Holly Hollis Group Day Care Home

Regulation: 3280.124(b)(4)/3280.182(1)

Description: Written consent/Initial and subsequent health assessments

Noncompliance Area: The emergency contact form for Child #1 lacked a written signature by the parent consenting to 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 must contain initial and subsequent health reports.

Regulation: 3280.124(f)/3280.181(c)

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

Noncompliance Area: The most recent emergency contact review on file for Child #2 is dated 10/1/25, more than 6 months prior to the date of inspection.

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: 3280.131(b)(2)

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

Noncompliance Area: The most recent health report form on file for Child #2 is dated 4/1/25, more than 12 months prior to the date of inpsection.

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: 3280.181(c)

Description: Emergency info/agreement updated 6 mos

Noncompliance Area: The most recent agreement form review on file for Child #2 is dated 10/1/25, more than 6 months prior to the date of inspection.

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: 3280.182(5)

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

Noncompliance Area: The emergency contact form for Child #1 lacked a written signature by the parent consenting to minor first aid procedures by facility staff.

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

Regulation: 3280.31(e)

Description: Age and training

Noncompliance Area: The file for Staff #1 lacked 8 out of 12 childcare training hours within the training timeframe of 12/2024-12/2025.

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

Regulation: 3280.31(e)(4)(i)

Description: Age and training

Noncompliance Area: Staff #1 and Staff #2-- have not completed Pediatric First Aid/CPR within the last 60 months. This is evidenced by the previously documented Pediatric First Aid/CPR certificate on file being dated 9/23/23.

Correction Required: Competence is the completion of training by a professional in the field of first-aid and 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: 3280.32(a)

Description: Comply with CPSL

Noncompliance Area: The most recent Child Abuse clearance on file for Staff #1 is dated 9/3/20, more than 60 months prior to the date of inspection. The most recent NSOR clearance on file for Staff #1 is dated 6/26/20, more than 60 months prior to the date of inspection. The most recent NSOR clearance on file for Staff #2 is dated 6/26/20, more than 60 months prior to the date of inspection.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). LACKING REQUIRED HIRING DOCUMENTS: Staff #1 and Staff #2 -- may not work in a childcare position at the facility.

Regulation: 3280.32(a)

Description: Comply with CPSL

Noncompliance Area: 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 9/10/20.

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

Regulation: 3280.65

Description: Protective Outlet Covers 5 yrs. or less

Noncompliance Area: In the Back Room, a yellow power strip was observed to be missing 3 outlet covers and the outlet to the right of the couch was observed to be missing 2 outlet covers.

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

Regulation: 3280.66(a)

Description: Locked or inaccessible - in original container

Noncompliance Area: In the front room, and Airwick air freshener, labeled keep out of the reach of children, was observed in a plug near the front window and accessible to children. In the front room, a container of Clorox wipes and a bottle of Lysol, labeled keep out of the reach of children, were observed on a shelf near the front window. In the front room, a bottle of hand sanitizer, labeled keep out of the reach of children, was observed on the counter and accessible to children. A box of Compound W, a container of various nail polishes, Jergens body lotion, Royal Crown hair dressing, Dr Teals Epsom Salt, Vaseline lotion, Repel bug spray, and an Airwick spray; all labeled keep out of the reach of children, were observed in the back room and accessible to children.

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 kept in a locked area or in an area inaccessible to children, and shall be stored away from food, food preparation areas and child care spaces.

Regulation: 3280.95(a)/3280.95(b)

Description: FIRE DETECTION/Staff responsibility

Noncompliance Area: The facility's fire detection log documented dates 10/1/25-11/1/25, 12/1/25-1/1/26, 1/1/26-2/1/26, 3/1/26-4/1/26, and 5/1/26-6/1/26, more that 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 primary staff person or designated staff person who is responsible for compliance with this chapter shall ensure the requirements in subsection (a) are met

Regulation: 3280.106

Description: Refrigerator

Noncompliance Area: The facility's refrigerator 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: 3280.123(a)

Description: Signed

Noncompliance Area: The file for Child #1 (present at the facility) lacked an agreement form.

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

Regulation: 3280.123(a)(3)

Description: Services proceeded

Noncompliance Area: The file for Child #3, enrolled more than 6 months, lacked a child service report form documenting the child's growth and development.

Correction Required: An agreement shall specify 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 at § 3280.124(f).

Regulation: 3280.124(a)

Description: Each child emergency contact person

Noncompliance Area: The file for Child #1 (present at the facility) lacked an emergency contact form.

Correction Required: Emergency contact information is required for each enrolled child. Emergency contact information shall reference who shall be contacted in an emergency.

Regulation: 3280.124(b)(3)

Description: Parent home/work address, phone

Noncompliance Area: The emergency contact form for Child #2 lacked the enrolling parent's home address. The emergency contact form for Child #3 lacked the enrolling parent's work address and work phone number.

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

Regulation: 3280.124(b)(6)

Description: Insurance coverage information

Noncompliance Area: The emergency contact form for Child #2 lacked the name of the child's health insurance.

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: 3280.124(b)(7)

Description: Name/address/phone release person

Noncompliance Area: The emergency contact form for Child #2 lacked the release person's phone number. The emergency contact form for Child #3 lacked the release person's address.

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

Regulation: 3280.124(f)/3280.181(c)

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

Noncompliance Area: The most recent 6-month review of the emergency contact form for Child #2 is dated 6/25/24, more than 6 months prior. The most recent 6-month review of the emergency contact form for Child #3 is dated 7/2/24, more than 6 months prior.

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: 3280.131(a)(3)/3280.182(1)

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

Noncompliance Area: The initial health report form on file for Child #3, enrolled on 6/30/24, is dated 10/10/22, more than 12 months prior to the child's start date.

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 must contain initial and subsequent health reports.

Regulation: 3280.14/3280.20

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: The facility's emergency plan lacked information regarding continuity of operations.

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: 3280.151(a)/3280.192(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 #2 is dated 9/21/22, more than 24 months prior.

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: 3280.171(c)

Description: Safe routes posted

Noncompliance Area: The operator did not have the pick-up/drop-off procedures posted at a conspicuous location in the childcare facility.

Correction Required: Written notification of safe routes shall be posted by the operator at a conspicuous location in the child care facility.

Regulation: 3280.181(c)

Description: Emergency info/agreement updated 6 mos

Noncompliance Area: The most recent 6-month review of the agreement form on file for Child #2 is dated 6/2/23, more than 6 months prior. The most recent 6-month review of the agreement form on file for Child #3 is dated 6/30/24, 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: 3280.26(a)(6)

Description: Emergency plan

Noncompliance Area: The facility did not have documentation that an emergency drill was completed.

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

Regulation: 3280.26(c)

Description: Training regarding plan

Noncompliance Area: The two most recent emergency plan training dates documented for Staff #2 are dated 7/24/23 and 6/25/25, more than 12 months apart.

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.

Regulation: 3280.26(d)

Description: Plan posted

Noncompliance Area: The operator did not have the emergency plan posted in a conspicuous location.

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

Regulation: 3280.31(e)

Description: Age and training

Noncompliance Area: The file for Staff #1 contained 2 out of 12 childcare training hours. The file for Staff #2 contained 0 out of 12 childcare training hours.

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

Regulation: 3280.32(a)

Description: Comply with CPSL

Noncompliance Area: The file for Staff #1 and Staff #2 contained an NSOR clearance dated 6/26/20, more than 60 months prior. The most recent mandated reporter training on file for Staff #2 is dated 9/1/19, more than 60 months prior.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services).. LACKING REQUIRED HIRING DOCUMENTS: Staff #1 and Staff #2-- may not work in a childcare position at the facility.

Regulation: 3280.65

Description: Protective Outlet Covers 5 yrs. or less

Noncompliance Area: In the front room, two electrical outlets lacked outlet covers. In the back room, the electrical outlet under the thermostat lacked an outlet cover.

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

Regulation: 3280.66(a)

Description: Locked or inaccessible - in original container

Noncompliance Area: In the bathroom, a d-Con insect trap, Lysol, Lysol Bathroom Foam, air freshener, and all-purpose cleaner, all labeled keep out of the reach of children, were observed behind the toilet and accessible to children. In the back-room area, a container of Clorox bleach, labeled keep out of the reach of children, was observed on a table and accessible to children.

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 kept in a locked area or in an area inaccessible to children, and shall be stored away from food, food preparation areas and child care spaces.

Regulation: 3280.76

Description: Building Surfaces

Noncompliance Area: In the backroom area, metal heating register grates were observed to be broken and not in good repair.

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: 3280.94(a)(1)

Description: Every 60 days

Noncompliance Area: The most recent fire drill documented on the facility's fire drill log is dated 4/12/25, more than 60 days prior.

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

Regulation: 3280.94(a)(5)

Description: Evacuation routes posted

Noncompliance Area: The operator did not have evacuation routes posted in a conspicuous location in the facility.

Correction Required: The primary staff person or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that evacuation routes are posted in a conspicuous location on each floor of the facility.

Regulation: 3280.95(a)

Description: FIRE DETECTION

Noncompliance Area: The most recent fire alarm test documented on the facility's fire detection log is dated 4/12/25, more than 30 days prior.

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: 3280.103

Description: Small Toys and Objects

Noncompliance Area: In the back of the Main Room, the surface of a composite wood shelf was observed to be peeling pieces less than 1 inch and accessible to children still placing objects in their mouths.

Correction Required: Toys and objects with a diameter of less than 1 inch, objects with removable parts that have a diameter of less than 1 inch, plastic bags and styrofoam objects may not be accessible to children who are still placing objects in their mouths.

Regulation: 3280.123(b)/3280.182(8)

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

Noncompliance Area: The Fee Agreement form on file for Child #2, Child #3, Child #4, and Child #5 was 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 must contain a copy of the initial agreement and subsequent written agreements between the parent and the operator. The parent receives the original agreement.

Regulation: 3280.124(a)

Description: Each child emergency contact person

Noncompliance Area: The Emergency Contact form for Child #4 lacked phone numbers for emergency contacts.

Correction Required: Emergency contact information is required for each enrolled child. Emergency contact information shall reference who shall be contacted in an emergency.

Regulation: 3280.124(b)(3)

Description: Parent home/work address, phone

Noncompliance Area: The Emergency Contact form for Child #5 lacked the enrolling parent's home address.

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

Regulation: 3280.124(b)(6)

Description: Insurance coverage information

Noncompliance Area: The Emergency Contact form for Child #5 lacked the name of the child's health insurance coverage.

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: 3280.124(b)(7)

Description: Name/address/phone release person

Noncompliance Area: The Emergency Contact form for Child #1 and Child #3 lacked a complete address for the release persons. The Emergency Contact form for Child #4 and Child #5 lacked a phone number for the release persons.

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

Regulation: 3280.124(c)

Description: Each child care space

Noncompliance Area: Emergency contact forms for the children present in the facility were not located in the Front Room or the Main Room.

Correction Required: When children are in the facility, emergency contact information shall be present in a child care space for children receiving care in the space.

Regulation: 3280.131(a)(4)

Description: Initial health report for school age; accordance with school attendance

Noncompliance Area: The initial health assessment on file for Child #5 (young school age) was not dated in accordance with requirements for medical examinations for school attendance in 28 Pa. Code 23.2 (relating to medical examinations) as it was completed when the child was three years old. (See LIS Code Sheet)

Correction Required: The initial health report for a school-age child must be dated in accordance with the requirements for medical examinations for school attendance in 28 Pa. Code § 23.2 (relating to medical examinations).

Regulation: 3280.14/3280.20

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: The facility did not have policies for shaken baby syndrome, abusive head trauma, and child maltreatment. The facility did not have a policy for Continuity of Operations in the emergency 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: 3280.171(a)

Description: Pick up and drop off points

Noncompliance Area: The facility did not have a written notification to local traffic safety authorities identifying their location and use of pedestrian and vehicular routes around the facility.

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

Regulation: 3280.181(c)

Description: Emergency info/agreement updated 6 mos

Noncompliance Area: The most recent fee agreement review for Child #5 was dated 6/2/23, exceeding the 6-month update period.

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: 3280.26(e)

Description: Letter to parents

Noncompliance Area: The facility did not have a parent letter explaining the emergency plan procedures.

Correction Required: The operator shall provide to the parent of each enrolled child a letter explaining the emergency procedures. The operator shall also provide to the parent of each enrolled child a letter explaining any subsequent update to the plan.

Regulation: 3280.31(e)

Description: Age and training

Noncompliance Area: Staff Person #1 (10.5 Hours) lacked a minimum of 12 hours of childcare training.

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

Regulation: 3280.31(e)(4)(i)

Description: Age and training

Noncompliance Area: The Pediatric First Aid/CPR training for Staff Person #1 exceeded the expiration date. (8/28/21-9/23/23)

Correction Required: Competence is the completion of training by a professional in the field of first-aid and 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: 3280.65

Description: Protective Outlet Covers 5 yrs. or less

Noncompliance Area: In the Front Room, a surge protector by the front window did not contain outlet covers. In the Main Room, and outlet next to the office door and by the Main Room entrance door did not contain outlet covers.

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

Regulation: 3280.75(c)

Description: Has all items

Noncompliance Area: The first aid kit in the Front Room did not contain soap and tweezers. The first aid kit in the Main Room did not contain soap, tweezers, scissors, and gloves.

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: 3280.76

Description: Building Surfaces

Noncompliance Area: In the Main Room, a vent cover on the floor was observed to have broken pieces.

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: 3280.94(a)(5)

Description: Evacuation routes posted

Noncompliance Area: The evacuation route was not posted in the facility in a conspicuous location.

Correction Required: The primary staff person or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that evacuation routes are posted in a conspicuous location on each floor of the facility.

Regulation: 3280.95(a)

Description: FIRE DETECTION

Noncompliance Area: The facility's fire detection log documented testing on 1/10/24-2/13/24 and 3/12/24-4/13/24, 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: 3280.102(a)

Description: Clean and good repair

Noncompliance Area: There was a cracked plastic toy bin and a cracked wooden hamburger bun in the right side of the Main Room. There was a changing pad used for diapering that had peeling plastic along the sides.

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: 3280.103

Description: Small Toys and Objects

Noncompliance Area: The facility had plastic bags located on the changing table that were accessible to the children and the changing pad had peeling plastic on the sides, which is less than 1 inch in size. The Main child care room is used for a variety of ages, including toddlers.

Correction Required: Toys and objects with a diameter of less than 1 inch, objects with removable parts that have a diameter of less than 1 inch, plastic bags and styrofoam objects may not be accessible to children who are still placing objects in their mouths.

Regulation: 3280.105(a)

Description: Clean, age appropriate

Noncompliance Area: The two cribs in Main Room used by the toddlers are not labeled for use by a specific child.

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

Regulation: 3280.123(a)

Description: Signed

Noncompliance Area: The agreement on file for Child #1 is not signed by the operator.

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

Regulation: 3280.123(a)(1)

Description: Amount of fee

Noncompliance Area: The agreement on file for Child #2 is missing the fee amount.

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

Regulation: 3280.123(a)(5)

Description: Designated release persons

Noncompliance Area: The agreements on file for Child #2 and Child #5 are missing release persons in case of an emergency.

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

Regulation: 3280.123(b)

Description: Parent receives original

Noncompliance Area: The files for Children #1, #2, #3, #4 and #5 were observed to contain the original agreements.

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

Regulation: 3280.124(b)(2)

Description: Physician name, address, phone

Noncompliance Area: The emergency contact form on file for Child #1 does not include the phone number for the child's pediatrician/source for 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: 3280.124(b)(3)

Description: Parent home/work address, phone

Noncompliance Area: The emergency contact form on file for Child #4 does not include the work address of the parent and the file for Child #5 does not include a complete home address for the parent.

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

Regulation: 3280.124(b)(7)

Description: Name/address/phone release person

Noncompliance Area: The emergency contact form on file for Child #1, #3, and #4 does not include a complete address 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: 3280.131(a)/3280.182(1)

Description: Health Information/Initial and subsequent health assessments

Noncompliance Area: The files for Child #2, Child #4 , and Child #5 were observed not to contain documentation of an initial health assessment within 60 days of enrollment (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. A child's record must contain initial and subsequent health reports.

Regulation: 3280.131(e)

Description: ACIP recommended immunization record

Noncompliance Area: The files for Child #2, #4, and #5 lacked an immunization record or exemption letter within the first 60 days from enrollment. Child #2, #4, and #5 must be dismissed from care by close of business on 7/11/23 and may only return to care when the immunization record is updated or when a parent provides a written, signed exemption letter.

Correction Required: 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: 3280.135(a)(3)

Description: Disposable diapers

Noncompliance Area: While observing a diaper change in the Main Room, staff were observed not throwing the soiled diaper away immediately after removing it. When the soiled diaper was thrown away, it was placed in an unlined trash can.

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

Regulation: 3280.135(b)

Description: Surfaces cleaned

Noncompliance Area: A diaper change was observed in the Main Room and the staff person did not sanitize the uncovered diaper changing surface after diapering.

Correction Required: Diaper changing surfaces shall be cleaned after each use by wiping the surface with a sanitizing solution or by changing a pad or other surface covering.

Regulation: 3280.151(a)/3280.192(3)

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

Noncompliance Area: The most recent health assessments on file for Staff #2 (8/1/2018) and Staff #3 (10/19/17) are over 24 months old and have not been updated.

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: 3280.183

Description: Confidentiality of Records

Noncompliance Area: Completed fee agreement forms were observed on top of the cubbies in the Gross Motor room, which are required to be kept confidential.

Correction Required: A facility person may not disclose information concerning a child or family, except in the course of inspections and investigations by agents of the Department.

Regulation: 3280.192(1)

Description: Name, address, and phone

Noncompliance Area: Staff #1 file lacked a documented home address.

Correction Required: A facility person's record shall include the name, address and telephone number of the facility person.

Regulation: 3280.192(6)

Description: Content of Records

Noncompliance Area: The file for Staff #1 and Staff #3 were observed not to have completed 12 hours of annual training within 12 months from date of hire (See LIS CODE SHEET). The file for Staff #2 contained 6 out of 12 hours of annual professional development training at the time of inspection.

Correction Required: A record shall include a copy of records of training required by the Department.

Regulation: 3280.24(a)

Description: Availability of certificate of compliance and applicable regulations

Noncompliance Area: The certificate of compliance that was posted in a conspicuous location, used by parents, was expired.

Correction Required: The facility's current certificate of compliance shall be posted in a conspicuous location used by parents. The operator shall provide the parent of each child enrolled with information on how to access the regulations in this chapter electronically and with instructions for contacting the appropriate regional child care office.

Regulation: 3280.26(a)(1)

Description: Emergency plan

Noncompliance Area: The emergency plan on site at the facility does not include shelter in place procedures during an emergency.

Correction Required: The facility shall have an emergency plan that provides for shelter of children during an emergency including lock-down, shelter in place at the facility and shelter at locations away from the facility premises.

Regulation: 3280.26(c)

Description: Training regarding plan

Noncompliance Area: Staff #1, #2, and #3 are missing documentation of emergency plan training at time of initial employment, on an annual basis, and at the time of each plan update.

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.

Regulation: 3280.26(d)

Description: Plan posted

Noncompliance Area: The emergency plan was not posted in the facility in a conspicuous location.

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

Regulation: 3280.31(f)

Description: Age and training

Noncompliance Area: Staff #1 did not complete the following required pre-service training within 90 days of hire, which was required to be completed per the updates to Chapter 3280 Group Child Care regulations, effective 12/19/20: Get Started with Center-Based Care; Building Blocks for Quality. Staff #2 (4/10/17) and Staff #3 (6/27/18) completed the original Health and Safety training but did not complete the required Health and Safety 1 hour update by 12/30/2022 per Announcement C-22-02.

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

Regulation: 3280.32(a)

Description: Comply with CPSL

Noncompliance Area: The 2 most recent mandated reporter training certificates on file for Staff #2 are dated 1/3/15 and 9/10/20, more than 60 months apart.

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

Regulation: 3280.32(a)/3280.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The record for Facility Person #1 contained an expired Child Abuse clearance (9/15/17) and FBI (9/6/17).clearance. The file also lacked a state police clearance. The record for Staff person #3 contained an expired state police clearance (9/6/17), and an expired FBI Clearance (9/6/17). Staff #1 & Staff #3 are unable to return to work after 7/11/2023 and may only return once updated clearances are obtained.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). LACKING REQUIRED HIRING DOCUMENTS: 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 #1 & Staff #3 are unable to return to work after 7/11/2023 and may only return once updated clearances are obtained

Regulation: 3280.34(b)/3280.192(2)(iv)

Description: Primary staff person's qualifications/Transcript, diploma and letters

Noncompliance Area: Facility Person #1 was categorized as a volunteer on the staff worksheet, but was observed performing the functions of a primary staff person by serving in the staff to child ratio. Facility person #1 lacks the required documented 2,500 hours of child care experience needed to meet the requirements of a primary staff person.

Correction Required: A primary shall have attained one of the following qualification levels specified at §3280.34(b)(1) - (5). 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: 3280.52(a)(1)/3280.113(a)(1)

Description: Primary staff person present/Staff assigned to specific children

Noncompliance Area: Upon entering the facility for the unannounced renewal inspection at 9:15 AM, staff person #2, a primary staff person, left a group of 8 children ranging in age from OT to SA alone with Facility person #1 (volunteer) in the main room while answering the door and later to retrieve something from the front room.

Correction Required: A primary staff person shall be present in a facility when six or fewer children are in care, unless the staff-child ratio specified in §3280.52(b) or (c) requires a second or third staff person. 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: 3280.65

Description: Protective Outlet Covers 5 yrs. or less

Noncompliance Area: In the right side of the Main Room, there was an electrical outlet located under the air conditioner that did not have an outlet cover. In the left side of the Main Room, there was an electrical outlet located on the wall that did not have an outlet cover. In the Gross Motor room, there was an extension cord, wall outlet, and power strip that were missing outlet covers.

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

Regulation: 3280.76

Description: Building Surfaces

Noncompliance Area: The ceiling in the gross motor room had multiple bulging cracks that spread across the ceiling and around a light fixture. In the right side of the Main Room, the floor in front an emergency exit door was made of plywood and depressed when person stood on it. A gap was observed around the floor grate that was located in front of the changing table in the middle of the main child care room that poses a risk for tripping. There was a loose wood plank on the wall with a protruding nail, which created pinch points directly behind toddler highchairs in the middle of the Main Room that could cause injury.

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: 3280.77(a)

Description: No peeling paint or plaster

Noncompliance Area: Peeling paint/plaster was present on the ceiling in the corner near the bathroom and in the corner by the exit door in the Main Room. In the Gross Motor room, there were multiple cracks and bulging plaster around a light fixture.

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

Regulation: 3280.94(a)(1)

Description: Every 60 days

Noncompliance Area: The fire drill 60-day test log includes test dates 10/3/22-12/10/22, 12/10/22-2/13/23, and 2/13/23-5/15/23, which are more than 60 days apart.

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

Regulation: 3280.94(a)(4)

Description: Hypothetical locations

Noncompliance Area: The fire drill log on file included multiple consecutive hypothetical locations of the fire used for the drill.

Correction Required: The primary staff person 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: 3280.94(a)(5)

Description: Evacuation routes posted

Noncompliance Area: The evacuation route was not posted in the facility in a conspicuous location.

Correction Required: The primary staff person or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that evacuation routes are posted in a conspicuous location on each floor of the facility.

Regulation: 3280.95(a)/3280.95(b)

Description: FIRE DETECTION/Staff responsibility

Noncompliance Area: The fire alarm 30-day test log includes test dates 10/13/22-11/13/22, 1/10/23-2/16/23, 3/13/23-4/13/23, 5/13/23-6/13/23, which are 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 primary staff person or designated staff person who is responsible for compliance with this chapter shall ensure the requirements in subsection (a) are met.

Regulation: 3280.102(a)

Description: Clean and good repair

Noncompliance Area: A doll house in the Main Room was observed to contain a cracked roof, causing a pinch point and sharp edge.

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: 3280.123(a)(5)

Description: Designated release persons

Noncompliance Area: The files for Child #2, #3 and #4 contained agreements which lacked the names of release persons.

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

Regulation: 3280.123(a)(6)

Description: Admission date

Noncompliance Area: The files for Child #1, #2, #3 and #4 contained agreement forms which lacked the enrollment dates for the children.

Correction Required: An agreement shall specify the date of the child's admission.

Regulation: 3280.124(b)(2)

Description: Physician name, address, phone

Noncompliance Area: The file for Child #1 contained an emergency contact form which lacked the telephone number of the child's medical provider.

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

Regulation: 3280.124(b)(7)

Description: Name/address/phone release person

Noncompliance Area: The file for Child #1 contained an emergency contact form which lacked a complete address for 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: 3280.124(c)

Description: Each child care space

Noncompliance Area: Emergency contact forms were not present in the Main Room for children receiving care in that space.

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: 3280.124(e)

Description: Written emergency plan posted

Noncompliance Area: 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 the Main 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: 3280.135(a)(3)

Description: Disposable diapers

Noncompliance Area: According to operator report, soiled diapers are placed in a bag before being taken outside to the garbage can. A hands-free covered can was not available for soiled diapers at the time of the inspection.

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

Regulation: 3280.151(a)

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

Noncompliance Area: The file for Facility Person #2 (volunteer) contained an initial health assessment dated more than 12 months in the past.

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: 3280.151(c)(2)

Description: Mantoux TB

Noncompliance Area: The file for Facility Person #2 (volunteer) contained documentation of initial tuberculosis screening by the Mantoux method which was dated more than 12 months in the past.

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: 3280.26(a)(6)

Description: Emergency plan

Noncompliance Area: Documentation of an emergency drill held between 12/19/20 and 12/19/21 was not available at the time of inspection.

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