Illumination Early Learning Center

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

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

Noncompliance Area: During the inspection on 5/28/26, security camera footage from 5/14/26 was reviewed and showed that Child #1, a young toddler, exited the YT1 Room alone at 9:42:01 a.m. and wandered outside the classroom in the hallway area near the YT1 Room. At 9:42:22 a.m., Child #2, another young toddler, was observed leaving the YT1 Room alone, while at the same time, Staff #2 was observed exiting the OT Room, which is near the YT1 Room. At 9:42:27 a.m., Child #1 was observed re-entering the YT1 Room by themselves and Staff #2 was observed bringing Child #2 back to the YT1 Room at 9:42:35 a.m. Child #1 was left unsupervised for approximately 21 seconds in the hallway area outside of the YT1 Room. Staff #3 acknowledged that they did not know that Child #1 and Child #2 had exited the classroom alone. At the time of the incident, Child #1 and Child #2 were assigned to Staff #3's primary 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. 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. TIERED LIS: 1. Children must be supervised at all times. This portion of the plan shall have an immediate correction date. 2. The Legal Entity/Director will update the supervision policy for the facility. At a minimum, the policy must include the following: 1. How proper supervision will be maintained when a staff is alone with a group of children, but needs to assist a child 1:1. 2. What protocols will be followed to ensure that children do not leave the childcare space alone. 3. What preparations staff can make in advance (i.e. gathering supplies, making commonly needed items more accessible) to limit the potential for a lapse in supervision. 4. How staff will position themselves within the classroom to prevent lapses in supervision and possible elopement during diaper changes, at times when a staff needs to retrieve items that may put the children out of their direct line of vision, and when a staff is distracted by someone else, such as a parent. 5. How and when staff will use team communication to ensure that children are always supervised. This updated supervision policy must be submitted to the Department prior to implementation for approval. Once approved by the Department, the director will ensure that all current employees and any new hires are trained on this policy. Documentation of the training must be maintained at the facility. The operator shall provide a date by when this will be completed. 3. The legal entity must arrange for all facility staff employed as of the date of the training to receive a minimum of 3 hours of PQAS-approved in-person or live training regarding supervision and ratios of children. The legal entity must receive DHS approval of the training content prior to scheduling the training. The operator shall provide a date by when this will be completed.

Regulation: 3270.151(c)(3)

Description: Exam communicable disease

Noncompliance Area: A review of staff files was conducted during the inspection. On the health assessment for Staff #2, the doctor indicated a "YES" answer for question #2, indicating that the staff person had communicable diseases, and no additional information was provided, as required.

Correction Required: An adult health assessment must include an examination for communicable diseases and the results of that examination.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: Staff #2 (see code sheet for first day with children) had a Pennsylvania State Police Clearance on file dated 3/13/26. This clearance was a volunteer clearance, but it was being used for employment purposes, which is not permitted. Also, during the inspection on 5/28/26, Staff #2 was observed having direct contact and routine interaction with children in the Outdoor Play Area.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A staff person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Staff person #2 cannot work in a childcare position that involves direct contact and routine interaction with children until all required paperwork is completed and on file 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 detection system was not tested at least once every 30 days. The most recent fire detection system testing log on file was observed to be 4/15/26. However, another fire detection system test should have occurred by 5/15/26, and there was no proof of this on file.

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: 3270.95(a)/3270.95(b)

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

Noncompliance Area: The fire detection system was not tested at least once every 30 days as indicated by the most recent fire detection system testing log being dated 1/14/26.

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: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: A chalkboard in the Large Outdoor Play Area had a rough rusted metal rim around it. This posed a potential scratching hazard.

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: 3270.124(f)/3270.181(c)

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

Noncompliance Area: The emergency contact and financial agreement information on file for Child #2 were dated 4/5/2025 and 11/5/2025. More than 6 months had lapsed since a parent last reviewed, updated, and signed the emergency contact and financial agreement forms.

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)(7)

Description: Free from contagious/communicable disease

Noncompliance Area: The health report on file for Child #10, which was dated 6/26/25, did not include a statement that the child is able to participate in childcare and appears to be free from contagious or communicable disease.

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: 3270.151(a)

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

Noncompliance Area: The only health assessment on file for Staff #13 (see code sheet for first day with children) was dated May 13, 2024, and was not completed within the required 12-month period prior to Staff #13 providing initial services in a childcare setting.

Correction Required: A facility person providing direct care who comes into contact with the children or who works with food preparation shall have a health assessment conducted within 12 months prior to providing initial service in a child care setting and every 24 months thereafter. A health assessment is valid for 24 months following the date of signature, if the person does not contract a communicable disease or develop a medical problem.

Regulation: 3270.31(e)

Description: Age and Training

Noncompliance Area: Staff #4 had eight hours of annual child care trainings on file, and not the required 12 clock hours of child care trainings.

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

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: During the Renewal Inspection on 1/14/26, Staff #5 was observed having direct contact and routine interaction with children in the Preschool 2 Classroom. Staff #5 provided a comprehensive background check, dated 6/17/24, for a state where the staff previously resided. This clearance indicates that it is not portable, which was confirmed via phone call with that state, and appropriate out-of-state clearances were not obtained prior to the staff working with children at this facility. Staff #10 had State Police Clearances on file dated 12/9/2020 and 1/7/2026. Also, Staff #10 had Child Abuse Clearances on file dated 12/14/2020 and 1/8/2026. More than 60 months had lapsed between the clearances. Staff #19 acknowledged that Staff #10 had routine interaction and direct contact with children during this lapse.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A staff 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. TIERED LIS: 1. The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A staff person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Staff person #5 cannot work in a childcare position that involves direct contact or routine interaction with children until all required paperwork is completed and on file at the facility. This portion of the plan shall have an immediate correction date. 2. The Legal Entity/Director will create a tracking system (i.e. spreadsheet, calendar) or a method for ensuring that clearances do not lapse. Also, the Legal Entity/Director will create a procedure for ensuring that the correct out-of-state clearances are obtained prior to individuals having direct contact or routine interaction with children. The Legal Entity/Director will submit the updated tracking system/method and procedure to the Northeast Regional Office for approval. Once approved, any staff who handle clearances related paperwork must be trained on the approved tracking system/method and procedure, and this training must be documented and placed in their files. The Legal Entity/Director will provide a date by when this will be completed.

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

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

Noncompliance Area: CONTINUED NONCOMPLIANCE: On 8/12/2025, Staff #1 was supervising a group of 8 preschoolers as they walked from the Preschool 1 classroom, through a locked hallway, to the Preschool 2 classroom. During this transition, Child #1 and Child #2 were left unsupervised for approximately one minute in the locked hallway. The children were initially found by Staff #2, Facility Person #21, and a non-staff maintenance worker, and they stayed with the children until Staff #1 arrived. Staff #1 returned the children to the Preschool 2 classroom. This incident was self-reported to the Regional Office on 8/13/25. An acceptable plan of correction was received indicating that children will be supervised at all times. On 9/17/25, the facility self-reported that on this date, Child #3 was left in the Young Toddler 2 classroom unsupervised. A review of security camera footage showed that at 9:39 a.m. on 9/17/25, Staff #3 and Staff #4 exited the Young Toddler 2 Classroom with a group of eight young toddlers. At approximately 10:02 a.m., Child #3 was observed exiting the same classroom alone. The child wandered unsupervised in the hallway for about one minute before re-entering the classroom. At 10:03 a.m., a non-staff member found Child #3 and gave them to Staff #5. Child #3 was unsupervised for an estimated 24 minutes. At the time of the incident, Child #3 was assigned to Staff #3's primary 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. 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. TIERED LIS: 1. Children must be supervised at all times. This portion of the plan shall have an immediate correction date. 2. For a period of 3 months, the facility shall have no lapses in supervision. The operator shall demonstrate compliance on unannounced visits over the next 3 months. This portion of the plan requires a date of correction that is at least 3 months from the date of the submission of the plan of correction. The operator shall provide a date by when this will be completed.

Regulation: 3270.103

Description: Small Toys and Objects

Noncompliance Area: The sensory table near the door in the Older Toddler Room was observed to have uncooked black beans and silver plastic pieces that were measured to be less than an inch in diameter. This table was accessible to the older toddlers who were being supervised in that room, and Staff #17 acknowledged that some of these children were 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: 3270.113(a)/3270.113(a)(1)

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

Noncompliance Area: On 8/12/2025, Staff #1 was supervising a group of 8 preschoolers as they walked from the Preschool 1 classroom, through a locked hallway, to the Preschool 2 classroom. During this transition, Child #1 and Child #2 were left unsupervised for approximately one minute in the locked hallway. The children were initially found by Staff #2, Facility Person #21, and a non-staff maintenance worker, and they stayed with the children until Staff #1 arrived. Staff #1 returned the children to the Preschool 2 classroom. This incident was self-reported to the Regional Office on 8/13/25.

Correction Required: Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Outdoor play space used by the facility is considered part of the facility premises. Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises. TIERED LIS: 1. Children must be supervised at all times. This portion of the plan shall have an immediate correction date. 2. The Legal Entity/Director must update existing supervision policies/procedures. The policies and procedures must include the following requirements: Staff will be able to see, hear, direct and assess the children at all times. Staff will know the whereabouts of the children in their assigned group. Staff will be physically present with the children in their assigned group at all times. Staff who are supervising children alone or with multiple staff will know their supervision roles and the correct procedure for positioning themselves in order to maintain appropriate supervision. During periods of transition where children are walking through locked areas (i.e. a locked hallway), staff will follow procedures to ensure they have all of the children in their supervision group at all times. These procedures must outline the supervision steps that the staff will take before, during, and after they proceed through a locked area. The Legal Entity/Director will submit the updated policies/procedures to the Northeast Regional Office for approval. Once approved, all existing staff and new hires must be trained on the approved policies and procedures, and it must be documented in their files. The operator shall provide a date by when this will be completed. 3. For a period of 2 months, the facility shall have no occurrences of non-compliance related to supervision of children. The operator shall demonstrate compliance on unannounced visits over the next 2 months. This portion of the plan requires a date of correction that is at least 2 months from the date of the submission of the plan of correction. The operator shall provide a date by when this will be completed.

Regulation: 3270.123(a)(3)

Description: Services proceeded

Noncompliance Area: Child #1, #2, #3, #5, #8, #9, and Child #10 had current child service reports on file. However, the facility was not using the Department's child service report or the Department's other approved forms. Child #4 had an approved child service report on file dated 11/25/24. However, an updated child service report was required to be completed by 5/2025.

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

Regulation: 3270.131(d)(7)

Description: Free from contagious/communicable disease

Noncompliance Area: Child #8 had had a current health assessment on file dated 7/29/25, but it was missing required information, such as the child's ability to participate in childcare and whether or not they appeared to be free from contagious or communicable disease.

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: 3270.161(d)

Description: Potentially hazardous food refrigerated

Noncompliance Area: A mermaid lunchbox was observed in a mermaid bookbag that was hanging from a wooden cubby shelf in the Older Toddler Room. This lunchbox contained a meat and cheese pasta meal. These perishable food items were required to be refrigerated.

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

Regulation: 3270.166(4)

Description: Bottles labeled

Noncompliance Area: A bottle in the Young Toddler 2 Room, that had a purple lid and clear body, which belonged to Child #11, was observed to be missing a label with the child's name on it.

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

Regulation: 3270.171(a)

Description: Pick-up and drop-off points

Noncompliance Area: The facility provided proof that on 6/1/2022, they notified the local traffic safety authorities in writing of the location of the facility and the program's use of pedestrian and vehicular routes around the child care facility. However, this was required to be done annually.

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

Regulation: 3270.27(e)

Description: Letter to parents

Noncompliance Area: The facility provided parents with a letter explaining the emergency procedures. However, this letter did not include accommodations for toddlers. This information was required since the facility provides care for toddler-aged children.

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)(i)

Description: Age and Training

Noncompliance Area: Staff #3, #9, #19, and #20 did not complete pediatric first-aid and CPR training prior to the previous trainings expiring after 2 years. This is evidenced by the following training dates: 9/28/22 and 10/21/24.

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

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

Description: Fire safety - 1 yr.

Noncompliance Area: Staff #10 had fire safety trainings on file dated 9/21/23 and 1/9/25. More than a year had lapsed between the trainings.

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: 3270.65

Description: Protective Outlet Covers 5 yrs. or less

Noncompliance Area: In the hallway outside of the Young Toddler 2 Room, there was an extension cord power strip that was next to a fish tank. This power strip had one uncovered electrical outlet that was accessible to children 5 years of age and younger.

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: A Neutrogena beach defense sunscreen that was labeled, "keep out of reach of children," was observed in a dinosaur bookbag that was hanging from a wooden cubby shelf in the Older Toddler Room. Also, in the hallway outside of the Young Toddler 2 Room, there was a white cubby shelf with a brown container. This container had Tetra AquaSafe, a Jungle Brand "no more algae tank buddies", and Pimafix. These items were labeled, "keep out of reach of children." In the same container, there was a Fins First aquatic substrate that was labeled, "not suitable for children". All of these items were 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: 3270.75(c)

Description: Has all items

Noncompliance Area: The first-aid kit in the Young Toddler 2 Room was observed to be missing tweezers.

Correction Required: A first-aid kit must contain the following: soap, an assortment of adhesive bandages, sterile gauze pads, tweezers, tape, scissors and disposable, nonporous gloves.

Regulation: 3270.76/3270.77(a)

Description: Building Surfaces/No peeling paint or plaster

Noncompliance Area: A playhouse in the Toddler Outdoor Play Area had used wet tissues on the ground. The Large Outdoor Play Area had plastic bags and used tissues on the ground near the helmet shelves. Also, a wooden step that was used to access one of the green slides in the Large Outdoor Play Area had chipping wood that posed a potential scratching hazard. Additionally, the Young Toddler 1 Room was observed to have peeling paint on the wall near the story books.

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

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: Staff person #7 had not completed the following required pre-service trainings within 90 days of their date of hire (see code sheet for date of hire): Pediatric first aid/CPR.

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

Regulation: 3270.106(f)

Description: 2 feet apart

Noncompliance Area: Child #1 was observed to be sleeping on a cot in the Young Toddler 1 Room. One side of the cot was against the wall and another side of the cot was against play furniture. Child #2 and #3 were also observed to be sleeping on cots in the Young Toddler 1 Room. One side of each of their cots were against the wall and another side of each of their cots were against shelving. These children did not have at least 2 feet of spacing on three sides of their cots.

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

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

Noncompliance Area: On 4/25/2025, Staff #2 and Staff #14 were supervising a group of 19 preschoolers on the outdoor playground. Camera footage showed that Staff #14 was using their cell phone and had their back turned towards the children instead of consistently supervising the children. Also, camera footage showed that, at approximately 12:00 p.m., Child #1 was left unsupervised on the outdoor playground, for approximately 8 minutes, when the group transitioned from the outdoor play area to go inside the facility. Staff #2 was responsible for this child at the time of the incident. The child was found by Staff #1, and they stayed with the child until Staff #13 arrived. Staff #13 returned the child to the classroom. This incident was self-reported to the Regional Office on 4/25/2025.

Correction Required: Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Outdoor play space used by the facility is considered part of the facility premises. Children must be supervised at all times. Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises. TIERED LIS: 1. Children must be supervised at all times. This portion of the plan shall have an immediate correction date. 2. The Legal Entity/Director must update existing supervision policies/procedures. The policies and procedures must include the following requirements: Staff will be able to see, hear, direct and assess the children at all times. Staff will know the whereabouts of the children in their assigned group. Staff will be physically present with the children in their assigned group at all times. Staff will know the appropriate procedures for situations of transition, including transitions to and from the playground, restroom, other childcare spaces, and anywhere else outside the childcare space while maintaining appropriate supervision requirements. The facility must also create and implement policies regarding cell phone usage when staff are supervising children. The Legal Entity/Director will submit the updated policies/procedures to the Northeast Regional Office for approval. Once approved, all existing staff and new hires must be trained on the approved policies and procedures, and it must be documented in their files. The operator shall provide a date by when this will be completed. 3. The legal entity must arrange for all staff to receive three hours of training regarding supervision and ratios of children. The legal entity must receive DHS approval of the training content prior to scheduling the training. The operator shall provide a date by when this will be completed.

Regulation: 3270.27(c)

Description: Training regarding plan

Noncompliance Area: Initial emergency plan training was not on file for Staff #6 and #8. This was required to be completed within 90 days of hire.

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

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

Description: Age and Training

Noncompliance Area: Staff #1, #4, and #5 did not complete pediatric first aid/CPR training prior to the previous trainings expiring after 2 years. This is evidenced by the following training dates: 9/28/22 and 10/21/24.

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

Regulation: 3270.95(a)/3270.95(b)

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

Noncompliance Area: The fire detection system was not tested at least once every 30 days as indicated by the following fire detection system testing logs that were on file: 10/4/24 and 11/4/24

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

Regulation: 3270.123(a)

Description: Signed

Noncompliance Area: The agreement on file for Child #2 was not signed by the operator.

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

Regulation: 3270.124(b)(3)

Description: Parent home/work address, phone

Noncompliance Area: The emergency contact information on file for Child #2 did not include an enrolling parent's work phone number.

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

Regulation: 3270.124(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 observed in the Indoor Play Room.

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

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: The emergency plan that was on file did not include a 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. The OCDEL ANNOUNCEMENT C-22-04 requires facility emergency plans to include continuity of operations during and after an emergency that includes continuing daily operations, 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.

Regulation: 3270.151(a)/3270.151(c)(2)

Description: 12 months prior to service and every 24 months thereafter/Mantoux TB

Noncompliance Area: Staff #2 had health assessments on file dated 2/7/22 and 7/29/24; Staff #3 had health assessments on file dated 6/21/21 and 7/31/23; Staff #6 had health assessments on file dated 1/19/22 and 4/29/24; and Staff #12 had health assessments on file dated 11/7/21 and 2/29/24. For each staff, more than 24 months had lapsed between health assessments. Staff #5 (see code sheet for date of hire) provided an initial health assessment dated 7/2/24, which is after the individual began working with children. Staff #5 also had an initial tuberculosis screening dated 4/20/22, which is more than 12 months prior to initial service at the facility. Staff #9 (see code sheet for date of hire) did not have a TB test on file, which was required prior to initial service at the facility. Staff #22 (see code sheet for date of hire) provided an initial health assessment dated 11/1/22, and an initial tuberculosis screening dated 11/3/22, which is more than 12 months prior to initial service at the facility.

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

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

Description: Fire safety - 1 yr.

Noncompliance Area: Staff #1 had fire safety trainings on file dated 9/26/22 and 1/19/24; Staff #3 had fire safety trainings on file dated 9/26/22 and 1/18/24; Staff #6 had fire safety trainings on file dated 9/26/22 and 7/8/24; and Staff # 12 had fire safety trainings on file dated 5/8/23 and 7/5/24. For each staff, more than a year had lapsed between trainings.

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: Staff persons #10 and #11 had not completed the following required pre-service training within 90 days of their date of hire (see code sheet for date of hire): pediatric first aid/CPR Staff person #18 has not completed the following required pre-service training within 90 days of their date of hire (see code sheet for date of hire): pediatric first aid

Correction Required: Staff person(s) shall complete professional development in the topics of 3270.31(f)1-10 within 90 days of hire. Staff person #18 will have until September 11, 2024 to complete the required training. Until such time as the required training has been completed, staff person #18 must be supervised, when interacting with children, by an AGS, who has completed the required training related to this citation. If there are no staff available to supervise staff person #18, staff person #18 may not work in a child-care position at the facility.

Regulation: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: Staff person #17 had not completed mandated reporter training prior to the previous training expiring. This is evidenced by the documented mandated reporter trainings on file being dated 10/4/18 and 3/27/24.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to Child Protective Services).

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The DHS FBI clearances on file for Staff #1 were dated 4/1/19 and 4/5/24. More than 60 months had lapsed between the clearances which were required to be updated by 4/1/24.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A staff 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: Staff #13 had written evaluations on file that were dated 3/28/23 and 4/16/24. More than 12 months had lapsed between evaluations.

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: 3270.66(d)

Description: Toxic plants not permitted

Noncompliance Area: Multiple toxic plants and shrubs, including two hydrangea and eight ligustrum ovalifolium shrubs, were observed to be accessible to children in the Large Outdoor Play Area.

Correction Required: Toxic plants are not permitted in a child care space.

Regulation: 3270.76/3270.102(a)

Description: Building Surfaces/Clean and good repair

Noncompliance Area: A pink and silver colored tricycle that was in the Large Outdoor Play Area was observed to have a crack in the seat. Four cracked, plastic white balls were observed in the Toddler Outdoor Play Area. The bamboo fence that surrounded the Toddler Outdoor Play Area was observed to have a cracked piece of bamboo.

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. 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: 3270.95(a)/3270.95(b)

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

Noncompliance Area: The fire detection system was not tested every 30 days as indicated by the following fire detection system logs that were on file: 7/5/24 to 8/5/24

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: 3270.106(f)

Description: 2 feet apart

Noncompliance Area: On 11/29/23, cert rep observed in the preschool and older toddler classroom's during nap time that several children's cots did not have 2 feet of space on 3 sides.

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

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

Noncompliance Area: On 11/29/23, staff person #1 in the older toddler classroom could not identify or name all the children in their assigned group. Staff #1 reported that she took over supervision from another staff earlier and had not reviewed the supervision cards.

Correction Required: Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Outdoor play space used by the facility is considered part of the facility premises. Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises. The Legal Entity will establish a supervision policy. The policy will include how the facility will demonstrate their knowledge and ability to adequately supervise children at all times. The policy must focus on ensuring that each child is seen, heard, assessed and able to be directed at all times. The policy must include how the facility will ensure appropriate supervision during transition times and while in the outdoor play area. The policy must also include a plan for each staff to be assigned the responsibility for supervision of specific children, including the requirement that the staff person know the names and whereabouts of the children in their assigned group and be physically present with the children in their group on the facility premises and on facility excursions off the facility premises. The legal entity must submit the policy to regional office for approval. All existing staff and new hires must be trained on the policy and sign an acknowledgment that must be kept on file.

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

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

Noncompliance Area: On 11/29/23, staff person #1 in the older toddler classroom could not identify or name all the children in their assigned group. Staff #1 reported that she took over supervision from another staff earlier and had not reviewed the supervision cards.

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

Regulation: 3270.183(b)

Description: No information disclosed

Noncompliance Area: On 10/11/23, cert rep was at the facility for a complaint investigation. The operator admitted to posting a child on social media that the parent had signed a no photos agreement.

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

Description: Exp, educ., training prior to facility/Two written references

Noncompliance Area: On 10/11/23, staff #1 was observed providing child care (see code sheet for DOH). The staff file does not contain educational experience and two non-family references.

Correction Required: A facility person's record shall include verification of child care experience, education and training prior to service at the facility. 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: 3270.94(a)(9)

Description: Written record

Noncompliance Area: On 10/11/23, cert rep observed fire drill log to be out of compliance. The last fire drill on record is dated 7/7/23, however, at the last renewal inspection a fire drill was conducted on 8/15/23. The operator did not document the drill.

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

Regulation: 3270.95(a)/3270.95(b)

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

Noncompliance Area: On 10/11/23, the operator reported that they have not tested the fire detection system in the last 30 days due to a new building management and other businesses affected. The drill indicates the system was tested on 7/7/23 however, the test and drill conducted in the presence of the inspector on 8/15/23 is not documented. The operator provided an inspection report but it is dated 05/06/22 which is more than one year ago.

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

Regulation: 3270.106(f)

Description: 2 feet apart

Noncompliance Area: A renewal inspection was conducted on 8/15/23. The inspector observed during naptime in rooms 141,142, PreK2, and PreK that several cots did not have 2 feet of space on three sides.

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: 3270.121(a)

Description: Review policies and procedures

Noncompliance Area: A renewal inspection was conducted on 8/15/23. The parent handbook did not contain a supervision policy. Director acknowledged that this not given to the parents in writing.

Correction Required: The operator shall review with the parent, at the time of application, 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)(6)

Description: Insurance coverage information

Noncompliance Area: During the renewal inspection on 08/15/23, child #4's emergency contact form did not contain the health insurance policy number.

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

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

Description: Immunization record/Dismissal policy

Noncompliance Area: A renewal inspection was conducted on 8/15/23. Child #3's immunization record indicates the child does not have the Rotavirus, DTAP, HIB, Pneumococcal or Polio vaccine and no exemption letter is in child's file. The child is in need of their 2-month immunizations. This is not in accordance with the ACIP recommended schedule.

Correction Required: A health report shall include a review of the child's immunized status according to recommendations of the ACIP. 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 #3 will be removed from care by close of business the day. The operator is notified until either the vaccination record is updated according to the ACIP recommended schedule or the parent provides an exemption letter.

Regulation: 3270.131(d)(7)/3270.131(d)(8)

Description: Free from contagious/communicable disease/Age appropriate screenings complete

Noncompliance Area: A renewal inspection was conducted on 08/15/23. The health report for Child#2 was not fully completed and did not indicate if the child is able to participate in child care and appears to be free from contagious or communicable disease. The form also did not indicate that age-appropriate screenings recommended by the American Academy of Pediatrics were conducted.

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. A health report shall include a statement that age-appropriate screenings recommended by the American Academy of Pediatrics were conducted since the time of the previous health report required by this section.

Regulation: 3270.133(6)

Description: Written consent

Noncompliance Area: A renewal inspection was conducted on 08/15/23. Child #1's medication in the PreK room did not have written consent from the parent to administer medication.

Correction Required: A parent shall provide written consent for administration of medication or a special diet.

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: A renewal inspection was conducted on 08/15/23. Reports for child injuries/illnesses were not kept in a facility file. The director acknowledged that they are not kept in a facility file.

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: 3270.25(a)

Description: Availability of certificate of compliance and applicable regulations

Noncompliance Area: A renewal inspection was conducted on 8/15/23. The facility did not provide the parent of each child enrolled with information on how to access the regulations electronically and with instructions for contacting the appropriate regional child care office.

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

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: During the renewal inspection on 8/15/23, Staff #1 (see code for date of hire) has a Health and Safety update dated 7/5/23. These were required to completed by 12/30/22. Staff #2 did not complete the health and safety 1-hour update.

Correction Required: Staff person(s) shall complete professional development in the topics of 3270.31(f)(1 -- 10): 1 hour health and safety update and center based health and safety training, respectively. Staff #2 will have until 8/30/23 to complete the required training.

Regulation: 3270.95(a)/3270.95(b)

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

Noncompliance Area: A renewal inspection was conducted on 8/15/23. The fire system testing was not completed every 30 days; (2/10/23-3/16/23, 3/16/23-4/21/23, and 5/10/23-6/28/23).

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: 3270.151(a)/3270.151(c)(2)

Description: 12 months prior to service and every 24 months thereafter/Mantoux TB

Noncompliance Area: While at the facility unannounced for the renewal inspection on 9/16/22 the inspector observed that staff #4 and staff #8 did not obtain the required health assessment and TB screening prior to providing direct care with children.

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

Regulation: 3270.31(e)

Description: Age and Training

Noncompliance Area: While at the facility unannounced for the renewal inspection on 9/16/22 the inspector observed that staff #4, #5, #8 did not have an annual minimum of 12 clock hours of child care training as is required.

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: While at the facility unannounced for the renewal inspection on 9/16/22 the inspector observed that staff #3,#6, #9, #10, were all employed longer than one year and did not have fire safety training on file as is required.

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: While at the facility unannounced for the renewal inspection on 9/16/22 the inspector observed that staff #6 did not obtain the required health and safety training within 90 days of hire.

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

Regulation: 3270.31(f)(10)

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

Noncompliance Area: While at the facility unannounced for the renewal inspection on 9/16/22 the inspector observed that staff #5 did not obtain the necessary pediatric first-aid and pediatric cardiopulmonary resuscitation within the first 90 days of hire as is required.

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

Regulation: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: While at the facility unannounced for the renewal inspection on 9/16/22 the inspector observed that staff #1had been a resident of New York within the last five years and did not have the appropriate out of state clearances. Staff #2 was observed to have resided in New Jersey within the last five years and did not have the appropriate out of state clearances.

Correction Required: The Child Protective Services Law(CPSL) was revised to include the requirement for all facility persons, volunteers, and household members who may have resided out of Pennsylvania within the previous five years to obtain a state criminal history check, state sex offender registry check, and a state child abuse and neglect history check from the state (s) in which they resided in the previous five years. This was required beginning September 30, 2019. Current facility persons and volunteers were required to meet these requirements beginning July 1, 2020.The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Facility Person # 1 and #2 may not work in a child care position at the facility.

Regulation: 3270.94(a)(1)/3270.95(b)

Description: Every 60 days/Director or designated staff person ensure compliance

Noncompliance Area: While at the facility unannounced for the renewal inspection on 9/16/22 the inspector observed the fire drill and detection log and noted that the facility was not conducting fire drills and manual testing consistently.

Correction Required: The Director 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.The Director or designated staff person who is responsible for compliance with this chapter shall ensure the requirements under subsection (a) are met.

Regulation: 3270.151(a)

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

Noncompliance Area: Facility person #2 has a date of hire listed as 8/16/21 and currently does not have a health assessment on file

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: 3270.192(5)

Description: Two written references

Noncompliance Area: Facility person #2 has only one written reference on file

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

Regulation: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: Facility person #1 has a PA Criminal Clearance on file dated 9/16/16 and is more than 60 months old

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