Just About Kids

Regulation: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: In the outdoor play space, a red slide was observed to have a long crack at the bottom of the slide. This crack created a sharp edge, as well as a potential pinch point.

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: 3270.103

Description: Small Toys and Objects

Noncompliance Area: On the "3" side of Room 2/3, two white bins and one brown bin were observed on the floor next to the gate. The bins contained art supplies, including several bottles of "Sargent Art Tempera Paint" and "Creatology Glitter Paillettes." These items had warning labels that read "Choking Hazard for Children Under Three Years of Age." These items were stored within reach of younger toddlers who use the gated area as means to enter/exit the "2" side of the room, creating a potential choking hazard.

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: 3270.104(a)

Description: Clean, good repair, proper size

Noncompliance Area: In Room 2/3, a large tube-style television was observed to be stored on a purple rolling media cart in the play area on the "3" side of the room. The television was not strapped down or stabilized in any manner, and wires were hanging down from the back, creating a toppling hazard. A second smaller, flatscreen-style television was observed in Room 4. This television was stored on top of a toy shelf and was not anchored, posing another toppling risk.

Correction Required: Furniture must be durable, safe, easily cleaned and appropriate for the child's size, age and special needs.

Regulation: 3270.131(a)

Description: Health information

Noncompliance Area: The file for Child #1 contained an initial health assessment dated more than 60 days after the child's first day of attendance at the facility.

Correction Required: The operator shall require the parent of an enrolled child, including a child, a foster child and a relative of an operator or a facility person, to provide an initial health report no later than 60 days following the first day of attendance at the facility.

Regulation: 3270.21

Description: General Health and Safety

Noncompliance Area: Two microwaves were observed to be dirty and in poor repair in the facility. These microwaves are used by staff to heat meals that children bring in from home. In Room 2/3, a microwave was observed above the sinks on the "3" side of the room. The inside of this microwave was worn and had burnt, rusty buildup on the interior surfaces. In Room 4, another microwave was observed on the counter. The interior of the microwave was dirty and had areas of what looked to be flaking rust above the cooking space.

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

Regulation: 3270.31(e)

Description: Age and Training

Noncompliance Area: The files for Staff Person #1 and Staff Person #2 did not include documentation of the full 12 hours of annual child care training.

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: The files for Staff Person #1 and #2 included NSOR clearances dated more than 60 months apart (both: 11/14/2019-3/4/2025).

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

Regulation: 3270.77(a)

Description: No peeling paint or plaster

Noncompliance Area: On the "2" side of Room 2/3, a small area of damaged, flaking plaster was observed at the corner of the walls decorated with the words "Autumn" and "Winter." In the same room, another small area of damaged, flaking plaster was observed on the wall behind the crib.

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

Regulation: 3270.104(a)

Description: Clean, good repair, proper size

Noncompliance Area: On 4/7/25, child #1, a 10-month old infant was seated in a highchair being fed by staff #1 who was standing directly in front of the child. The child turned, shifting their weight in the chair, causing the highchair to topple to the ground with the child. Upon review of the highchair it was determined that the highchair lacked the four corner stabilizer feet on the base. The highchair lacked a wide base without the stabilizer feet.

Correction Required: Furniture must be durable, safe, easily cleaned and appropriate for the child's size, age and special needs.

Regulation: 3270.105

Description: High Chairs

Noncompliance Area: On 4/7/25, child #1, a 10-month old infant was seated in a highchair being fed by staff #1 who was standing directly in front of the child. The child turned, shifting their weight in the chair, causing the highchair to topple to the ground with the child. Upon review of the highchair it was determined that the highchair lacked the four corner stabilizer feet on the base. The highchair lacked a wide base without the stabilizer feet.

Correction Required: High chairs shall have a wide base and a T-shaped safety strap.

Regulation: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: In room 2 there was an electronic soccer goal that had wires sticking out which could be a hazard 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: 3270.113(b)

Description: No physical punishment

Noncompliance Area: According to staff statements, Staff #1 placed Child #1 roughly into their crib causing the child's mouth to bleed.

Correction Required: A facility person may not use any form of physical punishment, including spanking a child.

Regulation: 3270.113(d)

Description: No harsh language

Noncompliance Area: According to staff statement, Staff #1 uses a harsh tone to speak to the children and makes inappropriate statements to them and in their presence, such as "Oh my God, I can't do this today!" and yelling, "Please stop crying!" out of frustration.

Correction Required: A facility person may not use harsh, demeaning or abusive language in the presence of children.

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: The file for Staff person #1 completed their Health and safety training part 1 on 2/18/25 and part 2 on 2/19/25 which were past their 90 days of hire (see LIS code sheet).

Correction Required: A facility shall be operated in conformity with applicable Federal and State laws and regulations.State agencies whose regulations may relate to the operation of a facility include the Department of Environmental Resources, the Department of Labor and Industry, the Department of Health, the Department of Education and the Department of Transportation. Conditions at the facility may not pose a threat to the health or safety of the children.

Regulation: 3270.182(7)

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

Noncompliance Area: An incident report was not filled out for Child #1 when it was observed their mouth was bleeding.

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: 3270.31(e)

Description: Age and Training

Noncompliance Area: The file for staff person #1 was lacking the required 12 hours of annual child care training.

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: The file for staff person #1 was lacking West Virginia out of state clearances and they currently live out of state.

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 their out of state clearances are obtained. 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--- may not work in a child care position at the facility.

Regulation: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: There was a cracked blue pencil box in the pre-k room. There were 2 cracked clear bins in the pre-k room. There was a blue plastic bin with cracked handles in the preschool room. There was a cracked plastic red bin in the infant room.

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)(6)

Description: Insurance coverage information

Noncompliance Area: The file for child # 1 lacked the health insurance policy number on the emergency contact form.

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: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: The facility policy to identify the Prevention of Shaken Baby Syndrome, Abusive Head Trauma, and Child Maltreatment lacked the Child Maltreatment statement.

Correction Required: A facility shall be operated in conformity with applicable Federal and State laws and regulations.State agencies whose regulations may relate to the operation of a facility include the Department of Environmental Resources, the Department of Labor and Industry, the Department of Health, the Department of Education and the Department of Transportation. Conditions at the facility may not pose a threat to the health or safety of the children.

Regulation: 3270.151(a)

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

Noncompliance Area: The file for staff # 1 contained a current health assessment dated 2/7/24. It was not obtained within 24 months of the previous assessment dated 1/13/22.

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

Regulation: 3270.161(d)

Description: Potentially hazardous food refrigerated

Noncompliance Area: There were 2 lunchboxes out of the refrigerator that contained yogurt.

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

Regulation: 3270.171(a)

Description: Pick-up and drop-off points

Noncompliance Area: The operator did not notify local traffic safety authorities within the past year, of the location of the facility and the program's use of pedestrian and vehicular routes around the child care 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: 3270.31(e)

Description: Age and Training

Noncompliance Area: The file for staff # 2 lacked 8 out of 12 required hours of annual child care training, from 12/19/22 to 12/19/23. The file for staff # 3 lacked 1 out of 12 required hours of annual child care training, from 12/19/22 to 12/19/23.

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

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

Description: Age and Training

Noncompliance Area: The file for staff # 3 contained a current Pediatric First Aid and Pediatric CPR training dated 5/3/23. The training was not obtained prior to the expiration of the previous certificate dated 2/10/21.

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: The files for staff # 1 contained a current Pediatric First Aid and Pediatric CPR certificate that was taken after 90 day of initial employment. Staff person(s) shall complete professional development in the topics of 3270.31(f)(1 -- 10) within 90 days of hire. The certificates for staff # 3 is date 10/4/22.

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(2)(iii)

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

Noncompliance Area: The file for staff # 1 contained a current mandated reporter training certificate dated 2/2/24 that was not obtained within 60 months of the previous certificate dated 11/8/17.

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

Regulation: 3270.123(a)(3)/3270.124(f)

Description: Services proceeded/Updated every 6 months

Noncompliance Area: The files for child #1, 2, 3 and 4 lacked updated child service reports.

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). 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(b)(1)

Description: Infant: updated health report every 6 months

Noncompliance Area: The file for child # 3, a young toddler, contained a current health report dated 2/20/23. That was not updated at least every 6 months. The prior report was dated 2/15/22.

Correction Required: The operator shall require the parent to provide an updated health report at least every 6 months for an infant or young toddler.

Regulation: 3270.131(b)(2)

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

Noncompliance Area: The file for child # 4 lacked an updated health report. The last report was dated 2/18/22.

Correction Required: The operator shall require the parent to provide an updated health report at least every 12 months for an older toddler or preschool child.

Regulation: 3270.151(a)/3270.192(3)

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

Noncompliance Area: The two most recent Health Assessments, in the files for Staff #1, Staff #3, and Staff #4, exceeded the 24-month renewal requirement.

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: 3270.31(e)

Description: Age and Training

Noncompliance Area: The file for staff #1, lacked 6 out of 12 required hours of annual childcare training, from 12/19/20 to 12/18/21.

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

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: The files for staff # 1, 2, 3, 4 and 5 lacked the updated health and safety training, by 12/30/22.

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: Staff person #5 had not completed the following required pre-service training within 90 days of their date of hire (see IS Code Sheet): Pediatric First Aid and Pediatric CPR. Certificate is dated 10/4/22.

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: The file for staff # 1 contained a current mandated reporter training certificate dated 2/28/21 that was not obtained within 60 months of the previous certificate dated 10/5/15. The file for staff # 2 contained a current mandated reporter training certificate dated 2/27/21 that was not obtained within 60 months of the previous certificate dated 10/2/15. The file for staff # 3 contained a current mandated reporter training certificate dated 2/26/21 that was not obtained within 60 months of the previous certificate dated 10/3/15. The file for staff # 4 contained a current mandated reporter training certificate dated 2/27/21 that was not obtained within 60 months of the previous certificate dated 10/4/15.

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

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The files for staff # 1 and # 4 lacked a current FBI clearance. The last FBI clearance in the files for staff # 1 and # 4 are dated 5/3/16.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). LACKING REQUIRED HIRING DOCUMENTS: Facility Persons #1 and #4 may not work in a child care position at the facility. 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 and #4 may not work in a child care position at the facility.

Regulation: 3270.114

Description: Outdoor Activity

Noncompliance Area: According to staff report, infants are not being taken outdoors daily.

Correction Required: Weather permitting, children shall be taken out doors daily.

Regulation: 3270.131(e)(1)

Description: Exemption documentation from parent/guardian

Noncompliance Area: The file for Child #1 contained record of immunization history which lacked a current influenza vaccination.

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

Regulation: 3270.151(a)

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

Noncompliance Area: The file for Staff #3 contained consecutive health assessments dated more than 24 months apart.

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

Regulation: 3270.27(a)(1)

Description: Emergency plan

Noncompliance Area: The observed emergency plan lacked accommodations for shelter of children during lock-down.

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

Regulation: 3270.27(a)(5)

Description: Emergency plan

Noncompliance Area: The observed emergency plan lacked accommodations for infants and toddlers.

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: 3270.27(a)(6)

Description: Emergency plan

Noncompliance Area: Documentation of an emergency drill being held in the past year was not available during the inspection.

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

Regulation: 3270.31(e)/3270.192(2)(iii)

Description: Age and Training/Exp, educ., training at facility

Noncompliance Area: The file for Staff #5 contained 11 of the 12 required hours of annual child care training between 12/19/20 and 12/19/21.

Correction Required: A staff person shall obtain an annual minimum of 12 clock hours of child care training.A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The files for Staff #1, #2, #3, #4 and #5 contained consecutive state police and child abuse clearances dated more than 60 months apart.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services).A facility person's record shall include 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 #--- may not work in a child care position at the facility.

Regulation: 3270.74

Description: Emergency Numbers Posted

Noncompliance Area: Emergency telephone numbers were not posted by the telephone in the Main PS/OT 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: 3270.95(a)/3270.95(b)

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

Noncompliance Area: The proof of purchase for the interconnected fire detection system was not available at the time of the inspection.

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

Regulation: 3270.113(a)(1)

Description: Staff assigned to specific children

Noncompliance Area: SECOND VIOLATION. Three staff meetings were required by the correction date in the 10/15/21 cited unannounced inspection summary. Two of the three required meetings were held at the time of the correction date, 2/28/22.. **Upon entry to the facility at 7:35 AM on 10/15/21, cert rep observed Staff #1 sitting at the front desk. Upon entry into the PS Room at 7:40 AM, cert rep observed Staff #1 with 9 children -- 7 PS and 2 YSA. When asked whom was in room with these children when Staff #1 was observed at the front desk, Staff #1 stated no one. Staff #1 stated she was just coming in for the day and added Staff #2 had been in the room but left to answer the door for a parent. PREVIOUSLY CITED ON SIN-00194647 ON 10/15/21.

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. In the future, staff persons will be assigned responsibility for supervision of specific children. Staff will remain physically present with the children in her group. One additional staff meeting shall be held within one month of the accepted date of the plan of correction to include a period for discussion of supervision violations and corrections. The agenda and meeting minutes will be provided to DHS the business day following the meeting.

Regulation: 3270.25(b)

Description: Post the inspection summary

Noncompliance Area: During the implementation visit on 1/5/22, SIN-00192453, which contained violations not yet verified as implemented and/or corrected, was not posted in a conspicuous location used by parents.

Correction Required: The operator shall post a copy of each inspection summary issued by the Department in a conspicuous location used by parents. The inspection summary shall remain posted until an agent of the Department verifies that each regulatory noncompliance item cited on the inspection summary has been corrected.

Regulation: 3270.51

Description: Similar Age Level

Noncompliance Area: At 9:08 AM on 1/5/22, Staff #1 was observed walking from the main room to the front door with 10 PS children. She allowed entry of one additional PS child, without parental accompaniment, and walked 11 PS children back to the main room, giving her a total of 11 PS children in her group.

Correction Required: When children are grouped in similar age levels, the following maximum child group sizes and ratios of staff persons apply: Infants 1:4 with a maximum group size of 8; Young toddlers 1:5 with a maximum group size of 10; Older toddlers 1:6 with a maximum group size of 12; Preschool children 1:10 with a maximum group size of 20; Young school-age children 1:12 with a maximum group size of 24; Older school-age children 1:15 with a maximum group size of 30.

Regulation: 3270.52

Description: Mixed Age Level

Noncompliance Area: Upon assessment of supervision and ratio on 1/5/22 at 9 AM in the toddler area of the main room, 5 OT and 3 YT were observed with one staff member. In the PS section of the main room, 10 PS were observed with another staff.

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: 20.71(b)(1)/20.71(b)(2)

Description: Convicted of a felony/Convicted of a crime involving child abuse, child neglect, moral turpitude or physical violence

Noncompliance Area: Clearances and RAP sheets provided for Staff #1 were observed to contain a felony and multiple misdemeanor convictions.

Correction Required: A staff person who has been convicted of a felony/felonies may not work in the facility. A staff person who has been convicted of a crime/crimes of child abuse, child neglect, moral turpitude or physical violence may not work in the facility.

Regulation: 3270.32(c)

Description: Convicted or awaiting trial

Noncompliance Area: Staff #1, whose file contained RAP sheets with a felony and multiple misdemeanor convictions, was observed in a child care position at the facility.

Correction Required: The operator may not allow an individual to enter the facility if the operator knows that the individual has been convicted or is awaiting trial on charges involving a crime of child abuse, child neglect, physical violence or moral corruptness.

Regulation: 3270.25(b)

Description: Post the inspection summary

Noncompliance Area: During an implementation visit on 12/2/21, two open Inspection Summaries, which had not yet been verified as corrected and implemented, SIN-00194647 and SIN-00192453, were not posted in a conspicuous location used by parents.

Correction Required: The operator shall post a copy of each inspection summary issued by the Department in a conspicuous location used by parents. The inspection summary shall remain posted until an agent of the Department verifies that each regulatory noncompliance item cited on the inspection summary has been corrected.

Regulation: 3270.113(a)(1)

Description: Staff assigned to specific children

Noncompliance Area: **Upon entry to the facility at 7:35 AM on 10/15/21, cert rep observed Staff #1 sitting at the front desk. Upon entry into the PS Room at 7:40 AM, cert rep observed Staff #1 with 9 children -- 7 PS and 2 YSA. When asked whom was in room with these children when Staff #1 was observed at the front desk, Staff #1 stated no one. Staff #1 stated she was just coming in for the day and added Staff #2 had been in the room but left to answer the door for a parent.

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. The legal entity shall conduct monthly staff meetings for a period of 3 months with a written agenda containing discussion of the current and previous supervision violations. The agenda and meeting minutes shall be provided to the regional DHS office the next business day following the meeting.

Regulation: 3270.113(a)(1)

Description: Staff assigned to specific children

Noncompliance Area: Upon entry to the facility at 7:35 AM on 10/15/21, cert rep observed Staff #1 sitting at the front desk. Upon entry into the PS Room at 7:40 AM, cert rep observed Staff #1 with 9 children -- 7 PS and 2 YSA. When asked whom was in room with these children when Staff #1 was observed at the front desk, Staff #1 stated no one. Staff #1 stated she was just coming in for the day and added Staff #2 had been in the room but left to answer the door for a parent.

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: 3270.151(a)/3270.192(3)

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

Noncompliance Area: The file for Staff #4, whom was observed with children, lacked an initial health assessment.

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

Regulation: 3270.151(c)(2)/3270.192(3)

Description: Mantoux TB/Health assessment, TB test

Noncompliance Area: The file for Staff #4, whom was observed with children, lacked an initial tuberculosis screening by the Mantoux method.

Correction Required: An adult health assessment must include tuberculosis screening by the Mantoux method at initial employment. Subsequent tuberculosis screening is not required unless directed by a physician, physician's assistant, CRNP, the Department of Health or a local health department.A facility person's record shall include a written report of initial and subsequent health assessments, including the results of initial and subsequent tuberculin skin tests, x-rays or other medical documentation necessary to confirm freedom from communicable tuberculosis.

Regulation: 3270.192(5)

Description: Two written references

Noncompliance Area: The file for Staff #4 lacked two written, nonfamily references.

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)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The file for Staff #4, whom was observed with children, lacked a disclosure statement, state police clearance or receipt for state police clearance. The file contained receipts for FBI and child abuse clearances, yet lacked complete FBI and child abuse clearances.

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 #4--- may not work in a child care position at the facility.

Regulation: 3270.52

Description: Mixed Age Level

Noncompliance Area: *Upon entry to the facility at 7:35 AM on 10/15/21, cert rep was granted entry by Staff #2, whom was observed through the door walking through the hallway. Staff #2 then followed cert rep into the Infant/YT room for assessment of supervision and ratio. Cert rep observed 4 OT sitting at the table on the YT side and Staff #3 with 1 INF and 1 YT on the Infant side. When asked who was responsible for the 4 OT children, Staff #2 reported those were her children. While Staff #2 was in the hallway, Staff #3 was alone with 1 INF, 1 YT and 4 OT. At 8:15 AM, cert rep observed Staff #1 take10 children - 8 PS, 2 YSA on a walk from the PS Room to the entry door to allow entry to 1 PS child. Staff #1 then walked from entry door to PS room with 11 children - 9 PS and 2 YSA - to give Staff #2 1 PS child for her group, which then consisted of 5 OT. At 8:20 AM, another OT child entered facility and was placed in Staff #2's group, for total of 7 children -- 1 PS, 6 OT.

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: **Upon entry to the facility at 7:35 AM on 10/15/21, cert rep was granted entry by Staff #2, whom was observed through the door walking through the hallway. Staff #2 then followed cert rep into the Infant/YT room for assessment of supervision and ratio. Cert rep observed 4 OT sitting at the table on the YT side and Staff #3 with 1 INF and 1 YT on the Infant side. When asked who was responsible for the 4 OT children, Staff #2 reported those were her children. While Staff #2 was in the hallway, Staff #3 was alone with 1 INF, 1 YT and 4 OT. At 8:15 AM, cert rep observed Staff #1 take10 children - 8 PS, 2 YSA on a walk from the PS Room to the entry door to allow entry to 1 PS child. Staff #1 then walked from entry door to PS room with 11 children - 9 PS and 2 YSA - to give Staff #2 1 PS child for her group, which then consisted of 5 OT. At 8:20 AM, another OT child entered facility and was placed in Staff #2's group, for total of 7 children -- 1 PS, 6 OT.

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

Regulation: 3270.113(a)

Description: Supervised at all times

Noncompliance Area: *.Upon entry to the facility at 7:35 AM on 10/15/21, cert rep observed Staff #1 sitting at the front desk. Upon entry into the PS Room at 7:40 AM, cert rep observed Staff #1 with 9 children -- 7 PS and 2 YSA. When asked whom was in room with these children when Staff #1 was observed at the front desk, Staff #1 stated no one. Staff #1 stated she was just coming in for the day and added Staff #2 had been in the room but left to answer the door for a parent.

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

Regulation: 3270.113(a)

Description: Supervised at all times

Noncompliance Area: **.Upon entry to the facility at 7:35 AM on 10/15/21, cert rep observed Staff #1 sitting at the front desk. Upon entry into the PS Room at 7:40 AM, cert rep observed Staff #1 with 9 children -- 7 PS and 2 YSA. When asked whom was in room with these children when Staff #1 was observed at the front desk, Staff #1 stated no one. Staff #1 stated she was just coming in for the day and added Staff #2 had been in the room but left to answer the door for a parent.

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