Kiddie Academy Of Center Valley

Regulation: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: It was observed in Room 8 and Room 9 that the faux leather material on the child-sized green couches was peeling off leaving them not in good repair.

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: 3270.107

Description: Refrigerator

Noncompliance Area: It was observed in Room 1 that the bottom of the refrigerator was dirty.

Correction Required: A facility shall have an operable, clean refrigerator used to store potentially hazardous foods. The refrigerator shall be capable of maintaining food at 45° F or below. An operating thermometer shall be placed in the refrigerator.

Regulation: 3270.106(a)

Description: Clean, age appropriate

Noncompliance Area: It was observed in the Apple Blossom room that the cots were not labeled.

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

Regulation: 3270.111(a)/3270.111(b)

Description: Written plan/Posted in group space

Noncompliance Area: It was observed that the schedules posted throughout the facility did not accurately reflect the daily activities and routines that the staff and children follow. The daily schedules did not reflect the opener and closer rooms or the times of transitions in and out of the classrooms into those individual 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: 3270.113(a)(1)

Description: Staff assigned to specific children

Noncompliance Area: It was observed in the Cherry Blossom room that during rest time, there were a total of 15 children present and 2 staff. When questioned about primary care groups, staff person #1 stated that they had 5 children in their group and staff person #2 stated they had 6 children in their group. There were 4 primary care cards that were left on the table by staff person #3. Staff person #3 had left the room and did not assign the responsibility of their group to either staff person #1 or staff person #2 before leaving.

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 must develop a written supervision policy and procedure to be implemented in the facility. The written policy must address subsection 3270.113(a)(1). The legal entity will submit policy/procedure to the Northeast Regional Office for approval. All existing staff and new hires must be trained on the approved policy and procedure and it must be documented in their files.

Regulation: 3270.113(a)(1)

Description: Staff assigned to specific children

Noncompliance Area: It was observed in the Cherry Blossom room that during rest time, there were a total of 15 children present and 2 staff. When questioned about primary care groups, staff person #1 stated that they had 5 children in their group and staff person #2 stated they had 6 children in their group. There were 4 primary care cards that were left on the table by staff person #3. Staff person #3 had left the room and did not assign the responsibility of their group to either staff person #1 or staff person #2 before leaving.

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: 3270.121(b)

Description: Given parents in writing

Noncompliance Area: It was observed and stated that the facility had neither created nor provided a supervision policy to all currently enrolled families.

Correction Required: At the time of enrollment, a parent shall receive in writing 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: Emergency contact form for child #4 did not contain the parent's work address or release person's 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(b)(1)/3270.131(b)(2)

Description: Infant: updated health report every 6 months/Toddler/preschool: updated health report every 12 months

Noncompliance Area: File for child #1, see code sheet for date of birth, contained two health reports; one dated 5/3/22, and an updated one dated 6/20/23. These dates verify that the previous and updated health reports on file for child #1 were completed more than 12 months apart. File for child #2, see code sheet for date of birth, contained two health reports; one dated 9/22/22, and an updated one dated 8/24/23. These dates verify that the previous and updated health reports on file for child #2 were completed more than 6 months apart. File for child #3, see code sheet for date of birth, contained two health reports; one dated 8/10/22, and an updated one dated 8/3/23. These dates verify that the previous and updated health reports on file for child #3 were completed more than 6 months apart. File for child #5, see code sheet for date of birth, contained a health report dated 6/12/23. The file did not contain an updated health report completed within the last 6 months as required.

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. 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: 3270.133(7)(i)/3270.182(4)

Description: Name of medication/Consent for administration of medications or special dietary needs

Noncompliance Area: It was observed in the Sprouts room that medication was present for child #6. However, the medication log, which was also being used to obtain signed parental consent to administer the medication, did not include the name of the medication as required.

Correction Required: A medication log shall include the name of the medication. A child's record shall contain signed parental consent for administration of medications or special dietary needs.

Regulation: 3270.152

Description: Adult Hygiene

Noncompliance Area: It was observed in the Little Acorn room that a staff person did not wash their hands after diapering a child.

Correction Required: A facility person shall wash his hands before meals and snacks, and after toileting and after diapering a child.

Regulation: 3270.192(2)(iv)

Description: Transcript, diploma and letters

Noncompliance Area: File for staff person #4, who is currently hired as an assistant group supervisor, contained verification of education, but did not contain adequate verification of 2 years experience working with children.

Correction Required: A facility person's record shall include acceptable verification of experience, education or training is a transcript or a diploma or a letter signed by a representative of the experiential, educational or training entity.

Regulation: 3270.81

Description: Glass

Noncompliance Area: It was observed that the Redwood classroom door contained a full pane of glass, and did not have any visual identifying marker on that glass at the time of inspection.

Correction Required: A visual strip or other visual identification shall be placed on glass located in a traffic area, a child care space or a play space.

Regulation: 3270.76/3270.102(a)

Description: Building Surfaces/Clean and good repair

Noncompliance Area: It was observed in the school age outdoor play space that a large bin containing outdoor play equipment had a lid that was broken allowing for approximately 6 inches of water to pool at the bottom of that large bin. This created a situation where the lid was left not in good repair, and led to the visible hazard of the pooling water.

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

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

Noncompliance Area: File for staff person #3, see code sheet for hire date, contained a health assessment dated 7/11/22 and documentation of TB screening results dated 7/13/22; these were completed more than 12 months prior to the facility's given date of initial service in child care for staff person #3. File for staff person #6, see code sheet for hire date, contained a health assessment dated 8/6/22 and documentation of TB screening results dated 8/8/22; these were completed more than 12 months prior to the facility's given date of initial service in child care for staff person #6.

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: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: File for staff person #4, see code sheet for hire date, contained an incomplete PA state police clearance. At the time of inspection, the documentation on file showed that the results of the record was pending. This was corrected and reprinted the day of inspection. File for staff person #5, see code sheet for hire date, contained two child abuse clearances dated 4/18/16 and 7/15/22, and two FBI clearance dated 3/22/16 and 7/13/22. These dates show that the clearances were updated more than 60 months apart. File for staff person #6, see code sheet for hire date, contained a FBI clearance dated 9/14/23. However, staff person #6 was initially hired provisionally and the file did not contain the adequate documentation needed for a provisional hire. The file did not contain the FBI fingerprint receipt which is required to be placed on file prior to the staff person being hired provisionally.

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: 3270.34(a)(6)

Description: Staff evaluations

Noncompliance Area: It was observed in the files for staff persons #2, #8, #9, #10, #11, #12, and #14 that the previously dated written evaluations completed by the facility's stated known director were dated more than 12 months from the current written evaluations observed on file. File for staff person #5, see code sheet for hire date, had a written evaluation on file dated 7/7/23, but did not have one written evaluation completed and filed by the director within their first 12 months of employment. File for staff person #7, see code sheet for hire date, had a written evaluation on file dated 7/6/23, but did not have one written evaluation completed and filed by the director within their first 12 months of employment. File for staff person #13, see code sheet for hire date, had a written evaluation on file dated 8/4/23, but did not have one written evaluation completed and filed by the director within their first 12 months of employment.

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: 3270.133(6)/3270.133(7)

Description: Written consent/Medication log

Noncompliance Area: It was observed that a medicated cream was present for child #1, but a medication log or signed parental consent for the administration of this medicated cream was not found on file at the facility.

Correction Required: A parent shall provide written consent for administration of medication or a special diet. An operator is responsible to establish and maintain a medication log if prescription or nonprescription medication is administered.

Regulation: 3270.135(b)

Description: Surfaces cleaned

Noncompliance Area: Although staff in the older toddler room were using a sanitizer cleaner to clean the changing table mat surface, the cleaning product was not left on the surface long enough to sanitize according to the manufacturer's instructions. It was observed that the cleaning product was sprayed and left on the surface for only approximately 2 minutes then wiped off, when the cleaning product itself explains the requirement of at least 3 minute contact time prior to wiping in order to sanitize a surface such as a changing table.

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

Regulation: 3270.163(a)(1)/3270.163(a)(4)

Description: Dairy/Grain

Noncompliance Area: It was observed at the time of inspection that children were served lunch by the facility. The lunch that was provided contained chicken nuggets, french-fries, and apple sauce. Therefore, the facility's lunch did not contain a least one dairy product or at least one grain as required.

Correction Required: A lunch or dinner prepared at the facility for children of toddler age or older shall include at least one dairy product. A lunch or dinner prepared at the facility for children of toddler age or older shall include at least one grain.

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

Description: Fire safety - 1 yr./Professional development certificate

Noncompliance Area: It was observed at the time of inspection that the file for staff person #1 contained documentation of an updated fire safety training completed on 8/8/23, but no documentation was on file verifying that staff person #1 completed fire safety training in 2022. Therefore no documentation was on file to show that the updated training completed 8/8/23, was completed annually as required.

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. Completion of professional development shall be documented by the signature and title of a representative of the professional development entity and include the date professional development was completed. Documentation shall be retained in the facility person's file or maintained in an electronic system as designated by the Department.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: File for staff person #1, see code sheet for hire date, contained two FBI clearances on file, one dated 3/1/18 and another dated 6/16/23. These dates verify that staff person #1 did not have an updated FBI clearance on file within the 60 month expiration date as required. File for staff person #2, see code sheet for hire date, did not contain out of state clearances. It was confirmed by facility staff during inspection that staff person #2 has lived outside of PA within the last 5 years, and out of state clearances are required. File for staff person #4, see code sheet for hire date, contained an incomplete PA state police clearance. At the time of inspection, the documentation on file showed that the results of the record was pending. This was corrected and reprinted the day of inspection.

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

Regulation: 3270.36(b)(5)/3270.192(2)(iv)

Description: HS/GED + 2 yrs/Transcript, diploma and letters

Noncompliance Area: File for staff person #3, who was currently employed as an assistant group supervisor, had on file at least 2 years of verified experience working with children, but did not have on file adequate documentation of their education.

Correction Required: An assistant group supervisor shall have a high school diploma or a general educational development certificate and 2 years experience with children. A facility person's record shall include acceptable verification of experience, education or training is a transcript or a diploma or a letter signed by a representative of the experiential, educational or training entity.

Regulation: 3270.36(b)(5)/3270.192(2)(iii)

Description: HS/GED + 2 yrs/Exp, educ., training at facility

Noncompliance Area: It was stated by facility staff that staff person #1 was an assistant group supervisor, and was being used as an assistant group supervisor. File for staff person #1 contained a high school diploma, but did not contain the needed documentation to verify 2 years experience working with children.

Correction Required: An assistant group supervisor shall have a high school diploma or a general educational development certificate and 2 years experience with children. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

Regulation: 3270.37(c)

Description: Aides supervised all times

Noncompliance Area: It was stated and confirmed that staff person #1 and staff person #2 were paired together in the Seedlings room. The documentation on file for both staff person #1 and #2 qualified them both to be aides. No additional staff were paired with these staff in the Seedlings room.

Correction Required: An aide or a combination of aides shall be supervised at all times by a staff person qualified at minimum as an assistant group supervisor.

Regulation: 20.71(a)(7)

Description: Fraud or deceit in obtaining or attempting to obtain a certificate of compliance

Noncompliance Area: During a complaint investigation on 5/17/23, the facility staff communicated both verbally and provided written statements verifying that fire drills were not being conducted every 60 days and therefore were being fraudulently recorded by staff on the facility's written fire drill log. Between May 2022-May 2023 fire drills were documented in writing on the facility's fire drill log as having been conducted on 5/20/22, 7/14/22, 9/2/22, 10/13/22, 12/5/22, 1/10/23, 9/7/23, and 5/9/23. Staff person #2 and #3 both stated in writing that the only actual fire drill that the facility participated in between May 2022 - May 2023 was completed on 5/9/23, and staff person #2 stated they were responsible for completing the fire drill logs. The facility's written fire drill logs show that staff persons #2-#8 were all recorded as having participated in the majority if not all of those documented dated drills. Staff #2-#8 stated that since hired, see code sheet for hire dates, they participated in the following number of full evacuation fire drills: staff person #2 approximately 3-5 fire drills, staff person #3 approximately 5 fire drills, staff person #4 approximately 2-3 fire drills, staff person #5 approximately 7 fire drills, staff person #6 in 1 fire drill, staff person #7 has never participated in a fire drill, and staff person #8 participated in 1 fire drill.

Correction Required: The Department may deny, refuse to renew or revoke a certificate of compliance for fraud or deceit in obtaining or attempting to obtain a certificate of compliance.

Regulation: 3270.134(a)

Description: Child's hands washed

Noncompliance Area: It was stated by staff #4, and #6-#9 that staff are not ensuring that infant's hands are being washed before meals and after diapering.

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: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: During a complaint investigation on 5/17/23, it was observed that although staff person #1 completed their 10 hour health and safety training topics on 3/9/23, they had not completed this required preservice training within 90 days of their date of hire (see code sheet for date of hire).

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

Regulation: 3270.33(a)/3270.34(b)

Description: Each staff person meets quals/Director qualifications

Noncompliance Area: During a complaint investigation on 5/31/23, the legal entity stated that staff person #2 had been given the responsibilities to double as the director of the facility, but staff person #2 does not have documentation on file to meet the qualifications to be hired as a director. Staff person #2 was performing the duties, as described in regulation, as the director but does not currently meet the qualifications to do so.

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 director shall have attained one of the following qualification levels specified at §3270.34(b)(1) - (4).

Regulation: 3270.51

Description: Similar Age Level

Noncompliance Area: It was observed with written documentation of attendance and stated by facility staff that on 5/16/23, between approximately 8am-4pm, the Big Acorn room contained 9 infants with only 2 staff. Leaving the infant room out of ratio for nearly the entire day.

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. 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 the documentation to the NE OCDEL Regional Office on a weekly basis for a period of 90 days after DHS approves the documentation format.

Regulation: 3270.51

Description: Similar Age Level

Noncompliance Area: It was observed with written documentation of attendance and stated by facility staff that on 5/16/23, between approximately 8am-4pm, the Big Acorn room contained 9 infants with only 2 staff. Leaving the infant room out of ratio for nearly the entire day.

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. The required staff:child ratios must be maintained at all times.

Regulation: 3270.61(h)

Description: Exceeding Capacity

Noncompliance Area: It was observed through documentation of attendance and stated by facility staff that on 5/16/23, between approximately 8am-4pm, the Big Acorn room contained 9 infants, but the Big Acorn room's establish capacity only measures for 8 children.

Correction Required: The capacity established for an indoor space may not be exceeded.

Regulation: 3270.92(a)

Description: No portable space heaters

Noncompliance Area: During a complaint investigation on 5/17/23, it was observed at the time of inspection that a portable space heater was plugged in and in use at the front office desk.

Correction Required: Portable space heaters are not permitted.

Regulation: 3270.94(a)(1)/3270.94(a)(8)

Description: Every 60 days/Exit building

Noncompliance Area: During a complaint investigation on 5/17/23, the facility staff communicated both verbally and provided written statements verifying that fire drills, ensuring that all staff and children exited the building, were not being conducted every 60 days and therefore were being fraudulently recorded by staff on the facility's written fire drill log. Between May 2022-May 2023 fire drills were documented in writing on the facility's fire drill log as having been conducted on 5/20/22, 7/14/22, 9/2/22, 10/13/22, 12/5/22, 1/10/23, 9/7/23, and 5/9/23. However, staff person #2 and #3 both stated in writing that the only fire drill with a full evacuation that the facility actually participated in between May 2022 - May 2023 was completed on 5/9/23, and staff person #2 stated they were responsible for completing the fire drill logs. The facility's written fire drill logs show that staff persons #2-#8 were all recorded as having participated in the majority if not all of those documented dated drills. Staff #2-#8 stated that since hired, see code sheet for hire dates, they participated in the following number of drills: staff person #2 approximately 3-5 fire drills, staff person #3 approximately 5 fire drills, staff person #4 approximately 2-3 fire drills, staff person #5 approximately 7 fire drills, staff person #6 in 1 fire drill, staff person #7 has never participated in a fire drill, and staff person #8 participated in 1 fire drill.

Correction Required: The Director or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that fire drills are conducted at least once every 60 days. The Director or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that facility persons and children exit the building, weather permitting.

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

Description: Every 60 days/Devices must be compliant

Noncompliance Area: During a complaint investigation on 5/17/23, the facility staff #2-#8 communicated both verbally and provided written statements verifying that fire drills were not being conducted every 60 days. The facility's written fire drill log documented fire drills conducted on 5/20/22, 7/14/22, 9/2/22, 10/13/22, 12/5/22, 1/10/23, 9/7/23, and 5/9/23. However, staff person #2 and #3 both stated in writing that the only fire drill that the facility actually participated in between May 2022 - May 2023 was completed on 5/9/23, and staff person #2 stated they were responsible for completing the fire drill logs. Also observed during the complaint investigation, the documentation on file regarding the testing of the fire alarms was not adequate. The facility is required to complete fire alarm testing every 30 days; facility had never verbalized any reason as to why this was not possible to complete and understood the need for testing according to compliance with standards established under section 1016(c) of the act (62 P.S. § 1016(c)). The testing report provided from the fire alarm company showed only 3 dates over the course of the last 12 months as a verified documented test of the alarms being pulled; those dates are: 6/30/22, 11/3/22, and 5/9/23. Documentation on file written by staff #2 shows a gap in the 30 day alarm tests recorded between May 2022- May 2023. Dates of record tests written by staff #2 are as follows: 5/20/22, 6/30/22, 7/14/22, 8/26/22, 9/2/22, 10/13/22, 11/3/22, 12/5/22, 1/10/23, 2/9/23, 3/7/23, 4/7/23, 5/9/23. In addition, the facility provided an invoice from their alarm company dated 1/16/23, which documented that an annual inspection/lights was last completed on 1/21/20, which is more than 12 months from the date of inspection.

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. 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 legal entity will create a fire drill log and fire alarm testing plan. It must include a list of all upcoming specified dates and times of when each fire drill and fire alarm testing will occur over the next 12 months. This plan must include the name of the designated staff person assigned to maintain the facility's fire drill log and fire alarm testing log. This plan must have a sheet for staff to sign off to verify their individual participation in each drill. This fire drill log and fire alarm testing plan will be sent to OCDEL for approval, and will be used by facility to conduct fire drills and complete fire alarm testing at those specific dates and times through the calendar year. All scheduled fire drills and fire alarm tests completed within the next 180 days must be logged, with all required information documented according to regulation and the facility's written plan, and sent to OCDEL for review within 1 week of the completion of each fire drill and each fire alarm test.

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

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

Noncompliance Area: During a complaint investigation on 5/17/23, the facility staff #2-#8 communicated both verbally and provided written statements verifying that fire drills were not being conducted every 60 days. The facility's written fire drill log documented fire drills conducted on 5/20/22, 7/14/22, 9/2/22, 10/13/22, 12/5/22, 1/10/23, 9/7/23, and 5/9/23. However, staff person #2 and #3 both stated in writing that the only fire drill that the facility actually participated in between May 2022 - May 2023 was completed on 5/9/23, and staff person #2 stated they were responsible for completing the fire drill logs. Also observed during the complaint investigation, the documentation on file regarding the testing of the fire alarms was not adequate. The facility is required to complete fire alarm testing every 30 days; facility had never verbalized any reason as to why this was not possible to complete and understood the need for testing according to compliance with standards established under section 1016(c) of the act (62 P.S. § 1016(c)). The testing report provided from the fire alarm company showed only 3 dates over the course of the last 12 months as a verified documented test of the alarms being pulled; those dates are: 6/30/22, 11/3/22, and 5/9/23. Documentation on file written by staff #2 shows a gap in the 30 day alarm tests recorded between May 2022- May 2023. Dates of record tests written by staff #2 are as follows: 5/20/22, 6/30/22, 7/14/22, 8/26/22, 9/2/22, 10/13/22, 11/3/22, 12/5/22, 1/10/23, 2/9/23, 3/7/23, 4/7/23, 5/9/23. In addition, the facility provided an invoice from their alarm company dated 1/16/23, which documented that an annual inspection/lights was last completed on 1/21/20, which is more than 12 months from the date of inspection.

Correction Required: The Director or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that fire drills are conducted at least once every 60 days. The Director or designated staff person who is responsible for compliance with this chapter shall ensure the requirements under subsection (a) are met.

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: Staff person #1 and #2 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 from a PQAS approved trainer and a PQAS approved curriculum.

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 #2 will have until 01/20/23 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 a GS or AGS who has completed the required training related to this citation. If there are no staff available to supervise staff person #1 and #2, then staff person #1 and #2 may not work in a child-care position at the facility.

Regulation: 3270.103

Description: Small Toys and Objects

Noncompliance Area: It was observed in the Saplings room that marker lids with a diameter of less than 1 inch were left accessible to the mouthing children present in that room.

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

Regulation: 3270.113(a)(1)

Description: Staff assigned to specific children

Noncompliance Area: It was observed in the Seedling room that 2 staff were present with 10 young toddlers, and when asked which children each staff had assigned to their primary care group, staff stated they had not yet assigned themselves care groups on that day.

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: 3270.123(a)(3)

Description: Services proceeded

Noncompliance Area: File for child #1, see code sheet for enrollment date, did not contain a child service report completed within the last 6 months.

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

Regulation: 3270.124(a)

Description: Each child emergency contact person

Noncompliance Area: Emergency contact form for child #2 was dated 10/14/22, but the child was enrolled prior to that date. Therefore an emergency contact form was not on file on or before the child's first day. Also the emergency contact form on file did not contain an emergency contact's name or telephone number.

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

Regulation: 3270.124(b)(2)/3270.124(b)(3)

Description: Physician name, address, phone/Parent home/work address, phone

Noncompliance Area: Emergency contact form for child #2 did not include the following: the name, address or telephone number of the child's physician, the enrolling parent's home or work address, and the enrolling parent's work telephone number.

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

Regulation: 3270.124(b)(7)

Description: Name/address/phone release person

Noncompliance Area: Emergency contact form for child #2 did not contain the release person's address.

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

Regulation: 3270.124(c)

Description: Each child care space

Noncompliance Area: It was observed in the Seedlings room that child #2 was present the day of inspection, but an emergency contact form for that child was not present in that room where the child was receiving care.

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: 3270.131(d)(5)

Description: Immunization record

Noncompliance Area: File for child #1 did not include written documentation of the status of all age appropriate immunizations recommended by the ACIP.

Correction Required: A health report shall include a review of the child's immunized status according to recommendations of the ACIP.

Regulation: 3270.166(4)

Description: Bottles labeled

Noncompliance Area: It was observed in the Big Acorn room that bottles for a child were not labeled.

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

Regulation: 3270.24(a)

Description: Immediate access

Noncompliance Area: It was observed the day of inspection, a staff person from another state Department agency was standing in the foyer of the building awaiting entry into the facility and stated they had been waiting to get in for several minutes and that this was not the first time this had occurred. Door bell was pushed again and phone call made into facility with no answer. It was not until the certification representative walked around to the outdoor play space to speak with a staff person explaining that no one was answering the door that someone then came to grant access.

Correction Required: A staff person shall provide to agents of the Department immediate access to the facility, the children and the files and records.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: File for staff person #1, see code sheet for date of hire, did not include out of state clearances and the file for staff person #1 verified that they lived outside of PA within the last 5 years. File for facility person #2, see code sheet for date of hire, contained neither a PA child abuse clearance nor documentation showing that the request for this clearance was made. Facility person #2 was observed the day of inspection physically present with children in care.

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 and #2 may not work in a child care position at the facility.

Regulation: 3270.51/3270.55(a)

Description: Similar Age Level/Toddler and preschool children

Noncompliance Area: It was observed in the Dogwood room that napping ratios were not properly being used during rest time. One staff was present with 19 preschool children. During rest time children were observed getting off their rest equipment to go to the bathroom and were allowed to move about the room to get their water bottles for a drink. Therefore napping ratios could not have been used and the room was out of ratio during those times when the children left their rest equipment.

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. The staff:child ratio while toddlers and preschoolers are napping is one staff person to 10 young toddlers, one staff person to 12 older toddlers, one staff person to 20 preschool children.

Regulation: 3270.76

Description: Building Surfaces

Noncompliance Area: It was observed on the outside of the building that the dryer vent was blocked and completely filled with lint leaving it unclean and a visible fire hazard.

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: 3270.106(f)

Description: 2 feet apart

Noncompliance Area: It was observed in the Big Acorn room that two cribs containing two sleeping infants did not have at least two feet of space on at least three sides of those cribs.

Correction Required: At least 2 feet of space is required on three sides of a bed, cot, crib or other rest equipment while the equipment is in use.

Regulation: 3270.135(a)(3)

Description: Disposable diapers

Noncompliance Area: It was observed that the Sapling and Sprouts classrooms were not immediately placing soiled disposable diapers into a plastic-lined, hands-free covered can.

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

Regulation: 3270.65

Description: Protective Outlet Covers 5 yrs. or less

Noncompliance Area: It was observed in the Redwoods room, that a power strip and extension cord, both plugged in and in use, contained uncover outlets accessible to children under 5 years of age in that classroom.

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

Regulation: 3270.66(a)

Description: Locked or inaccessible

Noncompliance Area: A wet jet mop containing the liquid cleaning solution was observed on the floor accessible to children in the bathroom between the Saplings and Sprouts classrooms.

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: 3270.77(a)

Description: No peeling paint or plaster

Noncompliance Area: Chipped and peeling paint was observed on the walls in the Spouts and Saplings classrooms.

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

Regulation: 3270.103

Description: Small Toys and Objects

Noncompliance Area: It was observed in the Seedling room that a plastic bag containing diapers was left on the bathroom floor under the sink leaving this bag accessible to mouthing children.

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: 3270.123(a)

Description: Signed

Noncompliance Area: Agreements for for child #3-#8 were not signed by the operator.

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

Regulation: 3270.124(b)(7)

Description: Name/address/phone release person

Noncompliance Area: Emergency contact form for child #2 did not contain the release person's address.

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

Regulation: 3270.133(1)

Description: Original container

Noncompliance Area: It was observed in the Little Acorns room that a prescription medication for child #1 was accepted and being stored without its original container.

Correction Required: A prescription or nonprescription medication may be accepted only in an original container. The medication shall remain in the container in which it was received.

Regulation: 3270.135(a)(3)

Description: Disposable diapers

Noncompliance Area: It was observed during a diaper change that the staff person did not disard a soiled diaper by immediately placing the diaper into a plastic-lined, hands-free covered can. Instead it was observed that the staff person set the diaper aside on the changing table while dressing the child after the diaper change, then disposing of the diaper by placing it into a plastic bag which was then tied and discarded into the appropriate garbage can.

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

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: Facility person #1 and staff person #2 were observed to be caring for children unsupervised. Facility person #1 and staff person #2 have not completed the following pre-service training required prior to caring for children unsupervised: mandated reporter training. Staff person #4 and #9 were observed to be caring for children unsupervised. Staff person #4 and #9 have not completed the following pre-service training required prior to caring for children unsupervised: Health and Safety Topics.

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. Until such time as the required pre-service trainings are completed, facility person #1 and staff person #2, #4, and #9 must be supervised, when interacting with children, by an AGS or GS who has completed the required training related to this citation. If there are no staff person(s) available to supervise facility person #1 and staff person #2, #4, and #9, facility person #1 and staff person #2, #4, and #9 may not work or volunteer in a child-care position at the facility.

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

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

Noncompliance Area: File for staff person #5, #9, and #10, (see code sheet for date of hire), did not contain documentation of a health assessment or TB test results completed at intial employment or within 12 months prior to providing initial service in a child care setting.

Correction Required: A facility person providing direct care who comes into contact with the children or who works with food preparation shall have a health assessment conducted within 12 months prior to providing initial service in a child care setting and every 24 months thereafter. A health assessment is valid for 24 months following the date of signature, if the person does not contract a communicable disease or develop a medical problem.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)/3270.171(c)

Description: Pick-up and drop-off points/Safe routes posted

Noncompliance Area: It was observed and stated that the facility did not submit an annual traffic letter to the local traffic safety authority notifying them of the location of the facility and the program's use of pedestrian and vehicular routes around the child care facility. It was also observed that the facility did not have written safe routes, also known as pick up and drop off procedures, posted at a conspicuous location used by parents in 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. Written notification of safe routes shall be posted by the operator at a conspicuous location in the child care facility.

Regulation: 3270.182(8)

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

Noncompliance Area: File for child #2 did not contain a copy of an initial or subsequent agreement between the parent and the operator.

Correction Required: A child's record shall contain a copy of the initial agreement and subsequent written agreements between the parent and the operator. The parent receives the original agreement.

Regulation: 3270.191

Description: Individual Records

Noncompliance Area: Facility was unable to confirm the existance of a full file or provide staff file information that was requested for staff person #13. Staff person #13 was observed in care the day of inspection.

Correction Required: An individual record is required for each facility person. The legal entity must view the DHS vodcasts related to "Requirements for an Effective Director of a Child Care Center" and "Staff Files". The legal entity will create written documentation and place in the staff person's file verifying that the Director, Legal Entity Representative, or any person(s) in charge of maintaining staff or facility persons files has watched and understands the material in these vodcasts.

Regulation: 3270.191

Description: Individual Records

Noncompliance Area: Facility was unable to confirm the existance of a full file or provide staff file information that was requested for staff person #13. Staff person #13 was observed in care the day of inspection.

Correction Required: An individual record is required for each facility person.

Regulation: 3270.192(5)

Description: Two written references

Noncompliance Area: File for facility person #1, (see code sheet for first day in care), did not contain two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person.

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(e)

Description: Letter to parents

Noncompliance Area: It was observed and stated that the facility did not provide to parents of each enrolled child a letter explaining the emergency plan procedures.

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

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: Staff person #8 and #13 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): pediatric first aid/CPR from a PQAS approved trainer and a PQAS approved curriculum. Staff person #4, #6, #8, and #13 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Health and Safety Topics

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 #4, #6, #8, and #13 will have until 7/30/22 to complete the required training(s). Until such time as the required training(s) has been completed, staff person #4, #6, #8, and #13 must be supervised, when interacting with children, by an AGS or GS who has completed the required training related to this citation. If there are no staff available to supervise staff person #4, #6, #8, and #13 staff person #4, #6, #8, and #13 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: File for facility person #1, (see code sheet for first day in care), did not contain a PA child abuse clearance, a DHS approved FBI clearance, or a NSOR verification certificate, and did not contain verification of applying for a DHS approved FBI or NSOR verification certificate. The disclosure statement on file for facility person #1 was neither wittnessed nor dated. Staff person #2 and #12, (see code sheet for date of hire) have not completed mandated reporter training within the last 60 months. This is evidenced by the previously documented mandated reporter trainings on file being dated 3/7/16 and 1/8/17 respectively. Staff person #6 has not completed the mandated reporter training within 90 days of their date of hire (see LIS code sheet). File for staff person #7, (see code sheet for date of hire), did not have a disclosure statement on file.

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(s) #2, #6, and #12 will have until 7/30/22 to complete the mandated reporter training. Until such time as the required training has been completed, staff person(s) #2, #6, and #12 must be supervised, when interacting with children, by an AGS or GS who has completed the required training related to this citation. If there are no staff person(s) available to supervise staff person #2, #6, and #12, staff person #2, #6, and #12 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: File for facility person #1, (see code sheet for first day in care), did not contain a PA child abuse clearance, a DHS approved FBI clearance, or a NSOR verification certificate, and did not contain verification of applying for a DHS approved FBI or NSOR verification certificate. The disclosure statement on file for facility person #1 was neither wittnessed nor dated. Staff person #2 and #12, (see code sheet for date of hire) have not completed mandated reporter training within the last 60 months. This is evidenced by the previously documented mandated reporter trainings on file being dated 3/7/16 and 1/8/17 respectively. Staff person #6 has not completed the mandated reporter training within 90 days of their date of hire (see LIS code sheet). File for staff person #7, (see code sheet for date of hire), did not have a disclosure statement on file.

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. The legal entity will submit complete files for any new hires, including volunteers or other facility persons, for a period of 90 days to the NE Regional Office. During that time, new hires may not begin to work in child care until their file has been approved by the NE Regional Office. Submitted files will be reviewed by the NE regional office within 1 week of submission.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: File for facility person #1, (see code sheet for first day in care), did not contain a PA child abuse clearance, a DHS approved FBI clearance, or a NSOR verification certificate, and did not contain verification of applying for a DHS approved FBI or NSOR verification certificate. The disclosure statement on file for facility person #1 was neither wittnessed nor dated. Staff person #2 and #12, (see code sheet for date of hire) have not completed mandated reporter training within the last 60 months. This is evidenced by the previously documented mandated reporter trainings on file being dated 3/7/16 and 1/8/17 respectively. Staff person #6 has not completed the mandated reporter training within 90 days of their date of hire (see LIS code sheet). File for staff person #7, (see code sheet for date of hire), did not have a disclosure statement on file.

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

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

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

Noncompliance Area: File for staff person #3, #8, and #10, (see code sheet for date of hire), did not contain documentation of education or experience to meet the applicable qualifications for assistant group supervisor, and facility stated all three staff are employed as assistant group supervisors. File for staff person #3 did not contain any education or experience. File for staff person #8 contained documentation of education that was not legible. File for staff person #10 contained a high school diploma but did not contain any verification of experience. File for staff person #9, (see code sheet for date of hire), did not contain adequate documentation of education to meet the applicable qualifications for group supervisor, and facility stated staff person #9 was employed as a group supervisor.

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. The Director, Legal Entity Representative, or any person in charge of maintaining staff or facility persons files must create a written policy and plan to establish new and maintain existing staff and facility person files, including clearance updates, to remain compliant with all applicable laws and regulations. This plan must be approved by the Regional Office and followed by the facility for all staff files in the future.

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

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

Noncompliance Area: File for staff person #3, #8, and #10, (see code sheet for date of hire), did not contain documentation of education or experience to meet the applicable qualifications for assistant group supervisor, and facility stated all three staff are employed as assistant group supervisors. File for staff person #3 did not contain any education or experience. File for staff person #8 contained documentation of education that was not legible. File for staff person #10 contained a high school diploma but did not contain any verification of experience. File for staff person #9, (see code sheet for date of hire), did not contain adequate documentation of education to meet the applicable qualifications for group supervisor, and facility stated staff person #9 was employed as a group supervisor.

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: 3270.34(a)(6)

Description: Staff evaluations

Noncompliance Area: File for staff person #11, (see code sheet for date of hire), did not contain a written staff evaluation completed by the director within the last 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: 3270.51/3270.113(a)(1)

Description: Similar Age Level/Staff assigned to specific children

Noncompliance Area: It was observed in the Redwood room on 7/1/22, that facility person #1 and staff person #2 were the only people present with 17 school aged children. Facility person #1 stated she was assigned the responsiblity of 9 children in the room and staff person #2 stated she was assigned the responsibility of 8 children in the room. Facility person #1 was later determined to be a volunteer only and therefore could neither assume the responsibility of care for 9 of those children nor be counted in ratio.

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. The required staff:child ratios must be maintained 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: 3270.51/3270.113(a)(1)

Description: Similar Age Level/Staff assigned to specific children

Noncompliance Area: It was observed in the Redwood room on 7/1/22, that facility person #1 and staff person #2 were the only people present with 17 school aged children. Facility person #1 stated she was assigned the responsiblity of 9 children in the room and staff person #2 stated she was assigned the responsibility of 8 children in the room. Facility person #1 was later determined to be a volunteer only and therefore could neither assume the responsibility of care for 9 of those children nor be counted in ratio.

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. The required staff:child ratios must be maintained 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. The Legal Entity / Director will establish a supervision and ratio policy. The policy will include how the facility will demonstrate their knowledge and ability to adequately supervise children while maintaining appropriate ratio at all times. The policy must focus on ensuring that each child is seen, heard, assessed and able to be directed at all times. The policy must include the required staff:child ratios for each age group. The policy must include how the facility will ensure appropriate supervision and ratios during transition times and while in the outdoor play area. The policy must include how the facility will ensure appropriate supervision and ratios during nap time. The policy must also include a plan for each staff to be assigned the responsibility for supervision of specific children, including the requirement that the staff person know the names and whereabouts of the children in his assigned group and be physically present with the children in his group on the facility premises and on facility excursions off the facility premises. The policy must also address how these groups will be transitioned from one staff person to another during staffing changes. This supervision and ratio policy must be submitted to the Department prior to implementation for approval. Once approved by the Department, the director will ensure that all current employees and any new hires are trained on this policy.

Regulation: 3270.65

Description: Protective Outlet Covers 5 yrs. or less

Noncompliance Area: It was observed that a power strip, which was plugged into the wall, contained outlets that were left uncovered accessible to children under 5 years of age in the Evergreen room.

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

Regulation: 3270.77(a)

Description: No peeling paint or plaster

Noncompliance Area: It was observed in the Sprouts room that an area on the wall near the bookshelf contained chipped and peeling paint.

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

Regulation: 3270.121(a)/3270.121(b)

Description: Review policies and procedures/Given parents in writing

Noncompliance Area: Provider does not have a supervision and dismissal policy written to review with parent and provide to parent at time of enrollment.

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. At the time of enrollment, a parent shall receive in writing 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: 3270.123(a)(5)/3270.182(8)

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

Noncompliance Area: Agreements do 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. A child's record shall contain a copy of the initial agreement and subsequent written agreements between the parent and the operator. The parent receives the original agreement.

Regulation: 3270.124(b)(3)

Description: Parent home/work address, phone

Noncompliance Area: Emergency contact information for child 1 does not include the home and work addresses and telephone numbers of the enrolling parent. Emergency contact form for child 3 is missing the work address for 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: Emergency contact information for child 1 does not include 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(b)(7)

Description: Name/address/phone release person

Noncompliance Area: Emergency contact information for child 2 does not include the address 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: 3270.27(a)(6)

Description: Emergency plan

Noncompliance Area: Provider does not have documented annual emergency drills on file at the facility.

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

Regulation: 3270.31(f)(10)

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

Noncompliance Area: The following staff do not have pediatric first-aid and cpr on file and have been working with children for more than 90 days - staff 1, 3, and 6.

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)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: On 12/1/2021 an unannounced inspection was conducted at the facility. Staff #2 did not have proof of a request for a DHS FBI clearance on file but has a DOE FBI clearance on file dated 4.17.20 and a DHS FBI clearance on file dated 10.30.21. Staff #2 did have proof of request for NSOR clearance dated 2.23.21 but did not have a completed NSOR clearance on file. Staff #2 did not sign a disclosure at initial hire. Staff 2 has a disclosure statement on file dated 3.20.21. An acceptable plan of correction was received that stated the following: If clearances are not completed, staff will be removed from care until all completed clearances are on file. Staff 2 will be removed from childcare and documentation will be places in staff 2's file. The date of correction was 12/2/2021. On 2/18/2021 an unannounced inspection was conducted at the facility. Staff person #2 was observed working at the facility but still does not have a completed NSOR clearance on file. In addition, Staff #3 does not have proof of request for or a completed NSOR clearance on file. Staff #3 also does not have mandated reporter training on file. Staff #4 has a request for a state police clearance dated 11/13/21 but does not have a completed state police clearance on file.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Facility Persons #2,#3 and #4 may not work in a child care positions 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.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: On 12/1/2021 an unannounced inspection was conducted at the facility. Staff #2 did not have proof of a request for a DHS FBI clearance on file but has a DOE FBI clearance on file dated 4.17.20 and a DHS FBI clearance on file dated 10.30.21. Staff #2 did have proof of request for NSOR clearance dated 2.23.21 but did not have a completed NSOR clearance on file. Staff #2 did not sign a disclosure at initial hire. Staff 2 has a disclosure statement on file dated 3.20.21. An acceptable plan of correction was received that stated the following: If clearances are not completed, staff will be removed from care until all completed clearances are on file. Staff 2 will be removed from childcare and documentation will be places in staff 2's file. The date of correction was 12/2/2021. On 2/18/2021 an unannounced inspection was conducted at the facility. Staff person #2 was observed working at the facility but still does not have a completed NSOR clearance on file. In addition, Staff #3 does not have proof of request for or a completed NSOR clearance on file. Staff #3 also does not have mandated reporter training on file. Staff #4 has a request for a state police clearance dated 11/13/21 but does not have a completed state police clearance on file.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Facility Persons #2,#3 and #4 may not work in a child care positions 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. Provider is required to attend and complete the existing provider orientation. Provider is required to contact the NE regional offices to sign up for existing next provider orientation which will be held on May 25, 2022.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: On 12/1/2021 an unannounced inspection was conducted at the facility. Staff #2 did not have proof of a request for a DHS FBI clearance on file but has a DOE FBI clearance on file dated 4.17.20 and a DHS FBI clearance on file dated 10.30.21. Staff #2 did have proof of request for NSOR clearance dated 2.23.21 but did not have a completed NSOR clearance on file. Staff #2 did not sign a disclosure at initial hire. Staff 2 has a disclosure statement on file dated 3.20.21. An acceptable plan of correction was received that stated the following: If clearances are not completed, staff will be removed from care until all completed clearances are on file. Staff 2 will be removed from childcare and documentation will be places in staff 2's file. The date of correction was 12/2/2021. On 2/18/2021 an unannounced inspection was conducted at the facility. Staff person #2 was observed working at the facility but still does not have a completed NSOR clearance on file. In addition, Staff #3 does not have proof of request for or a completed NSOR clearance on file. Staff #3 also does not have mandated reporter training on file. Staff #4 has a request for a state police clearance dated 11/13/21 but does not have a completed state police clearance on file.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Facility Persons #2,#3 and #4 may not work in a child care positions 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. The operator shall send all requests for and completed clearances for all new hires for a period of three months. The period shall commence upon the receipt of an acceptable plan of correction.

Regulation: 3270.34(a)(6)

Description: Staff evaluations

Noncompliance Area: Staff 7 has a current written evaluation on file dated 9.2021 but does not have a previous written evaluation on file.

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: 3270.51/3270.52

Description: Similar Age Level/Mixed Age Level

Noncompliance Area: On 2.18.22, 3.23.22 and 4.4.22, a complaint investigation was conducted. Staff interviews revealed that the facility has been out of ratio on a few occasions. On 4.4.22, inspector observed 10 preschool children and 14 mixed young and older school age children with 2 staff in the school age room.

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. The required staff:child ratios must be maintained at all times. 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 required staff:child ratios must be maintained at all times.

Regulation: 3270.76/3270.77(a)

Description: Building Surfaces/No peeling paint or plaster

Noncompliance Area: In the Evergreens room, inspector observed peeling paint in the birthday area. In the Redwood's room, inspector observed peeling paint on the wall by the chair under the window. Peeling paint was pointed out to the person (staff 5) who walked around with the inspector during renewal inspection.

Correction Required: Floors, walls, ceilings and other surfaces, including the facility's outdoor play space surfaces shall be kept clean, in good repair and free from visible hazards. Peeled or damaged paint or damaged plaster is not permitted on indoor or outdoor surfaces in the child care facility.

Regulation: 3270.113(b)/3270.113(d)

Description: No physical punishment /No harsh language

Noncompliance Area: A complaint investigation was conducted 12.1.21. Inspector observed a video that shows staff 1 grab child 1 by the collar of child's jacket and his wrist and gave child a shake. On a different portion of the video, inspector observed staff 1 push/throw child 1 to the ground, then grab child 1 by child's ankles and while child was up-side-down, bounce/shake child then placed child on the ground. Staff 3 admitted hearing staff 1 say to child 1 "I'm so tired of dealing with you" during the incident of throwing child 1 to the ground. Staff 3 witnessed and admitted staff 1 threw child to the ground. Staff 3 reported incident to staff 2. Staff 2 spoke with staff 1 about what was shown on the video. Staff 1 signed a statement admitting to pushing child 1 to the floor in an aggressive manor and grabbing child 1 by the ankles.

Correction Required: A facility person may not use any form of physical punishment, including spanking a child. A facility person may not use harsh, demeaning or abusive language in the presence of children.

Regulation: 3270.151(a)

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

Noncompliance Area: )n 10.13.21 a renewal inspection was conducted to review staff files. Staff 4 did not update the health assessment within 24 months from previous health assessment. Staff 4 has health assessments on file dated 6.25.18 and 8.6.21. Staff 8' health assessment was not conducted within 12 months prior to providing initial service in a child care setting . Staff 8 started working with children 10.20.21 and has a health assessment on file dated 8.26.20. On 12.1.21 staff 8 did not have a health assessment on file that was conducted within 12 months prior to employment.

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

Description: Mantoux TB/Health assessment, TB test

Noncompliance Area: On 10.13.21 when conducting a renewal inspection to review files, staff 8 did not received a tb screening at initial employment. Staff 8 has a tb screening on file dated 8.26.20. On 12.1.21 staff 8 does not have a tb screening on file.

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.