Kindercare Learning Ctr/ross Twp

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The file for Staff #1 contained a Department of Education FBI clearance and not the required Department of Human Service FBI clearance.

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 childcare position at the facility.

Regulation: 3270.34(a)(6)

Description: Staff evaluations

Noncompliance Area: Staff #2 lacked a written evaluation within a minimum of 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: 3270.61(h)

Description: Exceeding Capacity

Noncompliance Area: At 11:15 AM, 22 children were observed receiving care in the School Age childcare space that has a designated maximum capacity of 19.

Correction Required: The capacity established for an indoor space may not be exceeded except in situations described in § 3270.61(h)(1-3)

Regulation: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: In the PreK and PreK 2 Classrooms, both downstairs, plastic covers that were on top of the rest cots were cracked in multiple areas posing a pinching hazard to the children in care.

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: 3270.123(a)(3)

Description: Services proceeded

Noncompliance Area: The files for Child #3, #5, #6, and #7 contained child service reports that provide information to the family about the child's growth and development in the context of the services being provided dated more than 6 months apart. The files for Child #9 and #10 had child service reports in their file at the time of Renewal Inspection, it was observed that Child #9 and #10 did not have a child service report within 6 months of enrollment.

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: 3270.123(a)(4)

Description: Arrival/departure times

Noncompliance Area: The file for Child #2 contained an Agreement which did not specify the child's arrival and departure times.

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

Regulation: 3270.124(b)(2)

Description: Physician name, address, phone

Noncompliance Area: The Emergency Contact Form for Child #4 lacked the name, address, and telephone number of the child's physician.

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

Regulation: 3270.124(b)(3)

Description: Parent home/work address, phone

Noncompliance Area: The Emergency Contact Forms for Child #2 and #3 lacked the enrolling parents work address and telephone number. The Emergency Contact Form for Child #9 lacked the enrolling parents work telephone number.

Correction Required: 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: The Emergency Contact Form for Child #2 lacked the complete address of the individual designated by the parent to whom the child may be released. The Emergency Contact Form for Child #9 lacked 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: 3270.131(a)/3270.182(1)

Description: Health information/Initial and subsequent health reports

Noncompliance Area: The files for Child #3 and Child #8 contained Health Reports at the time of the Renewal Inspection, it was observed that the files for Child #3 and Child #8 did not contain Health Reports within 60 days of enrollment.

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. A child's record shall contain initial and subsequent health reports.

Regulation: 3270.131(b)(2)/3270.182(1)

Description: Toddler/preschool: updated health report every 12 months/Initial and subsequent health reports

Noncompliance Area: The files for Child #7, #9, and #10, preschool aged children, lacked updated health reports within the last 12 months.

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. A child's record shall contain initial and subsequent health reports.

Regulation: 3270.131(d)(5)/3270.131(e)(1)

Description: Immunization record/Exemption documentation from parent/guardian

Noncompliance Area: The file for Child #1, enrolled for more that 60 days at the facility, did not contain documentation of a 2nd dose of the DTAP vaccination, 2nd dose of the Hep B vaccination, 2 dose of the HIB vaccination, 2nd dose of the Pneumococcal vaccination, and a 2nd dose of the Polio vaccination as required based on the child's age as per the ACIP recommended schedule.

Correction Required: A health report shall include a review of the child's immunized status according to recommendations of the ACIP. The facility shall implement dismissal policies in accordance with the Department of Health regulation in 28 Pa. Code § 27.77 (relating to immunization requirements for children in childcare group settings). Child #1 must be dismissed from care by close of business 4/22/26 and may only return to care when the immunization record is updated or when a parent provides a written, signed exemption letter.

Regulation: 3270.131(d)(7)

Description: Free from contagious/communicable disease

Noncompliance Area: The Health Report for Child #4 lacked a statement indicating the child is able to participate in childcare and appears to be free from contagious or communicable diseases.

Correction Required: A health report shall include a statement that the child is able to participate in child care and appears to be free from contagious or communicable disease.

Regulation: 3270.151(a)

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

Noncompliance Area: The last two Health Assessments in the file for Staff #3 were 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: 3270.181(c)

Description: Emergency info/agreement updated 6 mos

Noncompliance Area: The file for Child #8 contained a Financial Agreement Form that had not been updated within the last 6 months.

Correction Required: A parent is required to review and update the emergency contact information and the financial agreement at least once in a 6-month period or as soon as there is a change in the information.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The files for Staff #1, #2, and #4 contained Child Abuse Clearances and FBI Clearances that were updated in an interval greater than 60 months. The file for Staff #3 contained an FBI Clearance that was updated in an interval greater than 60 months.

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: In the PreK Classroom downstairs there was peeling paint along the wooden bulletin board on the left side.

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

Regulation: 3270.113(c)

Description: No ridicule or threaten harm

Noncompliance Area: According to statements made by staff, staff #6 has been observed singling out and ridiculing children in the presence of the other children. As an example, Staff #6 has been observed saying, "You are four years old, you should not be having accidents," while sending the child to the restroom and not helping the child.

Correction Required: A facility person may not single out the child for ridicule, threaten harm to the child or the child's family and may not specifically aim to degrade the child or the child's family.

Regulation: 3270.113(d)

Description: No harsh language

Noncompliance Area: According to staff statement, staff #1 has been observed using a harsh, abusive, and demeaning tone in the presence of children on a weekly basis. Staff #1 often becomes frustrated and raises their voice, and screams mean things to the children. Staff #1 has been observed stating, "You are 4 years old, you shouldn't be having accidents."

Correction Required: 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: The file for Staff #5 contained a health assessment that was not conducted within 24 months of the previous 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.

Regulation: 3270.192(2)(iv)

Description: Transcript, diploma and letters

Noncompliance Area: The file for Staff #3 lacked proof of qualifications for education in the form of a diploma, transcript, or letter signed by a representative or the experiential, educational or training entity.

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: 3270.192(5)

Description: Two written references

Noncompliance Area: The file for Staff #3, lacked two written, nonfamily references from individuals attesting to the 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: 3270.31(e)(4)(i)

Description: Age and Training

Noncompliance Area: Although the file for Staff #1 had current Pediatric First Aid/CPR at the time of inspection, it was observed the most recent Pediatric First Aid/CPR was not obtained prior to expiration of the previous training.

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: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The disclosure statement in the file for Staff #2 lacked a witness. The file for Staff #2contained an FBI clearance that was not obtained within 60 months of the previous clearance. Although the file for Staff #3 contained a signed disclosure statement at the time of inspection, it was observed that Staff #3 lacked a signed disclosure statement prior to working in a childcare position. The file for Staff #4, who has lived in Ohio in the past five years lacked a Child Abuse Clearance and a Sex Offender Registry verification from Ohio.

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 childcare position at the facility.

Regulation: 3270.34(a)(6)

Description: Staff evaluations

Noncompliance Area: Staff #2 lacked an annual written evaluation that was conducted within the past 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: 3270.65

Description: Protective Outlet Covers 5 yrs. or less

Noncompliance Area: In PreK 2 classroom there was an electrical outlet along the back wall that lacked a protective receptacle cover. This outlet was accessible to children 5 years of age and younger.

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

Regulation: 3270.66(a)

Description: Locked or inaccessible

Noncompliance Area: In the Preschool Classroom, a bottle of Glass Cleaner which was labeled, "Keep out of the reach of children" was accessible to children while they were in the room as it was hanging on a low shelf next to the eating area. In the Infant Classroom a diaper changing table was observed to be unlocked making a bottle of glass cleaner, 2 bottles of disinfectant, two containers of Aquaphor, and 1 container if A + D Ointment labeled, "Keep out of the reach of children" accessible to children in the room.

Correction Required: Cleaning materials and other toxic materials shall be kept in an area or container that is locked or made inaccessible to children.

Regulation: 3270.91(a)

Description: Stairs, exits, etc. unobstructed

Noncompliance Area: In the Preschool Classroom there was a dollhouse and a bookshelf obstructing one of the exit doors from the classroom.

Correction Required: Stairways, hallways, exits from rooms, exits from the facility and other means of egress serving as an exit shall be unobstructed.

Regulation: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: The two most recent mandated reporter trainings on file for Staff #1 are dated 7/2/20 and 7/3/25, more than 60 months apart. The two most recent mandated reporter trainings on file for Staff #2 are dated 1/23/20 and 2/6/25, more than 60 months apart.

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

Regulation: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: In the PreK Room, both a red and clear plastic bin were observed to be cracked posing a cutting hazard to the children in care.

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)(4)/3270.182(3)

Description: Written consent/Consent for emergency medical care required prior to admission

Noncompliance Area: The Emergency Contact Form in the file for Child #2 lacked written consent signed by a parent for emergency medical care.

Correction Required: Emergency contact information must include the written consent signed by a parent for emergency medical care. A child's record shall contain signed parental consent for emergency medical care for the child. Written consent is required prior to admission.

Regulation: 3270.124(b)(7)

Description: Name/address/phone release person

Noncompliance Area: The Emergency Contact Forms for Child #2 and #7 lacked the address of the individual designated by the parent to whom the child may be released. The Emergency Contact Form for Child #3 lacked the telephone number of the individual designated by the parent to whom the child may be released. The Emergency Contact Form for Child #5 lacked the name, address, and telephone number of the individual designated by the parent to whom the child may be released. The Emergency Contact Form for Child #6 lacked the address and telephone number of the individual designated by the parent to whom the child may be released.

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

Regulation: 3270.131(a)/3270.182(1)

Description: Health information/Initial and subsequent health reports

Noncompliance Area: The files for Child #2 and #3, enrolled for more than 60 days lacked an initial health report

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. A child's record shall contain initial and subsequent health reports.

Regulation: 3270.131(b)(2)/3270.182(1)

Description: Toddler/preschool: updated health report every 12 months/Initial and subsequent health reports

Noncompliance Area: Although the file for Child #6 contained a valid Health Reports at the time of the Renewal Inspection, it was observed that the health reports for Child #6 was updated in an interval greater than 12 months.

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. A child's record shall contain initial and subsequent health reports.

Regulation: 3270.131(d)(5)/3270.131(e)(1)

Description: Immunization record/Exemption documentation from parent/guardian

Noncompliance Area: The file for Child #1, enrolled for more that 60 days at the facility, did not contain documentation of a 2nd dose of the Rotavirus vaccination, a 2nd dose of the DTAP vaccination, a 2nd dose of the HIB vaccination, a 2nd dose of the Pneumococcal vaccination, and 2nd dose of the Polio vaccination as required based on the child's age as per the ACIP recommended schedule. The file for Child #4, enrolled for more that 60 days at the facility, did not contain documentation of a Hepatitis A vaccination as required based on the child's age as per the ACIP recommended schedule.

Correction Required: A health report shall include a review of the child's immunized status according to recommendations of the ACIP. The facility shall implement dismissal policies in accordance with the Department of Health regulation in 28 Pa. Code § 27.77 (relating to immunization requirements for children in child care group settings). Child #2 and #4 must be dismissed from care by close of business 4/10/25 and may only return to care when the immunization record is updated or when a parent provides a written, signed exemption letter.

Regulation: 3270.151(c)(3)

Description: Exam communicable disease

Noncompliance Area: The file for Staff #5 contained a Health Assessment that stated they had a communicable disease. There was no accompanying documentation stating the condition and the risk it might pose to other exposed to this individual.

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

Regulation: 3270.182(5)

Description: Consent for administration of minor first-aid required prior to admission

Noncompliance Area: The Emergency Contact form for Child #2 lacked signed parental consent for administration of minor first-aid procedures by facility staff.

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

Regulation: 3270.192(2)(iv)

Description: Transcript, diploma and letters

Noncompliance Area: The file for Staff #7 contained a degree and foreign transcripts and therefore their credentials could not be determined. (See LIS Code Sheet)

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: 3270.27(f)

Description: Emergency plan

Noncompliance Area: The Emergency Plan Delivery documentation that was submitted during the renewal inspection lacked information on the local municipality that the emergency plan was shared.

Correction Required: The operator shall send a copy of the emergency plan and subsequent plan updates to the local municipality and to the county emergency management agency.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: Although the files for Staff #1, #2, #4, and #6 contained current State Police Clearances at the time of Renewal Inspection, it was observed that Staff #1, #2, #4, and #6 did not obtain State Police Clearances within 60 months of the previous clearance. The file for Staff #3 contained State Police, Child Abuse, and FBI Clearances that were updated in an interval greater than 60 months. The file for Staff #8 contained a State Police Clearance Request. The file for Staff #9 contained an FBI Clearance that was updated in an interval greater than 60 months. (SEE LIS CODE SHEET)

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: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: Staff person #2 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Get Started with Center-based Care: Building Blocks for Quality.

Correction Required: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10 or (g)1-10. Until such time as the required training has been completed, staff person #2 must be supervised, when interacting with children, at a minimum by an AGS who has completed all preservice trainings and has all qualifications to care for children unsupervised. If there are no staff person(s) available to supervise staff person #2, staff person #2 may not work in a child-care position at the facility.

Regulation: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: Staff person #1 completed her current mandated reporter training on 2.6.25, more than 60 months after the previous training dated 1.23.20.

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

Regulation: 3270.123(a)(1)

Description: Amount of fee

Noncompliance Area: The child file for Child #3 contained a current financial agreement form that lacked the fee amount.

Correction Required: An agreement shall specify the amount of the fee to be charged per day or per week.

Regulation: 3270.123(a)(3)

Description: Services proceeded

Noncompliance Area: The child file for Child #1 contained a current child service report dated 1/30/24 which was not completed every 6 months. The child file for Child #2, Child #4, and Child #5 contained a child service report on file that lacked a date therefore it cannot be determined if it was completed every 6 months. The child file for Child #6 lacked an updated child service report; the last one on file is dated 4/28/22. The child file for Child #7 contained a current child service report dated 1/23/24 which was not completed every 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: 3270.131(b)(1)

Description: Infant: updated health report every 6 months

Noncompliance Area: The child file for Child #1, who is a young toddler, was observed to contain health reports that were conducted more than 6 months apart; those health report dates are dated 2/1/23 and 1/31/24.

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)/3270.182(1)

Description: Toddler/preschool: updated health report every 12 months/Initial and subsequent health reports

Noncompliance Area: The child file for Child #2, who is a preschool child, was observed to lack an updated health report; the most recent health report on file is dated 1/19/22 which is more than 12 months old. The child file for Child #4, who is a preschool child, was observed to lack an updated health report; the most recent health report on file is dated 1/20/23 which is more than 12 months old.

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. A child's record shall contain initial and subsequent health reports.

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

Description: Immunization record/Dismissal policy

Noncompliance Area: The child file for Child #5 contained a current immunization record that was observed to lack the Hep B vaccination and there was not exemption on file.

Correction Required: A health report shall include a review of the child's immunized status according to recommendations of the ACIP. The facility shall implement dismissal policies in accordance with the Department of Health regulation in 28 Pa. Code § 27.77 (relating to immunization requirements for children in childcare group settings). Child #5 must be dismissed from care by close of business 4/10/24 and may only return to care when the immunization record is updated or when a parent provides a written, signed exemption letter.

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 staff file for Staff person #2, contained a current health assessment dated 11/8/23 which was conducted more than 24 months from the previously dated 6/4/21 health assessment on file. The staff file for Staff person #3 contained a current health assessment dated 5/9/23 which was not conducted prior to providing initial service in a childcare setting. The staff file for Staff person #4, lacked a current health assessment; the last health assessment on file is dated 3/15/22 which is more than 24 months old. The staff file for Staff person #5, contained a current health assessment dated 3/24/23 which was conducted more than 24 months from the previously dated 6/25/20 health assessment on file. The staff file for Staff person #7, contained a current health assessment dated 3/10/23 which was conducted more than 24 months from the previously dated 2/3/20 health assessment on file. The staff file for Staff person #8, lacked a current health assessment; the last health assessment on file is dated 12/6/21 which is more than 24 months old.

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)

Description: Mantoux TB

Noncompliance Area: The staff file for Staff person #3 contained a current tuberculosis screening and results dated 5/9/23 which was not conducted prior to providing initial service in a childcare setting.

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.

Regulation: 3270.151(c)(3)

Description: Exam communicable disease

Noncompliance Area: The staff file for Staff person #6 contained a current health assessment dated 3/30/23 that had 'Yes' checked off to having a communicable disease and additional information describing the condition and the risk it might pose was not provided.

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

Regulation: 3270.181(c)

Description: Emergency info/agreement updated 6 mos

Noncompliance Area: The child file for Child #1 contained a current financial agreement and emergency contact form that were not reviewed and signed by the parent every 6 months; the two most recent reviews of the financial agreement and emergency contact form were reviewed and signed on 5/19/23 and 12/14/23. The child file for Child #2 contained a current financial agreement and emergency contact form that were not reviewed and signed by the parent every 6 months; the two most recent reviews of the financial agreement were reviewed and signed on 8/28/22 and 12/13/23 and the emergency contact form was reviewed and signed on 11/30/22 and 12/13/23. The child file for Child #4 contained a current financial agreement and emergency contact form that were not reviewed and signed by the parent every 6 months; the two most recent reviews of the financial agreement and emergency contact form were reviewed and signed on 5/30/23 and 12/19/23. The child file for Child #5 contained a current financial agreement and emergency contact form that were not reviewed and signed by the parent every 6 months; the two most recent reviews of the financial agreement were reviewed and signed on 5/19/23 and 12/18/23 and the emergency contact form was last reviewed and signed on 5/22/23 which is more than 6 months. The child file for Child #6 contained a current financial agreement and emergency contact form that were not reviewed and signed by the parent every 6 months; the two most recent reviews of the financial agreement and emergency contact form were reviewed and signed on 5/18/23 and 12/14/23. The child file for Child #7 contained a current financial agreement and emergency contact form that were not reviewed and signed by the parent every 6 months; the two most recent reviews of the financial agreement and emergency contact form were reviewed and signed on 5/28/23 and 12/13/23.

Correction Required: A parent is required to review and update the emergency contact information and the financial agreement at least once in a 6-month period or as soon as there is a change in the information.

Regulation: 3270.182(5)

Description: Consent for administration of minor first-aid required prior to admission

Noncompliance Area: The child file for Child #3 that contained a current emergency contact information form that lacked signed parental consent for administration of minor first-aid procedures by facility staff.

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

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: Staff person #3 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Health and Safety Training. Staff person #3 has since completed the training on 1/2/24.

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

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The file for Staff person #1 was observed to contain a National Sex Offender Registry (NSOR) check on file dated 1/3/24 which was not obtained within 90 days of hire (See IS CODE SHEET) as required for provisional hiring under the CPSL.

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

Regulation: 3270.20(a)(1)

Description: Inpatient hospitalization or ER treatment of child

Noncompliance Area: During a complaint investigation conducted on 2/21/24, it was confirmed that Child #1 received an injury while in care on 11/10/23 and had gone to the emergency room for stitches and Western Region was not notified within 24 hours of the incident.

Correction Required: The operator shall immediately notify a child's parent and shall telephone notice to the appropriate regional office within 24 hours if a child in care at the facility is hospitalized or receives emergency room treatment.

Regulation: 3270.20(b)

Description: Mail or deliver written report to regional office within 72 hours

Noncompliance Area: During a complaint investigation conducted on 2/21/24, it was confirmed that Child #1 received an injury while in care on 11/10/23 and had gone to the emergency room for stitches and the operator had not sent Western Region the written incident report until 11/14/23 which was more than 72 hours after the emergency room treatment.

Correction Required: The operator shall mail or deliver a written report to the appropriate regional office within 72 hours after hospitalization of a child in care, emergency room treatment of a child in care, death of a child in care, a facility fire requiring the services of a fire department.

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: Staff person #1 had not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Pediatric First Aid/CPR. Staff person #1 has since obtained Pediatric First Aid/CPR on 10/10/23.

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

Regulation: 3270.113(a)

Description: Supervised at all times

Noncompliance Area: At approximately 1:15pm, during naptime in the Discovery 2 and PreK Room, depending on where staff were positioned in the room, they could not adequately supervise one of the napping children due to where the child's mat was placed and furniture obstructing the Staff's ability to see and assess that child who was napping.

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: 3270.123(a)(3)

Description: Services proceeded

Noncompliance Area: The child file for Child #1, Child #2, Child #3, Child #4, Child #5, Child #6, Child $7, Child #8, and Child #10 all lacked a current child service report on file at least once every 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(b)(6)

Description: Insurance coverage information

Noncompliance Area: The child file for Child #9 contained an emergency contact information form that was observed to lack the health insurance policy number.

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

Regulation: 3270.124(b)(7)

Description: Name/address/phone release person

Noncompliance Area: The child file for Child #5, Child #6 and Child #10 contained an emergency contact information form that was observed to lack the address for one of the designated release persons listed. The child file for Child #7 contained an emergency contact information form that was observed to lack the address for four of the designated release persons listed.

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: 3270.131(a)

Description: Health information

Noncompliance Area: The child file for Child #10 was observed to lack an initial health report.

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: 3270.131(b)(1)

Description: Infant: updated health report every 6 months

Noncompliance Area: The child file for Child #1, who is a young toddler, contained two health reports on file dated 5/16/22 and 12/1/22 that were not conducted every 6 months from the previously dated health report. The child file for Child #2, who was a young toddler at the time, contained two health reports on file dated 4/20/23 and 4/20/22 that were not conducted every 6 months from the previously dated health report. The child file for Child #3, was observed to lack an updated health report; the most recent health report on file is dated 6/27/22. The child file for Child #4, who was a young toddler at the time, lacked an updated health report every 6 months; the dates of the two most recent health reports on file were dated 8/19/22 and 5/3/21.

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 child file for Child #5, who is a preschool aged child, was observed to lack an updated health report; the most recent health report on file is dated 12/15/21. The child file for Child #7, who is a preschool aged child, was observed to contain two health reports dated 3/5/21 and 5/3/22 that were not obtained at least every 12 months from the previously dated health report.

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

Description: Immunization record/Dismissal policy

Noncompliance Area: The child file for Child #5 and Child #8 lacked a flu shot for 2022.

Correction Required: A health report shall include a review of the child's immunized status according to recommendations of the ACIP. The facility shall implement dismissal policies in accordance with the Department of Health regulation in 28 Pa. Code § 27.77 (relating to immunization requirements for children in childcare group settings). Child #5 and Child #8 must be dismissed from care by close of business 4/25/23 and may only return to care when the immunization record is updated or when a parent provides a written, signed exemption letter.

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: The facility emergency plan lacked information regarding a continuity of operations plan. Staff person #4 and Staff person #5 had not completed the one-hour Pennsylvania Health and Safety Update 2022 training by 12/30/22 as required per announcement C-22-06. Staff person #4 completed the training on 1/2/23 and Staff person #5 completed the training on 1/5/23.

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 staff file for Staff person #8, contained a current health assessment dated 6/15/22 which was conducted more than 24 months from the previously dated 6/12/20 health assessment on file. The staff file for Staff person #9, contained a current health assessment dated 9/29/22 which was conducted more than 24 months from the previously dated 3/31/20 health assessment on file.

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

Regulation: 3270.181(c)

Description: Emergency info/agreement updated 6 mos

Noncompliance Area: The child file for Child #1 contained a financial agreement that was not reviewed and updated by the parent at least once in a 6-month period and needs reviewed; the dates of the most recent reviews for the financial agreement were 8/3/22 and 12/2/21. The child file for Child #2 contained an emergency contact information form that was not reviewed and updated by the parent at least once in a 6-month period; the dates of the most recent review for the emergency contact information form were 11/29/22 and 3/24/22. The child file for Child #3 contained a financial agreement that was not reviewed and updated by the parent at least once in a 6-month period; the date of the most recent review for the financial agreement was 8/9/22. The child file for Child #4 contained a financial agreement and emergency contact information form that were not reviewed and updated by the parent at least once in a 6-month period; the dates of the most recent review for the financial agreement was 8/3/22 and for the emergency contact information form were 12/6/22 and 3/26/22. The child file for Child #5 contained a financial agreement that was not reviewed and updated by the parent at least once in a 6-month period and needs reviewed; the dates of the most recent review for the financial agreement was 9/8/22. The child file for Child #6 contained a financial agreement and emergency contact information form that were not reviewed and updated by the parent at least once in a 6-month period; the dates of the most recent review for the financial agreement was 8/10/22 and for the emergency contact information form were 12/1/22 and 3/28/22. The child file for Child #8 contained a financial agreement that was not reviewed and updated by the parent at least once in a 6-month period and needs reviewed; the dates of the most recent review for the financial agreement was 8/10/22. The child file for Child #10 contained a financial agreement and emergency contact information form that were not reviewed and updated by the parent at least once in a 6-month period; the dates of the most recent review for the financial agreement was 8/2/22 and for the emergency contact information form were 3/27/22 and 11/30/22.

Correction Required: A parent is required to review and update the emergency contact information and the financial agreement at least once in a 6-month period or as soon as there is a change in the information.

Regulation: 3270.182(1)

Description: Initial and subsequent health reports

Noncompliance Area: The child file for Child #3, was observed to lack an updated health report; the most recent health report on file is dated 6/27/22. The child file for Child #5, who is a preschool aged child, was observed to lack an updated health report; the most recent health report on file is dated 12/15/21. The child file for Child #10 was observed to lack an initial health report.

Correction Required: A child's record shall contain initial and subsequent health reports.

Regulation: 3270.192(5)

Description: Two written references

Noncompliance Area: The staff files for Staff person #4 and Staff person #5 contained two pages identified as the two nonfamily references. However, one of the two references in each staff's file appeared to be identical, with the exact same wording placement on the page and typeface. Therefore, one reference in each file were deemed unacceptable and, as result, each lacks one nonfamily reference.

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

Regulation: 3270.27(a)(6)

Description: Emergency plan

Noncompliance Area: An annual emergency drill conducted on 11/9/22 lacked the total number of children who participated, time it took to complete drill, special accommodations the facility used for any category of children, and any problems encountered that is required to be documented when conducting the emergency drill, per announcement C-22-04.

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

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

Description: Age and Training

Noncompliance Area: The staff file for Staff person #6 contained current Pediatric First Aid/CPR training dated 3/29/22 which was not updated prior to the previous Pediatric First Aid/CPR certificate on file expiring on 2/18/22.

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

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

Description: Fire safety - 1 yr.

Noncompliance Area: The staff file for Staff person #6 was observed to not have completed fire safety training on annual basis as evidence by the last two documented fire safety trainings were dated 10/11/21 and 4/5/23.

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

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: Staff person #4 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): 10 hr. health and safety training.

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 will have until 5/12/23 to complete the required training. Until such time as the required training has been completed, Staff person #4 must be supervised, when interacting with children, by an AGS who has completed the required training related to this citation. If there are no staff available to supervise Staff person #4, Staff person #4 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: The staff file for Staff person #2 was observed to contain a valid disclosure statement dated 2/1/23 which was not signed at time of hire (See IS CODE SHEET). The staff file for Staff person #3 was observed lack a National Sex Offender Registry (NSOR) certificate within 45 days of hire (See IS CODE SHEET); a NSOR certificate on file is dated 1/31/23.

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: 3270.35(b)/3270.192(2)(ii)

Description: Group sup qualifications/Exp, educ., training prior to facility

Noncompliance Area: The staff file for Staff person #6, who is functioning as a group supervisor, lacked proper documentation of education and childcare experience to qualify as a group supervisor.

Correction Required: A group supervisor shall have attained one of the qualification levels specified at §3270.35(b)(1)-(4). A facility person's record shall include verification of child care experience, education and training prior to service at the facility.

Regulation: 3270.36(b)(1)/3270.192(2)(iv)

Description: HS/GED + 30 credits/Transcript, diploma and letters

Noncompliance Area: The staff file for Staff person #4 and Staff person #5, who is functioning as an assistant group supervisor, contained a foreign degree that lacked additional documentation to show that the degree had been evaluated to determine its validity and whether or not it meets qualifications for the position.

Correction Required: An assistant group supervisor shall have a high school diploma or a general educational development certificate and 30 credit hours from an accredited college or university in early childhood education, child development, special education, elementary education or the human services field. 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)(3)/3270.192(2)(ii)

Description: HS/GED, 15 credits + 1 yr/Exp, educ., training prior to facility

Noncompliance Area: The staff file for Staff person #7, who is functioning as an assistant group supervisor, was observed to lack one year of childcare experience.

Correction Required: An assistant group supervisor shall have a high school diploma or a general educational development certificate, 15 credit hours from an accredited college or university in early childhood education, child development, special education, elementary education or the human services field and 1 year of experience with children. A facility person's record shall include verification of child care experience, education and training prior to service at the facility.

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

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

Noncompliance Area: The staff file for Staff person #1 and Staff person #3, who is functioning as an assistant group supervisor, was observed to lack two years of childcare experience.

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 prior to service at the facility.

Regulation: 3270.76

Description: Building Surfaces

Noncompliance Area: In Preschool A Room the door to the restroom inside the classroom was observed to have a section of damaged wood on the exterior of the door causing it not to be in good repair.

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

Regulation: 3270.95(a)/3270.95(b)

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

Noncompliance Area: Upon review of the facility's 30-day fire testing documentation, the following tests were observed to have been conducted more than 30 days apart: 3/17/23 - 4/18/23.

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

Regulation: 3270.131(a)

Description: Health information

Noncompliance Area: The child file for Child #1 (See LIS Code sheet) contained an initial health assessment on file dated 10/27/21 which was not provided within 90 days following first day of attendance. The child file for Child #3 (See LIS Code sheet) contained an initial health assessment on file dated 3/15/21 which was not provided within 90 days following first day of attendance.

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: 3270.131(b)(2)

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

Noncompliance Area: The child file for Child #4, an older toddler, contained a current health report dated 4/9/22 which was not updated at least every 12 months from the previously dated 3/16/21 health report. The child file for Child #7, an older toddler, lacked a current health report for 2022; the last health report on file is dated 3/5/21.

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: 3270.131(e)(1)

Description: Exemption documentation from parent/guardian

Noncompliance Area: The child file for Child #7 lacked a flu shot for 2021.

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 staff file for Staff person #2 contained a current health assessment dated 12/28/21 which was conducted more than 24 months from the previously dated 9/5/19 health assessment. The staff file for Staff person #3 contained a current health assessment dated 10/10/21 which was conducted more than 24 months from the previously dated 9/15/19 health assessment. The staff file for Staff person #4 contained a current health assessment dated 6/25/20 which was conducted more than 24 months from the previously dated 4/24/18 health assessment. The staff file for Staff person #5 contained a current health assessment dated 3/30/22 which was conducted more than 24 months from the previously dated 3/3/20 health assessment. The staff file for Staff person #6 contained a current health assessment dated 9/28/21 which was conducted more than 24 months from the previously dated 4/23/19 health assessment. The staff file for Staff person #7 contained a current health assessment dated 10/19/21 which was conducted more than 24 months from the previously dated 4/1/19 health assessment. The staff file for Staff person #8 contained a current health assessment dated 4/24/21 which was conducted more than 24 months from the previously dated 3/27/19 health assessment. The staff file for Staff person #9 contained a current health assessment dated 11/5/21 which was conducted more than 24 months from the previously dated 11/1/19 health assessment. The staff file for Staff person #10 contained a current health assessment dated 12/29/21 which was conducted more than 24 months from the previously dated 11/13/19 health assessment. The staff file for Staff person #11 contained a current health assessment dated 3/29/22 which was conducted more than 24 months from the previously dated 2/12/20 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.

Regulation: 3270.151(c)(5)

Description: Physician/CRNP assessment

Noncompliance Area: The staff file for Staff person #12 contained a health assessment that indicated the individual was not suitable to provide child care.

Correction Required: An adult health assessment must include the physician's or CRNP's assessment of the person's suitability to provide child care.

Regulation: 3270.181(c)

Description: Emergency info/agreement updated 6 mos

Noncompliance Area: The child file for Child #1 contained a financial agreement and emergency contact information form that were not reviewed and updated by the parent at least once in a 6 month period; the two most recent dates of review were 8/29/21 and 3/27/22. The child file for Child #2 contained a financial agreement and emergency contact information form that were not reviewed and updated by the parent at least once in a 6 month period; the two most recent dates of review were 8/3/21 and 3/25/22. The child file for Child #3 contained a financial agreement and emergency contact information form that were not reviewed and updated by the parent at least once in a 6 month period; the two most recent dates of review were 7/28/21 and 3/24/22. The child file for Child #4 contained a financial agreement and emergency contact information form that were not reviewed and updated by the parent at least once in a 6 month period; the two most recent dates of review were 8/1/21 and 3/27/22. The child file for Child #5 contained a financial agreement and emergency contact information form that were not reviewed and updated by the parent at least once in a 6 month period; the two most recent dates of review were 7/28/21 and 3/25/22. The child file for Child #6 contained a emergency contact information form that was not reviewed and updated by the parent at least once in a 6 month period; the two most recent dates of review were 8/3/21 and 3/25/22. The child file for Child #7 contained a financial agreement and emergency contact information form that were not reviewed and updated by the parent at least once in a 6 month period; the two most recent dates of review were 8/2/21 and 3/27/22.

Correction Required: A parent is required to review and update the emergency contact information and the financial agreement at least once in a 6-month period or as soon as there is a change in the information.

Regulation: 3270.31(e)

Description: Age and Training

Noncompliance Area: The staff file for Staff person #1, Staff person #2, Staff person #4, Staff person #6, and Staff person #7 contained 5 out of 12 hours of child care training for 12/19/20-12/19/21.

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 staff file for Staff person #7 contained current pediatric first-aid/CPR training dated 9/29/20 which was not renewed on or before the previously dated 9/17/18 pediatric first-aid/CPR certification expired.

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: 3270.32(a)/3270.192(2)(iii)

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

Noncompliance Area: The staff file for Staff person #2 contained current mandated reporter training dated 7/2/20 which was not renewed within 60 months of the previously dated 5/18/15 training certificate on file. The staff file for Staff person #4 contained current mandated reporter training dated 3/20/22 which was not renewed within 60 months of the previously dated 10/11/16 training certificate 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 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 staff file for Staff person #1 contained an updated Child Abuse clearance dated 3/5/21 and an updated FBI clearance dated 3/4/21, both of which were not renewed within 60 months of the previously dated 1/7/16 Child Abuse clearance and previously dated 10/8/15 FBI clearance expiring. The staff file for Staff person #2 contained an updated Child Abuse clearance dated 3/8/21 which was not renewed within 60 months of the previously dated 1/5/16 Child Abuse clearance expiring.

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: 3270.95(a)/3270.95(b)

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

Noncompliance Area: Upon review of the facility's 30 day testing log of the fire detection system, the following tests were observed to be more than 30 days apart: 6/11/21 - 7/22/21, 7/22/21 - 8/31/21, 10/7/21 - 11/9/21, and 2/10/22 -3/22/22,

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.