Illumination School Age At Good Shephard Academy

Regulation: 3270.102(c)

Description: Outdoor equip.- protective surfacing

Noncompliance Area: The wood mulch around the monkey bars in the Outdoor Play Area was measured to be 7 inches. The wood mulch around the blue slide, that was located near the monkey bars, was measured to be 6.5 inches. Also, the wood mulch around the small jungle gym's curved yellow slide was measured to be 5.5 inches. The wood mulch around the straight yellow slide, that was attached to this same jungle gym, was measured at 7 inches and the wood mulch around the blue slide was measured to be 8 inches. At least nine inches of loose fill material is required around embedded equipment at all times.

Correction Required: Outdoor equipment that requires embedded mounting must be mounted over a loose-fill or unitary playground protective surface covering that meets the recommendations of the United States Consumer Product Safety Commission. The equipment must be anchored firmly and be in good repair.

Regulation: 3270.123(a)(3)/3270.123(a)(5)

Description: Services proceeded/Designated release persons

Noncompliance Area: Child #2 (see code sheet for date of admission) did not have any child service reports on file which provided information to the family about the child's growth and development in the context of the services being provided. The agreement on file for Child #1 did not specify the persons designated by a parent to whom the child may be released.

Correction Required: An agreement signed by the operator and the parent must specify the following: 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). An agreement shall specify the persons designated by a parent to whom the child may be released.

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: Staff #2 had not completed the following required pre-service training within 90 days of their date of hire (see code sheet for hire date): Pediatric First Aid and CPR. Staff #2 completed the training on 2/16/26.

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

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The only NSOR Clearance on file for Staff #3 was dated 5/1/26, which was after they began working with children. Staff #5 acknowledged that Staff #3 had direct contact and routine interaction with children prior to Staff #3 having the NSOR Clearance on file. Staff #4 had State Police Clearances on file dated 3/3/21 and 4/10/26; Child Abuse Clearances on file dated 3/4/21 and 4/7/26; DHS FBI Clearances on file dated 3/19/21 and 4/9/26; and NSOR Clearances on file dated 4/7/21 and 4/9/26. More than 60 months had lapsed between each clearance and Staff #5 acknowledged that Staff #4 had direct contact and routine interaction with children during the 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.

Regulation: 3270.65

Description: Protective Outlet Covers 5 yrs. or less

Noncompliance Area: Two electrical outlet covers near the service door in the cafeteria were observed to be missing protective receptacle covers. These outlets were accessible to preschoolers who were being supervised in that room.

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: Two Clean Check commercial sprays and two Dawn dish detergents labeled, "keep out of reach of children", were observed on a kitchen table. The kitchen is next to the cafeteria, which is a childcare space, and the doors to the kitchen were propped wide open, allowing children to have access to these items. Also, three Clean Check commercial sprays and one XtraCare hand sanitizer labeled, "keep out of reach of children", were observed on a metal shelf, near the condiments table, in the cafeteria. These items were also accessible to the children being supervised in that room.

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: 3270.76/3270.102(a)

Description: Building Surfaces/Clean and good repair

Noncompliance Area: The service door, that was next to the condiments table in the cafeteria, had a hole with sharp wooden pieces. A wall near the door in the Outdoor Play Area had a rusty metal grate with sharp edges. One toilet in the girls' restroom had an exposed bolt.

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: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: The jungle gym, with the telescope, had a sharp, cracked piece of plastic. The fence in the Outdoor Play Area had two exposed screws. One screw was located about elbow height and the other one was about knee height. The Girls' Restroom had three toilets, each with two exposed screws near their base. The Boys' Restroom had one toilet with two exposed screws near its base.

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: 3270.102(c)

Description: Outdoor equip.- protective surfacing

Noncompliance Area: The mulch around the monkey bars was measured to be 6 inches. The mulch around the slide and rock-climbing wall, that was located near the monkey bars, was measured to be 5 inches. Also, the mulch around the blue slide, that was part of the pirate ship jungle gym, was measured to be 5.5 inches. The mulch around the straight yellow slide, that was attached to this same jungle gym, was measured at 6.5 inches and the mulch around the curved yellow slide was measured to be 5.5 inches. At least nine inches of loose fill material is required around embedded equipment at all times.

Correction Required: Outdoor equipment that requires embedded mounting must be mounted over a loose-fill or unitary playground protective surface covering that meets the recommendations of the United States Consumer Product Safety Commission. The equipment must be anchored firmly and be in good repair.

Regulation: 3270.123(a)(4)

Description: Arrival/departure times

Noncompliance Area: The agreement on file for Child #2 was observed to be missing the child's departure time.

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

Regulation: 3270.27(a)(5)

Description: Emergency plan

Noncompliance Area: The emergency plan on file did not include accommodations for children with disabilities and chronic medical conditions. Staff #1 acknowledged that one child has a disability, and another child has a chronic medical condition.

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

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

Description: Age and Training

Noncompliance Area: Staff #4 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: 8/26/22 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(f)

Description: Health and Safety Training

Noncompliance Area: Staff person #5 had not completed the following required pre- service training within 90 days of their date of hire (see code sheet for hire date): Pediatric First Aid/CPR

Correction Required: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10. Until such time as the required training has been completed, staff person #5 must be supervised, when interacting with children at a minimum by, an AGS who has completed all preservice trainings and has all qualifications to care for children unsupervised. If there are no staff person(s) available to supervise staff person #5, staff person #5 may not work in a child-care position at the facility.

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: Staff person #5 has completed Pediatric first aid and CPR training, however the training was not completed through a Pennsylvania Quality Assurance System (PQAS) approved curriculum and the trainer has not provided documentation that they are PQAS-certified in that training curriculum.

Correction Required: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10. Until such time as the required training has been completed, staff person #5 must be supervised, when interacting with children at a minimum by, an AGS who has completed all preservice trainings and has all qualifications to care for children unsupervised. If there are no staff person(s) available to supervise staff person #5, staff person #5 may not work in a child-care position at the facility.

Regulation: 3270.66(a)

Description: Locked or inaccessible

Noncompliance Area: Ultra Defense hand sanitizer, labeled "keep out of reach of children", was observed in the Main Room on the dry erase board shelf. This was accessible to the children being supervised in that room.

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: Soap was observed to be missing from the first aid kit in the Main Room.

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: 3270.77(a)

Description: No peeling paint or plaster

Noncompliance Area: The purple pillar, located on the left side of the entrance to the Main Room, was observed to have cracked plaster near its base. Another purple pillar, located on the right side of the entrance to the Main Room, was observed to have peeling paint near its base.

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

Regulation: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: The fence in the Outdoor Play Area was observed to have one exposed bolt that was about hip height and two exposed bolts that were about knee height.

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(b)(3)

Description: Parent home/work address, phone

Noncompliance Area: The emergency contact information on file for Child #2 and Child #5 did not include a 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: 3270.151(a)/3270.151(c)(2)

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

Noncompliance Area: Staff person #1 (see code sheet for date of hire) had a tuberculosis screening test and health assessment on file dated 11/2022, which is more than 12 months prior to initial service at the facility. Staff person #1 also had a current tuberculosis screening test and health assessment on file dated 9/2024, which is after the individual began working 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: Staff person #4 had documentation on file that they completed 9 hours of annual child care training, and not the required 12 hours.

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: Staff person #4 had fire safety trainings on file dated 5/8/23 and 7/5/24. These trainings were required to be completed annually.

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: 3270.52

Description: Mixed Age Level

Noncompliance Area: On 9/25/2024, Staff person #5 was observed to be supervising a group of 12 children: 7 preschoolers and 5 young school-age children. This number of children requires at least 2 staff persons.

Correction Required: When children are grouped in mixed age levels, the age of the youngest child in the group determines the staff: child ratio and maximum group size in accordance with the requirements in § 3270.51 (relating to similar age level).

Regulation: 3270.52

Description: Mixed Age Level

Noncompliance Area: On 9/25/2024, Staff person #5 was observed to be supervising a group of 12 children: 7 preschoolers and 5 young school-age children. This number of children requires at least 2 staff persons.

Correction Required: When children are grouped in mixed age levels, the age of the youngest child in the group determines the staff: child ratio and maximum group size in accordance with the requirements in § 3270.51 (relating to similar age level). The Legal Entity shall create or update policies surrounding staff-to-child ratios for groups of similar and mixed age level children. These policies must also include that children will be counted as preschoolers until they attend the first day of Kindergarten. Additionally, these policies must include the staff: child ratios applicable to the program's operation. These policies must be submitted to the Northeast Regional Office for approval. Once approved, all existing staff and any new hires must be trained on the approved policy and documentation must be kept on file at the facility.

Regulation: 3270.66(d)

Description: Toxic plants not permitted

Noncompliance Area: Two purple and two yellow chrysanthemum plants were observed to be accessible to children in the Outdoor Play Space.

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

Regulation: 3270.94(a)(1)

Description: Every 60 days

Noncompliance Area: On 12/11/23, cert rep reviewed the fire drill log and the last fire drill was conducted on 9/11/23.

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.

Regulation: 3270.34(c)

Description: Employed and present 30 hrs/wk

Noncompliance Area: On 12/11/23, the director from another Illuminations facility acknowledged that a director was only present two to three days a week and not everyday since this program in not a school age only program and operates fewer than 30 hours per week.

Correction Required: A director shall be employed by a facility and be present at the facility site a minimum of 30 hours per week.

Regulation: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: On 10/11/23, a renewal inspection was conducted. The outside fence in the playground area have exposed, sharp bolts on the corners and gates and are accessible to children.

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

Regulation: 3270.121(a)

Description: Review policies and procedures

Noncompliance Area: On 10/11/23, a renewal inspection was conducted. The parent handbook did not contain a supervision policy and the director acknowledged it was 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)(3)/3270.124(b)(7)

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

Noncompliance Area: On 10/11/23, a renewal inspection was conducted. Child #2's emergency contact form did not list the parents work address, work phone number or the release persons address.

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

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

Description: Immunization record/Dismissal policy

Noncompliance Area: On 10/11/23, a renewal inspection was conducted. Child #1's immunization record indicates the child does not have the flu vaccine for 2022 and no exemption letter is in the child's file. The child is over six months of age. (Please see code sheet.)

Correction Required: A health report shall include a review of the child's immunized status according to recommendations of the ACIP. The facility shall implement dismissal policies in accordance with the Department of Health regulation in 28 Pa. Code § 27.77 (relating to immunization requirements for children in child care group settings). Child #1 will be removed from care by close of business on 10/11/23 until either the vaccination record is updated according to the ACIP recommended schedule or the parent provides an exemption letter.

Regulation: 3270.181(d)

Description: Dated signature affixed

Noncompliance Area: On 10/11/23, a renewal inspection was conducted. Child(ren) #2, 3,&4 's emergency contact form was not signed by the parents.

Correction Required: Following review, a parent shall attest to the accuracy of information in the emergency contact information and the financial agreement at each review by affixing a dated signature to the record.

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

Description: Fire safety - 1 yr.

Noncompliance Area: On 10/11/23, a renewal inspection was conducted. Staff person #1 and #2 have not completed annual fire safety training. Previous fire safety training was not on file. (Please see code sheet for DOH).

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: On 10/11/23, a renewal inspection was conducted. Staff person #2 has not completed the health and safety 1 hour update.

Correction Required: Staff person 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 person #2, will have until 12/12/23 to complete the required training.

Regulation: 3270.65

Description: Protective Outlet Covers 5 yrs. or less

Noncompliance Area: On 10/11/23, a renewal inspection was conducted. An uncovered and accessible outlet was observed in the cafeteria.

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: On 10/11/23, a renewal inspection was conducted. In the cafeteria, a container of Clorox wipes was observed on the window ledge and is 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: 3270.76

Description: Building Surfaces

Noncompliance Area: On 10/11/23, a renewal inspection was conducted. Cert Rep observed garbage in the outside play space along the building and is accessible to children.

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

Regulation: 3270.95(a)/3270.95(b)

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

Noncompliance Area: On 10/11/23, a renewal inspection was conducted. The fire detection system could not be tested due the facility being in a school. The facility provided an annual inspection report from Cintas which identified 2 items that did not pass inspection. At the time of the inspection, the facility did not provide documentation stating if the deficiencies have been corrected. A subsequent fire alarm test report dated 11/17/23 was received, which indicates the same two items failed. Additionally, proof of purchase for the fire detection system is not available.

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: 3270.111(a)/3270.111(b)

Description: Written plan/Posted in group space

Noncompliance Area: At the time of the inspection, the facility was unable to provide for review a written daily activity schedule. This activity schedule was not posted at the facility.

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

Regulation: 3270.111(c)

Description: Promote development

Noncompliance Area: A renewal inspection occurred at the facility. A physical site review was conducted. During the renewal inspection, there was no plan for developmentally appropriate activities being offered to children. As a result, children were observed throwing toys at fans, running through the classroom, and walking out of the classroom unsupervised by an adult, all while other children attempted to eat and complete homework.

Correction Required: Daily activities shall promote the development of skills, social competence and self-esteem. Daily experiences shall recognize the child as an individual and give some choice of activities that respect personal privacy, lifestyle and cultural background.

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

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

Noncompliance Area: A renewal inspection occurred at the facility. A physical site review was conducted. Staff # 3 and # 4 were unable to identify the exact number of children present, and the names of children they were caring for in their supervision group during the inspection. Children were also viewed walking in and out of the child care space and going in and out of the snack room unsupervised.

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

Regulation: 3270.123(a)

Description: Signed

Noncompliance Area: A renewal inspection occurred at the facility. A review of children's files was conducted. The agreement forms for children # 1, # 2, # 3, # 4 , # 5 and # 6 were not signed by either the parent or operator.

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

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

Description: Admission date/Application, admission, withdrawal dates

Noncompliance Area: A renewal inspection occurred at the facility. A review of children's files was conducted. The files of children # 1, # 2, # 3, # 4, # 5 and # 6 did not contain the children's dates of admission.

Correction Required: An agreement shall specify the date of the child's admission. A child's record shall contain the dates of application, admission and withdrawal of the child.

Regulation: 3270.124(b)(6)

Description: Insurance coverage information

Noncompliance Area: A renewal inspection occurred at the facility. A review of children's files was conducted. The file of child # 2 was missing documentation of the health insurance policy number.

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

Regulation: 3270.124(e)

Description: Written emergency plan posted

Noncompliance Area: At the time of the inspection, a plan for transporting a child to emergency care and staffing provisions in the event of an emergency were not provided for review or posted conspicuously.

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: 3270.134(a)

Description: Child's hands washed

Noncompliance Area: At the renewal inspection, children were viewed during snack time and the children did not wash their hands before eating.

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

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: Staff person # 1 has not completed the following required pre-service training within 90 days of their date of hire and was observed unsupervised (see LIS code sheet): Health and Safety Topics and pediatric first aid/CPR. Staff person # 3 has not completed the mandated reporter training within 90 days of their date of hire and was observed working unsupervised (see LIS code sheet).

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 # 1 and # 3 will have until 10/12/22 to complete the required training. Until such time as the required training has been completed, staff person # 1 and # 3 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 # 1 and # 3, staff person # 1 and # 3 may not work in a child-care position at the facility. A facility shall be operated in conformity with applicable Federal and State laws and regulations. State agencies whose regulations may relate to the operation of a facility include the Department of Environmental Resources, the Department of Labor and Industry, the Department of Health, the Department of Education and the Department of Transportation. Conditions at the facility may not pose a threat to the health or safety of the children. Until such time as the required pre-service trainings are completed, staff person # 1 and # 3 must be supervised, when interacting with children, by an (AGS) who has completed the required training related to this citation. If there are no staff person(s) available to supervise staff person # 1 and # 3, staff person # 1 and # 3 may not work in a child-care position at the facility.

Regulation: 3270.151(a)/3270.192(3)

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

Noncompliance Area: A renewal inspection occurred at the facility and a review of staff files was conducted. Staff # 3 and # 4 were observed caring for children and their files did not contain a health assessment or tuberculosis screening.

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

Regulation: 3270.151(c)(1)/3270.151(c)(2)

Description: Physical examination/Mantoux TB

Noncompliance Area: A renewal inspection occurred at the facility and a review of staff files was conducted. Staff # 3 and # 4 were observed caring for children and their files did not contain a health assessment or tuberculosis screening.

Correction Required: An adult health assessment must include a physical examination. 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: 3270.171(a)

Description: Pick-up and drop-off points

Noncompliance Area: At the time of the inspection, the facility was unable to provide documentation for review that the operator notified the local traffic safety authorities of the facility's safe routes for pick-up and drop-off procedures of the facility.

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

Regulation: 3270.171(b)/3270.171(c)

Description: Safe pick-up and drop-off in writing/Safe routes posted

Noncompliance Area: At the time of the inspection, the facility was unable to provide documentation for review of the facility's safe routes for pick-up and drop-off procedures of the facility.

Correction Required: Safe pedestrian crossways, pick-up and drop-off points and bike routes shall be appropriately determined in the vicinity of the facility and communicated to the children and parents in writing. Written notification of safe routes shall be posted by the operator at a conspicuous location in the child care facility.

Regulation: 3270.18(a)

Description: On file at facility

Noncompliance Area: At the time of the inspection, the facility was unable to provide a copy for review of their comprehensive general liability insurance.

Correction Required: The legal entity shall have comprehensive general liability insurance to cover the persons who are on the premises. A current copy of the insurance policy shall be on file at the facility.

Regulation: 3270.192(5)

Description: Two written references

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. The files of Staff # 3 and # 4 were missing two letters of written reference. Staff # 3 and # 4 were working at the facility at the time of this inspection. The file of Staff # 2 was missing 1 letter of written reference. Staff # 2 has worked in child care without two letters of reference in the 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: 3270.27(c)

Description: Training regarding plan

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. The files of Staff # 3 and # 4 did not contain documentation that these staff have reviewed the facility's emergency plan 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(f)

Description: Health and Safety Training

Noncompliance Area: Staff person # 1 and # 3 have not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Health and Safety Topics and pediatric first aid/CPR.

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 # 1 and # 3 will have until 10/12/22 to complete the required training. Until such time as the required training has been completed, staff person # 1 and # 2 must be supervised, when interacting with children, by an (AGS) who has completed the required training related to this citation. If there are no staff available to supervise staff person # 1 and # 3, staff person # 1 and # 3 may not work in a child-care position at the facility.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. The file for Staff #1 did not contain a signed/dated disclosure statement, State Police Clearance, FBI Clearance, or NSOR Clearance. The file for Staff #2 did not contain a date of signature on the disclosure statement, Child Abuse Clearance, or NSOR Certificate. The file for Staff #3 did not contain a date of signature on the disclosure statement, an FBI Clearance or NSOR Clearance, or proof that either clearance was requested. The file for Staff #4 did not contain a signed/dated disclosure statement, a completed State Police clearance, or proof that the clearance was requested. Staff # 4 did not complete mandated reporter training within 90 days of their hire date. Staff # 3 and # 4 were observed to be working unsupervised during the inspection. Staff # 3 and # 4 have worked in childcare without following the proper provisional hiring procedures. See Code Sheet for all dates of hire.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A provisional employee may not be permitted to work alone with children and must work within the vicinity of a permanent employee. A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Facility Person # 1, #2, # 3 and # 4 may not work in a child care position at the facility until all clearances are received.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. The file for Staff #1 did not contain a signed/dated disclosure statement, State Police Clearance, FBI Clearance, or NSOR Clearance. The file for Staff #2 did not contain a date of signature on the disclosure statement, Child Abuse Clearance, or NSOR Certificate. The file for Staff #3 did not contain a date of signature on the disclosure statement, an FBI Clearance or NSOR Clearance, or proof that either clearance was requested. The file for Staff #4 did not contain a signed/dated disclosure statement, a completed State Police clearance, or proof that the clearance was requested. Staff # 4 did not complete mandated reporter training within 90 days of their hire date. Staff # 3 and # 4 were observed to be working unsupervised during the inspection. Staff # 3 and # 4 have worked in childcare without following the proper provisional hiring procedures. See Code Sheet for all dates of hire.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Facility Person # 1, # 2, # 3 and # 4 may not work in a child care position at the facility until all clearances are received. The legal entity, director or any facility persons responsible for hiring and paperwork at the facility must register for and attend the Existing Provider Orientation presented by the NE Regional Office on 11/30/2022.

Regulation: 3270.33(a)/3270.192(2)(ii)

Description: Each staff person meets quals/Exp, educ., training prior to facility

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. The file of Staff # 3 and # 4 were missing proof of education. Staff # 3 and # 4 could not be appropriately qualified for a child care role at the facility. Staff # 3 and # 4 were working at the facility at the time of this inspection.

Correction Required: A staff person or a substitute staff person shall meet one of the applicable staff qualifications for the position in which the person is performing. A facility person's record shall include verification of child care experience, education and training prior to service at the facility.

Regulation: 3270.74

Description: Emergency Numbers Posted

Noncompliance Area: At the time of the inspection, a list of emergency telephone numbers was not viewed posted at the facility.

Correction Required: The telephone number of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted by each telephone in the facility.

Regulation: 3270.94(a)(1)

Description: Every 60 days

Noncompliance Area: At the time of the inspection, the facility was unable to provide a copy of the facility's fire drill log for review.

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.