Immaculate Conception School Preschool

Regulation: 3270.124(e)

Description: Written emergency plan posted

Noncompliance Area: At the time of the inspection, there was not a written plan identifying the means of transporting a child to emergency care and staffing provisions in the event of an emergency the before/after care child care space.

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: 3270.151(a)

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

Noncompliance Area: At the time of the inspection, staff person #2 did not update their health assessment every 2 years, as required. This is evidenced by the health assessment on file dated 9/19/23.

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: At the time of the inspection, staff person #3 did not have any hours of childcare training on file during their 9/24-9/25 training period. Staff person #5 only had 7.5 hours of childcare training on file during the 9/24-9/25 training period.

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: At the time of the inspection, staff persons #2 and #3 did not have documentation of fire safety training conducted by a fire protection professional within the past 12 months.

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

Regulation: 3270.33(a)

Description: Each staff person meets quals

Noncompliance Area: At the time of the inspection, staff person #3 did not have education on file. Staff person #4 did not have 2,500 hours of documented childcare experience to accompany the high school diploma on file. These staff could not qualify for the position they were performing.

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.

Regulation: 3270.94(a)(4)

Description: Hypothetical locations

Noncompliance Area: At the time of the inspection, the fire drill log did not contain a hypothetical location of the fire in the facility for the drill.

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

Regulation: 3270.95(a)/3270.95(b)

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

Noncompliance Area: At the time of the inspection, the last documented manual monthly monitoring of the fire detection system was done on 10/28/25 and the previous monitoring date of 9/16/25. This reflects a timeframe of longer than the required 30-day period for manually monitoring the fire detection system.

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

Regulation: 3270.111(a)/3270.111(b)

Description: Written plan/Posted in group space

Noncompliance Area: A written plan of daily activities and routines, including a time for free play, was not posted in the before/after care or Pre-K 4 rooms.

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: 3270.123(a)(5)

Description: Designated release persons

Noncompliance Area: The agreement on file for child #5 did not specify the persons designated by a parent to whom the child may be released.

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

Regulation: 3270.123(a)(6)

Description: Admission date

Noncompliance Area: The agreement on file for children #1, #2, #3 and #5 did not specify the date of the child's admission.

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

Regulation: 3270.124(b)(2)

Description: Physician name, address, phone

Noncompliance Area: The emergency contact forms for child #3 did not contain the name, address and phone number of the child's physician or source of medical care. The forms used for before/after care children did not include the name, address and telephone number of the child's physician or source of medical care.

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

Regulation: 3270.124(b)(3)

Description: Parent home/work address, phone

Noncompliance Area: The emergency contact forms for children #2, #3, #4 and #5 did not include the work addresses and telephone numbers of the enrolling parent. The forms used for before/after care children did not include the home and work addresses and telephone numbers of the enrolling parent.

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

Regulation: 3270.124(b)(6)

Description: Insurance coverage information

Noncompliance Area: The forms used for before/after care children did not include health insurance coverage and policy number for a child under a family policy or Medical Assistance benefits.

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

Regulation: 3270.124(b)(7)

Description: Name/address/phone release person

Noncompliance Area: The emergency contact form for children #1, #2, #3 and #4 did not include the address of the individual designated by the parent to whom the child may be released. The forms used for before/after care children did not include a name, address and telephone number of the individual designated by the parent to whom the child may be released.

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

Regulation: 3270.124(c)

Description: Each child care space

Noncompliance Area: Emergency contact forms were missing for the children present in the before/after care, Pre-K 3 and Pre-K 4 rooms.

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

Regulation: 3270.124(f)

Description: Updated every 6 months

Noncompliance Area: The emergency contact form for child #4 did not include a parent signature or date of review.

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.

Regulation: 3270.131(d)(7)

Description: Free from contagious/communicable disease

Noncompliance Area: The health report on file for child #1 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: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: The emergency plan did not 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.

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: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: The facility did not have a policy relating to child maltreatment.

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. Announcement C-22-03: Updates to Prevention of Shaken Baby Syndrome, Abusive Head Trauma, and Child Maltreatment Requirements states To maintain compliance with 45 CFR 98.41(a)(1)(vi), in addition to the training requirements, child care providers must have a policy and procedure to identify the prevention of shaken baby syndrome, abusive head trauma, and child maltreatment. The policy must include, but is not limited to: · Recognition of potential signs and symptoms of shaken baby syndrome and abusive head trauma; · Strategies for coping with a crying, fussing, or distraught child; and · Address the prevention and identification of child maltreatment.

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 did not receive a health assessment and TB screening until 9/30/24 and not at initial service in the facility. Staff person #2 did not receive a health assessment at initial service in the facility until 10/4/24 and does not have a TB screening on file (see LIS code sheet for date of hire) Staff person #3 does not have Tb screening dated within 12 months of initial service in the facility. This is evidenced by the TB screening on file dated 3/31/21 (see LIS code sheet for date of hire). Staff person #4 and staff person #6 did not receive a health assessment and TB screening until 10/4/24 and 10/9/24, respectively, which was not at initial service in the facility (See LIS code sheet for date of hire).

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: 3270.151(c)(3)/3270.151(c)(5)

Description: Exam communicable disease/Physician/CRNP assessment

Noncompliance Area: The health assessment for staff persons #7 and #10 did not include an examination for communicable diseases and the results of that examination or the physician's or CRNP's assessment of the person's suitability to provide childcare.

Correction Required: An adult health assessment must include an examination for communicable diseases and the results of that examination. An adult health assessment must include the physician's or CRNP's assessment of the person's suitability to provide child care.

Regulation: 3270.161(d)

Description: Potentially hazardous food refrigerated

Noncompliance Area: In both of the Pre-K 3 and Pre-K 4 classrooms, potentially hazardous food including yogurt, Lunchables, and tuna salad were observed in children's lunchboxes in their cubbies and were not refrigerated.

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

Regulation: 3270.182(3)/3270.182(5)

Description: Consent for emergency medical care required prior to admission/Consent for administration of minor first-aid required prior to admission

Noncompliance Area: The emergency contact form for child #2 did not include signed parental consent for administration of minor first-aid procedures by facility staff. The forms used for before/after care children did not contain signed parental consent for emergency medical care for the child. It also did not contain signed parental consent for administration of minor first-aid procedures by facility staff.

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

Regulation: 3270.192(5)

Description: Two written references

Noncompliance Area: Staff person #2 did not have two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person 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: 3270.20(e)/3270.182(7)

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

Noncompliance Area: The operator acknowledged that there was no facility file for accidents, injuries and illnesses involving a child in care at the facility.

Correction Required: Copies of reports of injury, death or fire shall be kept in a file at the facility. 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: 3270.27(a)(6)

Description: Emergency plan

Noncompliance Area: The operator did not have documentation of emergency drills being conducted annually at the facility.

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

Regulation: 3270.27(c)

Description: Training regarding plan

Noncompliance Area: Staff persons #1, #2 #3, #7, #8 and #10 do not have documentation of emergency plan training within 90 days of hire and then again when the plan was reviewed in September 2024 (see LIS code sheet for date 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)

Description: Age and Training

Noncompliance Area: Staff person #1, #2, #5 and #7 do not have any clock hours of the required 12 clock hours of childcare training on file during the 9/23-9/24 training period. Staff person #3, #8 and #10 only have 10 clock hours of childcare training during the 9/23-9/24 training period.

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 #1, #2, #3, #5, #7 and #10 do not have annual fire safety training on file. Staff person #8 has fire safety training on file dated 11/13/24 but none within the first 12 months of employment (see LIS code sheet for date of hire).

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 #1 and # 8 have not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Pediatric First Aid/CPR. Staff person #2 and #7 have not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Health and safety training requirements and Pediatric First Aid/CPR.

Correction Required: Staff person(s) shall complete professional development in the topics of 3270.31(f)(1-9), within 90 days of hire. Staff persons #1, #2, #7 and #8 will have until 12/11/24 to complete the required training. Until such time as the required training has been completed, staff persons #1, #2, #7 and #8 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 persons #1, #2, #7 and #8, staff persons #1, #2, #7 and #8 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: Staff person #1, #2, and #3 do not have dates of signature on their disclosure statements. Staff person #6 did not sign the disclosure statement until 10/9/24 and not at initial hire (see LIS code sheet for date of hire). Staff person #2 did not have a PA State Police clearance and FBI clearance on file. Staff person #2 also did not receive a Child Abuse Clerance and a NSOR certificate until 8/23/24 and 5/6/24, respectively, and was employed at the facility for more than 45 days (see LIS code sheet for date 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. Staff Person #2 may not work in a child care position at the facility.

Regulation: 3270.33(a)

Description: Each staff person meets quals

Noncompliance Area: Staff person #1, #2, and #7 did not have education and/or experience on file and therefore, could not qualify for the position they are performing.

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.

Regulation: 3270.34(a)(6)

Description: Staff evaluations

Noncompliance Area: Staff person #1, #2, #3, #7, #8 and #10 do not have written evaluations dated within the past 12 months on file and have been employed at the facility for more than 12 months.

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

Regulation: 3270.67(d)

Description: Contaminated trash in closed plastic-lined receptacle

Noncompliance Area: In the Pre-K 3 room, a trash can without a lid was observed and inside were tissues that were contaminated by human secretions.

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

Regulation: 3270.82(h)

Description: Handwashing signs

Noncompliance Area: The facility did not have handwashing signs posted by the toilets and sinks in the facility.

Correction Required: A facility person and an able child shall wash his hands after toileting and before eating. A sign on which this requirement is written shall be posted at each toilet, training chair, diapering area and sink in the facility.

Regulation: 3270.95(a)/3270.95(b)

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

Noncompliance Area: The operator did not have a manual monthly monitoring log for testing the fire detection system every 30 days.

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)

Description: Written plan

Noncompliance Area: There is no written daily schedule posted in the school age room.

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

Regulation: 3270.113(a)(1)

Description: Staff assigned to specific children

Noncompliance Area: Staff person #1 & staff person #2 were not assigned the responsibility of specific children.

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

Regulation: 3270.124(e)

Description: Written emergency plan posted

Noncompliance Area: There is no 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 the school age 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: 3270.25(a)

Description: Availability of certificate of compliance and applicable regulations

Noncompliance Area: Neither the regulations nor directions to access the regulations electronically are posted in the facility. There are no instructions for contacting the regional office posted in the facility.

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: 3270.52

Description: Mixed Age Level

Noncompliance Area: Staff person #1 & staff person #2 are not in ratio. There are 6 preschool aged children and 22 young school age children.

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: 3270.74

Description: Emergency Numbers Posted

Noncompliance Area: No emergency telephone numbers are posted by the telephone in the school age room.

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: 3270.75(a)

Description: In child care spaces

Noncompliance Area: There is no first aid kit in the before/after care room.

Correction Required: A first-aid kit shall be in a child care space.

Regulation: 3270.18(a)

Description: On file at facility

Noncompliance Area: The facility does not have 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(3)

Description: Health assessment, TB test

Noncompliance Area: Neither staff person #1 nor staff person #2 has a health assessment on file

Correction Required: 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: 3270.192(5)

Description: Two written references

Noncompliance Area: Staff person #1 does not have any written, non-family references. Staff person #2 has one written, non-family reference.

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