviews, Child #1 was left along in the Gym for approximately 2 minutes on 12/20/24 between 8:25 AM - 8:30 AM before bus dismissal while Staff #1 and Staff #2 were outside waiting for the buses with the rest of the supervision group.

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. IF USING TIERED LIS: The required staff:child ratios must be maintained at all times. The legal entity must submit documentation in a format approved by DHS proving that the facility is maintaining the required staff:child ratios at all times. The legal entity will confirm continuing compliance by sending copies of the documentation to the -------- Region Office on a weekly basis for a period of three months after DHS approves the documentation format.

Regulation: 3270.20(a)(1)

Description: Inpatient hospitalization or ER treatment of child

Noncompliance Area: Based on staff statements, on 10/11/24, child #1 was receiving care and bumped their head against a wall in the restroom and resulted in receiving emergency room treatment sometime between 10/11/24 to 10/13/24. The regional office was notified on 10/22/24 but was not within 24 hours of receiving 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.

Regulation: 3270.113(a)

Description: Supervised at all times

Noncompliance Area: Based on staff statements, on 10/11/24 at approximately 11:45am, child #1 bumped their head against a wall in the boy's restroom which resulted in a mild concussion. Staff person #1 was assisting another child with handwashing and did not observe child #1 bump their head due to staff person #1 was unable to see and properly supervise their group of assigned children on the other side of the restroom.

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: 3270.182(7)

Description: Reports of accidents, injuries and illnesses. Original report - parent same day Copy - facility accident file. Copy - child's file

Noncompliance Area: An incident report on file for child #1 who bumped their head that resulted in a mild concussion on 10/11/24 was completed and dated 10/14/24 and was not given to the parent on the day of the incident.

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: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: Magnatiles with broken plastic pieces were observed in the Dreamers classroom.

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: 3270.107

Description: Refrigerator

Noncompliance Area: Refrigerators in the Imagineers, Steelers, and Panthers classrooms lacked a thermometer.

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

Regulation: 3270.123(a)(1)

Description: Amount of fee

Noncompliance Area: The Financial Agreement form on file for Child #3 lacked amount of the fee to be paid by the parent/guardian.

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

Regulation: 3270.123(a)(2)

Description: Date fee to be paid

Noncompliance Area: The Financial Agreement form on file for Child #3 lacked the date the fee is to be paid by the parent/guardian.

Correction Required: An agreement shall specify the date on which the fee is to be paid.

Regulation: 3270.123(a)(3)

Description: Services proceeded

Noncompliance Area: The two most recent Child Service Reports on file for Child #1 are dated 10/26/23 and 5/31/24, more than 6 months apart.

Correction Required: The services to be provided to the family and the child, including the Department's approved form to provide information to the family about the child's growth and development in the context of the services being provided. The operator shall complete and update the form and provide a copy to the family in accordance with the updates regarding emergency contact information in § 3270.124(f) (relating to emergency contact information).

Regulation: 3270.123(a)(4)

Description: Arrival/departure times

Noncompliance Area: The Financial Agreement form on file for Child #1 lacked the child's arrival and departure times.

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

Regulation: 3270.123(b)/3270.182(8)

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

Noncompliance Area: The Financial Agreement forms for Child #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10 were the original and not a copy.

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)(2)

Description: Physician name, address, phone

Noncompliance Area: The Emergency Contact form for Child #1 lacked the address of physician or medical care. The Emergency Contact form for Child #5 lacked the phone number of physician or medical care.

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

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

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

Noncompliance Area: The Emergency Contact form for Child #9 lacked written parental consent for the facility to obtain 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)(6)

Description: Insurance coverage information

Noncompliance Area: The Emergency Contact form for Child #1 and Child #9 lacked the health insurance coverage and 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(b)(7)

Description: Name/address/phone release person

Noncompliance Area: The Emergency Contact form for Child #2, Child #5, and Child #7 lacked complete addresses for all listed release persons. The Emergency Contact form for Child #9 lacked a telephone number for all listed 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(f)/3270.181(c)

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

Noncompliance Area: The file for Child #1 contained parental reviews for the Emergency Contact form dated 3/31/23 and 10/1/23, more than 6 months apart. The most recent 6 month review signature for the Emergency Contact form on file for Child #7 is dated 7/12/24, more than 6 months after the previous 6 month review signature.

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

Description: Immunization record/Dismissal policy

Noncompliance Area: The file for Child #1 lacked documentation of written immunization record without a letter of exemption from the parent. Child #1 must be dismissed from care by close of business on 7/18/24, and may only return to care when the immunization record is updated or when a parent provides a written, signed exemption letter.

Correction Required: A health report shall include a review of the child's immunized status according to recommendations of the ACIP. The facility shall implement dismissal policies in accordance with the Department of Health regulation in 28 Pa. Code § 27.77 (relating to immunization requirements for children in child care group settings).

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: Staff #2 and Staff #17 were observed to be caring for children unsupervised. Staff #2 and Staff #17 have not completed the following pre-service training required prior to caring for children unsupervised: Pediatric First Aid/CPR

Correction Required: A facility shall be operated in conformity with applicable Federal and State laws and regulations. State agencies whose regulations may relate to the operation of a facility include the Department of Environmental Resources, the Department of Labor and Industry, the Department of Health, the Department of Education and the Department of Transportation. Conditions at the facility may not pose a threat to the health or safety of the children. Until such time as the required pre-service trainings are completed, Staff #2 and Staff #17 must be supervised, when interacting with children, by an AGS who has completed the required training related to this citation. If there are no staff person(s) available to supervise Staff #2 and Staff #17, Staff #2 and Staff #17 may not work in a child-care position at the facility.

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 most recent health assessment for Staff #4 (dated 3/21/21) and Facility Person #10 (dated 8/11/21), more than 24 months prior. The two most recent health assessments on file for Staff #6 (dated 10/26/20 and 1/4/23) and Staff #9 (dated 2/18/22 & 7/2/24), are more than 24 months apart. The file for Facility Person #11 lacked a valid staff 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. 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 Facility Person #14 lacked documentation of a Tuberculosis test result being completed within 12 months prior to date of hire (See LIS CODE SHEET). The Tuberculosis test result on file for Staff #14 dated 6/9/23.

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: 3270.181(c)

Description: Emergency info/agreement updated 6 mos

Noncompliance Area: The two most recent 6 month review signatures for the Financial Agreement form on file for Child #1 are dated 8/30/23 and 3/5/24, more than 6 months apart. The most recent review and update by the parent on the Financial Agreement forms for Child #3 (8/23/23) and Child #7 (8/23/23) are dated more than 6 months prior.

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 for Child #4 lacked written parental permission for the facility to administer minor first aid procedures.

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: The files for Staff #1 and Staff #16 only includes 1 written nonfamily reference letter. The files for Facility Person #13 and Facility Person #14 lacked 2 written nonfamily reference letters.

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: 3270.27(f)

Description: Emergency plan

Noncompliance Area: The facility lacked documentation of the Emergency Plan and subsequent plan updates being sent to the local municipality and County Emergency Management Services.

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

Regulation: 3270.31(e)

Description: Age and Training

Noncompliance Area: The file for Staff #4 lacked a minimum of 12 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: The two most recent fire safety trainings on file for Staff #3 (3/31/22 and 7/3/24), Staff #4 (dated 6/22/22 and 7/14/24), Staff #5 (dated 6/24/23 & 7/7/24), are more than 1 year apart.

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: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: The file for Staff #8 did not complete the following pre-service training within 90 days of hire (SEE IS CODE SHEET): Pediatric First Aid/CPR. The training was completed on 6/6/24.

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

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The file for Facility Person #11 (dated 6/13/23) Facility Person #14 (dated 7/16/24), and Facility Person #15 (dated 6/20/24) contained a Child Abuse clearance beyond their date of hire (SEE IS CODE SHEET). The file for Facility Person #14 lacked documentation of application of an NSOR certificate prior to date of hire required for provisional hiring under the CPSL (See IS CODE SHEET). The NSOR request for Facility Person #14 was dated 7/11/24.

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

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The two most recent Mandated Reporter trainings on file for Staff #4 are dated 1/25/18 and 7/8/24, more than 60 months apart. The disclosure statement on file for Staff #7 lacked a witness signature. The disclosure statement on file for Facility Person #15 was dated 7/23/24, which is beyond their date of hire (SEE IS CODE SHEET). Facility Person #10, Facility Person #11, Facility Person #12, and Facility Person #13 have not completed the Mandated Reporter training within 90 days of their date of hire (SEE IS CODE SHEET).

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

Regulation: 3270.66(b)

Description: Original container

Noncompliance Area: A unlabeled spray bottle containing cleaning materials was observed in the Imagineers Room.

Correction Required: Cleaning materials and other toxic materials shall be stored in an original labeled container or in a container that specifies the content. Toxics shall be stored away from food, food preparation areas and child care spaces.

Regulation: 3270.75(b)

Description: Inaccessible to children

Noncompliance Area: The first aid kit in the Adventurers Room was accessible to children.

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

Regulation: 3270.94(a)(4)

Description: Hypothetical locations

Noncompliance Area: The facility's fire drill log contained consecutive hypothetical locations of the fire for drills conducted on 10/31/23 and 11/17/23.

Correction Required: The Director or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that the hypothetical locations of the fire are rotated around the facility for each drill such that the hypothetical location is never the same for consecutive drills.

Regulation: 3270.95(a)/3270.95(b)

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

Noncompliance Area: The two most recent annual fire tests conducted by a fire professional are dated 6/20/23 and 7/5/24, more than 12 months apart.

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

Regulation: 3270.131(a)(3)/3270.182(1)

Description: Initial health report for older toddler/preschool no more than 1 year/Initial and subsequent health reports

Noncompliance Area: The file for child #2 contains an initial health assessment that was obtained late. The facility had a medical summary dated 4/2022 on file that appeared to be a health assessment but wasn't. The health assessment was due 11/9/22 and was obtained 2/2023.

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

Regulation: 3270.131(a)(3)/3270.182(1)

Description: Initial health report for older toddler/preschool no more than 1 year/Initial and subsequent health reports

Noncompliance Area: The file for child #1 contains a health assessment that appears to be age appropriate however, it is not dated.

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

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: The file for staff #1 contains health and safety update training that was completed late. The training was due 12/2022 and completed 1/2023.

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