Let Me Be Me Shining Starz Academy

Regulation: 3270.27(c)

Description: Training regarding plan

Noncompliance Area: During the renewal inspection completed on 04/08/26 the file reviewed for staff person #2 did not include annual emergency plan training.

Correction Required: The operator shall assure that each facility person receives training regarding the emergency plan at the time of initial employment, on an annual basis and at the time of each plan update. The operator shall document the date of each training and the names of all facility persons who received the training and kept on file at the facility.

Regulation: 3270.31(e)

Description: Age and Training

Noncompliance Area: During the renewal inspection completed on 04/08/26 the file reviewed for staff person #3 did not include 12 clock hours of childcare training.

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

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

Description: Fire safety - 1 yr.

Noncompliance Area: During the renewal inspection completed on 04/08/26 the file reviewed for staff person #1, staff person #2, and staff person #3 contained expired fire safety training.

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

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: During the renewal inspection completed on 04/08/26 the file reviewed for staff person #1 hired (see code sheet) contained an NSOR certificate dated 12/03/20 and a mandated reporter certificate dated 04/2018 which is more than 60 months old. The file reviewed for staff person #2 hired (see code sheet) contained an NSOR certificate dated 12/03/20 which is more than 60 months old.

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 #1 and staff person #2 may not work in a childcare position at the facility.

Regulation: 3270.95(a)

Description: Devices must be compliant

Noncompliance Area: During the renewal inspection completed on 04/08/26 the annual fire report reviewed was more than a year old.

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)).

Regulation: 3270.123(a)(3)

Description: Services proceeded

Noncompliance Area: During the renewal inspection on 04/02/25 the file reviewed for child #1 and child #2 did not include a child service report.

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(f)/3270.181(c)

Description: Updated every 6 months/Emergency info/agreement updated 6 mos

Noncompliance Area: During the renewal inspection on 04/02/25 the emergency contact form and fee agreement reviewed for child #1 was not reviewed/updated within 6-month time period.

Correction Required: The parent shall update in writing emergency contact information once in a 6-month period or as soon as there is a change in the information. 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: 3270.18(a)

Description: On file at facility

Noncompliance Area: During the renewal inspection on 04/02/25 provider was unable to produce current liability insurance upon request.

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

Regulation: 3270.27(a)(6)

Description: Emergency plan

Noncompliance Area: During the renewal inspection on 04/02/25 there was no documentation that emergency drills was conducted annually. Last documented annual emergency drill was dated 01/08/24.

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: During the renewal inspection on 04/02/25 the file reviewed for staff person #3 did not include pediatric first and CPR training.

Correction Required: Staff persons shall complete professional development in pediatric first aid and pediatric cardiopulmonary resuscitation within 90 days of hire.

Regulation: 3270.34(a)(6)

Description: Staff evaluations

Noncompliance Area: During the renewal inspection on 04/02/25 the file reviewed for staff person #2 did not include updated written evaluation. Evaluation reviewed was dated 09/2023.

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: 3270.52

Description: Mixed Age Level

Noncompliance Area: During the renewal inspection on 04/02/25 upon arrival at approximately 8am, CR observed staff person #1 alone caring for (4) children. Children continued to arrive resulting in staff person #1 being alone caring for (8) children, youngest child being an infant.

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

Regulation: 3270.54(a)

Description: Two facility persons present in facility

Noncompliance Area: During the renewal inspection on 04/02/25 upon arrival at approximately 8am, CR observed staff person #1 in the facility alone with (4) children.

Correction Required: At least two facility persons shall be present in the facility when two or more children are in care. At a minimum, one of the facility persons shall be a staff person.

Regulation: 3270.34(c)

Description: Employed and present 30 hrs/wk

Noncompliance Area: During the unannounced monitoring inspection on 02/25/25 the director was not present at the facility. Director has not been working minimum of 30 hours per week. Continued noncompliance from unannounced monitoring on 11/14/24 and 01/21/25.

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

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: During the unannounced monitoring on 01/21/25 the file for staff person #1 hired (see code sheet) contained a DHS FBI clearance that was more than 60 months old. DHS FBI clearance reviewed was dated 07/15/17. Continued noncompliance from renewal inspection on 09/04/24.

Correction Required: 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(c)

Description: Employed and present 30 hrs/wk

Noncompliance Area: During the unannounced monitoring inspection, on 01/21/25, the record reviewed for staff person #1(who was identified as the director) did not include an updated FBI fingerprint clearance. The FBI fingerprint clearance in the record was dated 07/15/2017, which is more than 60-months old. Therefore, a director is not employed at the facility. Continued noncompliance from unannounced monitoring on 11/14/24.

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

Regulation: 3270.151(c)(1)/3270.192(3)

Description: Physical examination/Health assessment, TB test

Noncompliance Area: During the unannounced monitoring on 11/14/24 the file reviewed for staff person #2 did not contain an updated health assessment. Continued noncompliance from renewal inspection on 09/04/24.

Correction Required: An adult health assessment must include a physical examination. 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: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: During the unannounced monitoring on 11/14/24 the file for staff person #1 hired (see code sheet) contained a DHS FBI clearance that was more than 60 months old. DHS FBI clearance reviewed was dated 07/15/17. Continued noncompliance from renewal inspection on 09/04/24.

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(c)

Description: Employed and present 30 hrs/wk

Noncompliance Area: During the unannounced monitoring inspection, on 11/14/24, the record reviewed for staff person #1(who was identified as the director) did not include an updated FBI fingerprint clearance. The FBI fingerprint clearance in the record was dated 07/15/2017, which is more than 60-months old. Therefore, a director is not employed at the facility.

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

Regulation: 3270.124(b)(6)

Description: Insurance coverage information

Noncompliance Area: During the renewal inspection on 9/4/24 the emergency contact form reviewed for child #1, child #2 and child #3 did not include policy number for health insurance coverage.

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: 3270.151(c)(1)/3270.192(3)

Description: Physical examination/Health assessment, TB test

Noncompliance Area: During the renewal inspection on 9/4/24 the file reviewed for staff person #2 did not contain an updated health assessment.

Correction Required: An adult health assessment must include a physical examination. A facility person's record shall include a written report of initial and subsequent health assessments, including the results of initial and subsequent tuberculin skin tests, x-rays or other medical documentation necessary to confirm freedom from communicable tuberculosis.

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

Description: Age and Training

Noncompliance Area: During the renewal inspection on 9/4/24 the file reviewed for staff person #1, staff person #2, and staff person #3 did not contain certificate for pediatric first aid/ cpr from a PQAS certified instructor.

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: During the renewal inspection on 9/4/24 the file reviewed for staff person #1, staff person #2, and staff person #3 did not contain updated annual fire safety training.

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: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: During the renewal inspection on 9/4/24 the file reviewed for staff person #3 hired (see code sheet) contained a PSP criminal clearance and DHS FBI clearance that was more than 60 months old. Staff person #3 was also observed caring for (2) children alone. The file for staff person #1 hired (see code sheet) contained a DHS FBI clearance that was more than 60 months old.

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 facility person #3 may not work in a childcare position at the facility.

Regulation: 3270.75(c)

Description: Has all items

Noncompliance Area: During the renewal inspection on 9/4/24 the first aid kit observed in childcare space did not contain gloves.

Correction Required: A first-aid kit must contain the following: soap, an assortment of adhesive bandages, sterile gauze pads, tweezers, tape, scissors and disposable, nonporous gloves.

Regulation: 3270.95(a)

Description: Devices must be compliant

Noncompliance Area: During the renewal inspection on 9/4/24 provider was unable to demonstrate fire detection and unable to confirm if system was interconnected.

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)).

Regulation: 3270.124(a)/3270.181(c)

Description: Each child emergency contact person/Emergency info/agreement updated 6 mos

Noncompliance Area: During the renewal inspection on 09/27/23 the fee agreement reviewed for child #1 was expired and there was no emergency contact form in the file.

Correction Required: Emergency contact information is required for each enrolled child. Emergency contact information must reference who shall be contacted in an emergency. 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: 3270.131(b)(2)/3270.182(1)

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

Noncompliance Area: During the renewal inspection on 09/27/23 the health assessment reviewed for child #1 was expired, dated 06/28/22.

Correction Required: The operator shall require the parent to provide an updated health report at least every 12 months for an older toddler or preschool child. A child's record shall contain initial and subsequent health reports.

Regulation: 3270.151(c)(1)/3270.192(3)

Description: Physical examination/Health assessment, TB test

Noncompliance Area: During the renewal inspection on 09/27/23 the file reviewed for staff person #2 and staff person #3 did not contain health assessment.

Correction Required: An adult health assessment must include a physical examination. 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: 3270.27(c)

Description: Training regarding plan

Noncompliance Area: During the renewal inspection on 09/27/23 the file reviewed for staff person #3 did not contain emergency plan training at the time of initial employment.

Correction Required: The operator shall assure that each facility person receives training regarding the emergency plan at the time of initial employment, on an annual basis and at the time of each plan update. The operator shall document the date of each training and the names of all facility persons who received the training and kept on file at the facility.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: During the renewal inspection on 09/27/23 the file reviewed for staff person #1 and staff person #2 contained expired mandated reporter training. The file reviewed for staff person #3 did not contain child abuse clearance. The file reviewed for staff person #2 did not contain disclosure statement.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). The operator is required to submit to the Children and Youth Agency a plan of supervision or alternate arrangement as required by the Child Protective Services Law. Facility Person 3 may not work in a childcare position at the facility. A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Facility Person # 3 may not work in a childcare position at the facility.

Regulation: 3270.95(a)/3270.95(b)

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

Noncompliance Area: The facility fire detection system was not able to be tested as it is not accessible and there was no annual written documentation from a fire safety professional indicating that the fire detection system has been tested and is operable.

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. Submit annual written documentation from a fire safety professional indicating that the fire detection system has been tested and is operable. Ensure that this is done annually and retained with the fire drill log.

Noncompliance Area: Two children's records did not contain a child service report that had been completed within the past 6 months. (#1 and #4)

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). Complete and submit a current up-to-date child service report for the indicated children. Ensure that all child service reports are completed every 6 months in accordance with this regulation.

Noncompliance Area: Several children's records did not contain emergency contact and financial agreement information that had been updated within the past 6-months. (#1, #2, #3 and #4)

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. Obtain and submit a written copy of the current up-to date emergency contact and financial agreement information for the identified children. Ensure that this information is updated every 6 months for all enrolled children as specified. Revise and submit written policies and procedures to ensure that children's emergency contact information is updated at least every 6 months or as soon as the information changes.

Noncompliance Area: Two facility person's records did not include written verification of initial and/or annual emergency plan training. (#1- initial) (#2-annual)

Correction Required: The operator shall assure that each facility person receives training regarding the emergency plan at the time of initial employment, on an annual basis and at the time of each plan update. The operator shall document the date of each training and the names of all facility persons who received the training and kept on file at the facility. Provide and submit written verification of the completed training for all identified facility persons. Ensure that emergency plan training is completed and documented upon initial employment and annually.

Noncompliance Area: One staff person's record did not contain written verification of annual minimum 6 hours of child care training. (#2)

Correction Required: A staff person shall obtain an annual minimum of 6 clock hours of child care training. Obtain and submit written verification of annual minimum 6 hours of child care training for the identified staff person.

Noncompliance Area: One staff person's record did not contain written verification of annual fire safety training. (#3)

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. Obtain and submit written verification of annual fire safety training for the identified staff person.

Noncompliance Area: The facility was not in compliance with the CPSL and with Chapter 3490 (relating to protective services): One staff person's record did not contain the required CPSL hiring documents. (#1-hired 8/6/19- no mandated reported training and no dated/signed DISCLOSURE STATEMENT)

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). LACKING REQUIRED HIRING DOCUMENTS: 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. Obtain and submit a copy of the dated DISCLOSURE STATEMENT FORM and completed mandated reporter training for the identified staff person. Ensure that the DISCLOSURE STATEMENT form is appropriately signed, dated and retained in all facility person's files. Ensure that the mandated reporter training is completed within 90 days of hire as specified in the CPSL.

Noncompliance Area: One staff person's record did not contain written verification of education and experience for their assistant group supervisor position.(#1)

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. Obtain and submit written verification of education and experience for the identified staff person.

Noncompliance Area: The rear exit was obstructed by strollers.

Correction Required: Stairways, hallways, exits from rooms, exits from the facility and other means of egress serving as an exit shall be unobstructed. Remove the items and ensure that all stairways, hallways, exits from rooms, exits from the facility and other means of egress serving as an exit remain unobstructed. Notify staff of this requirement and submit written verification of staff notification that includes each staff person's signature.

Noncompliance Area: One staff person was observed changing a child's diaper and did not ensure that the child's hands were washed after being diapered. CONTINUING NON-COMPLIANCE

Correction Required: A staff person shall ensure that a child's hands are washed before meals and snacks, after toileting and after being diapered.The legal entity must arrange for all staff persons to be trained in proper hand washing procedures. Submit written verification of the completed training for all facility staff.

Noncompliance Area: Two children's records did not contain signed parental consent for emergency medical care and for administration of minor first-aid procedures by facility staff. (#1 and #4)

Correction Required: A child's record shall contain signed parental consent for emergency medical care for the child. Written consent is required prior to admission.A child's record shall contain signed parental consent for administration of minor first-aid procedures by facility staff. Written consent is required prior to admission.Obtain and submit written verification of signed parental consents for the identified children as specified in the regulation. Ensure that all children's records contain the required parental consents prior to admission.

Noncompliance Area: One facility person's record did not include written verification of emergency plan training at the time of initial employment. (#2) CONTINUING NON-COMPLIANCE

Correction Required: The operator shall assure that each facility person receives training regarding the emergency plan at the time of initial employment, on an annual basis and at the time of each plan update. The operator shall document the date of each training and the names of all facility persons who received the training and kept on file at the facility. Revise and submit written facility policies and procedures to ensure that emergency plan training is completed and properly documented at the time of initial employment and annually.

Noncompliance Area: The facility was not in compliance with the CPSL and with Chapter 3490 (relating to protective services): One facility person's record did not contain the required CPSL hiring documents. (#2-hired 10/15/17-no completed FBI- rap sheet missing pages)Documentation submitted on 7/11/19 did not include written verification of the completed FBI. CONTINUING NON-COMPLIANCE

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). LACKING REQUIRED HIRING DOCUMENTS: A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Facility Person #4 may not work in a child care position at the facility until the completed CPSL clearance documents have been submitted. Obtain and submit a copy of the completed FBI clearance, including the rap sheet for the identified staff persons. Ensure that all DISCLOSURE STATEMENT forms are completed in entirety and clearances with a record contain the attached rap sheets.

Noncompliance Area: Two children have been enrolled for more than 60 days and their records did not contain a current, up-to-date health report. (#1 and #2)

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. Obtain and submit a current up-to-date health report for the indicated children. Revise and submit written policy and procedures to ensure that children's health reports are completed and submitted as specified in this regulation.

Noncompliance Area: One staff person was observed changing a child's diaper and did not ensure that the child's hands were washed after being diapered. Documentation submitted on 7/11/19 did not include written verification of the completed training for all facility staff.

Correction Required: A staff person shall ensure that a child's hands are washed before meals and snacks, after toileting and after being diapered. The legal entity must arrange for all staff persons to be trained in proper hand washing procedures. Submit written verification of the completed training for all facility staff.

Noncompliance Area: One staff person's health assessment was not signed by a physician, physician's assistant or CRNP and did not contain written verification of the physician's or CRNP's assessment of the person's suitability to provide child care. (#3)

Correction Required: A health assessment shall be conducted and a report shall be written and signed by a physician, physician's assistant or CRNP. The signature must include the individual's professional title .An adult health assessment must include the physician's or CRNP's assessment of the person's suitability to provide child care. Obtain the required signature if the physician, physician's assistant or CRNP and submit written verification of the physician's or CRNP's assessment of the person's suitability to provide child care. Ensure that the staff health assessments include the required contents as specified in these regulations.

Noncompliance Area: The operator lacked verification of the annual written notification to local traffic safety authorities of the location of the facility and the program's use of pedestrian and vehicular routes around the day 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 day care facility. Provide and submit verification of written notification of the location of the facility and the program's use of pedestrian and vehicular routes around the day care facility to the local safety authorities as specified.

Noncompliance Area: Safe routes, including safe pedestrian crossways, pick-up and drop-off points and bike routes were not appropriately determined in the vicinity of the facility, communicated to the children and parents in writing and posted.

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

Noncompliance Area: Two children's records did not contain signed parental consent for emergency medical care and for administration of minor first-aid procedures by facility staff. (#1 and #4)

Correction Required: A child's record shall contain signed parental consent for emergency medical care for the child. Written consent is required prior to admission. A child's record shall contain signed parental consent for administration of minor first-aid procedures by facility staff. Written consent is required prior to admission. Obtain and submit written verification of signed parental consents for the identified children as specified in the regulation. Ensure that all children's records contain the required parental consents prior to admission/

Noncompliance Area: A copy of the 55 PA CODE 3270 regulations were not posted in a conspicuous location used by parents, with instructions for contacting the appropriate regional day care office posted at the same location.

Correction Required: The facility's current certificate of compliance and a copy of the applicable regulations under which the facility is certified shall be posted in a conspicuous location used by parents, with instructions for contacting the appropriate regional day care office posted at the same location. Post a copy of the facility's current certificate of compliance and regulations in a conspicuous location as specified.

Noncompliance Area: One facility person's record did not include written verification of emergency plan training at the time of initial employment. (#2) Documentation submitted on 7/11/19 did not include written verification written facility policies and procedures to ensure that emergency plan training is completed and properly documented at the time of initial employment and annually.

Correction Required: The operator shall assure that each facility person receives training regarding the emergency plan at the time of initial employment, on an annual basis and at the time of each plan update. The operator shall document the date of each training and the names of all facility persons who received the training and kept on file at the facility. Revise and submit written facility policies and procedures to ensure that emergency plan training is completed and properly documented at the time of initial employment and annually.

Noncompliance Area: One staff person's record did not contain written verification of annual minimum 6 hours of child care training. (#1)

Correction Required: A staff person shall obtain an annual minimum of 6 clock hours of child care training. Obtain and submit written verification of annual minimum 6 hours of child care training for the identified staff person.

Noncompliance Area: The facility was not in compliance with the CPSL and with Chapter 3490 (relating to protective services): Two facility person's records did not contain the required CPSL hiring documents. (#1-hired 5/1/18-no completed CHILD ABUSE and DISCLOSURE STATEMENT not signed by witness) (#2-hired 10/15/17-no completed FBI- rap sheet missing pages) CONTINUING DEFICIENCY -Documentation submitted on 7/11/19 did not include the completed FBI clearance and rap sheet.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). LACKING REQUIRED HIRING DOCUMENTS: A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Facility Person #1 and #4 may not work in a child care position at the facility until the completed CPSL clearance documents have been submitted. Obtain and submit a copy of the completed DISCLOSURE STATEMENT and a copy of the completed FBI clearance, including the rap sheet for the identified staff persons. Ensure that all DISCLOSURE STATEMENT forms are completed in entirety and clearances with a record contain the attached rap sheets. Revise and submit written policies and procedures regarding the CPSL hiring requirements to ensure that all staff persons (new and existing) have the required CPSL clearances documents in accordance with the CPSL.

Noncompliance Area: One facility person did not have an individual record that was presented at the time of the inspection. (#2)

Correction Required: An individual record is required for each facility person. Obtain and submit a copy of the completed file for the identified facility person. Ensure that each facility person has a completed individual record.

Noncompliance Area: The facility was not in compliance with the CPSL and with Chapter 3490 (relating to protective services): Two facility person's records did not contain the required CPSL hiring documents. (#1-hired 10/15/17-no completed FBI) (#2-no proof of requests for STATE POLICE, CHILD ABUSE, FBI and no signed DISCLOSURE STATEMENT)

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services).LACKING REQUIRED HIRING DOCUMENTS: 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 Persons #1 and #2 may not work in a child care position at the facility until the completed CPSL clearance documents have been submitted. Submit a copy of the required CPSL clearance documents for the identified staff persons and ensure that all facility persons have the required CPSL clearance documents in accordance with the CPSL.

Noncompliance Area: The rear exit was obstructed by strollers.

Correction Required: Stairways, hallways, exits from rooms, exits from the facility and other means of egress serving as an exit shall be unobstructed. Remove the strollers and ensure that all stairways, hallways, exits from rooms, exits from the facility and other means of egress serving as an exit remain unobstructed. Notify staff of this requirement and submit written verification of staff notification.

Noncompliance Area: No one at the facility has been checking for recalled toys or equipment since the previous director left.

Correction Required: Children's toys and equipment, including furniture and rest equipment, described as hazardous by the United States Consumer Product Safety Commission may not be used by children at the facility and may not be on the premises at the facility. At the time of inspection, the operator shall submit to the Department written affirmation on a form provided by the Department stating that the facility is in compliance with this requirement.

Noncompliance Area: Child #2 does not have health insurance policy number in their record.

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.

Noncompliance Area: Child #4 does not have addresses for release persons in their record.

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.

Noncompliance Area: Child #1, enrolled on 6/5/17, only has a shot record in his file, not a complete 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.

Noncompliance Area: Child #3, a preschooler, last has a physical in his record dated 3/8/17.

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.

Noncompliance Area: Child #4 does not have parent signature for first aid.

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.

Noncompliance Area: Staff person #2 only has one reference in her record.

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

Noncompliance Area: Staff persons #1 & 3 have both been employed more than 30 days and have not completed Mandated Reporter Training.

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.

Noncompliance Area: Facility does not have a director.

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

Noncompliance Area: Staff person #2, hired on 12/26/17, has a physical in her record dated 9/20/16, more than 1 year old at date of hire.

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

Noncompliance Area: Staff person #1 was hired on 9/25/17 with a VOLUNTEER State Police clearance. During inspection on 11/3/17, while employee was still in their provisional period, the record was reviewed and the legal entity was informed that volunteer clearances were not acceptable for employment and a new State Police clearance indicating employment must be obtained. During subsequent visits, Staff person #1 was not observed at the facility caring for children. On 2/22/18, during an unannounced visit, staff person #1 was observed caring for children and she still does not have a correct State Police clearance in her record. Her provisional period ended on 12/25/17.

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

Noncompliance Area: Facility person #1, identified as a business manager of the facility, does not have a record on file. While he does not act as a staff person in the ratio, he does enter the facility to deliver supplies; food, paper towels, etc. OCDEL must see his completed clearances. He had applied but the Commonwealth switched FBI clearance companies and he was unable to get his FBI completed.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Facility Person # 1 may not work in a child care position at the facility. An individual record is required for each facility person.

Noncompliance Area: No one at the facility is signed up to receive the US CPSC alerts, nor is checking for recalled toys and equipment.

Correction Required: Children's toys and equipment, including furniture and rest equipment, described as hazardous by the United States Consumer Product Safety Commission may not be used by children at the facility and may not be on the premises at the facility. At the time of inspection, the operator shall submit to the Department written affirmation on a form provided by the Department stating that the facility is in compliance with this requirement.

Noncompliance Area: Children # 1 & 4 do not have which services are being provided specified on the agreement.

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).

Noncompliance Area: The agreement for child #1 does not specify arrival and departure times. The agreements for children # 1 & 2 do not specify date of admission.

Correction Required: An agreement shall specify the child`s arrival and departure times.An agreement shall specify the date of the child`s admission.

Noncompliance Area: The agreements for children # 1, 2, 3, & 4 do not specify release persons.

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

Noncompliance Area: Children # 2 & 4 do not have a completed emergency contact form in their record.

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

Noncompliance Area: The emergency contact form for child # 3 is missing physician info.

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

Noncompliance Area: Children # 1, 2, 3, & 4 do not have parent signature for emergency medical care in their records.

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.

Noncompliance Area: The emergency contact form for child # 3 is missing health insurance info.

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.

Noncompliance Area: The emergency contact form for child #1 is missing 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.

Noncompliance Area: Children # 2 & 4, both attending more than 60 days, do not have health reports in their records.

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.

Noncompliance Area: Facility person # 2 does not have a physical.

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.

Noncompliance Area: The facility provides breakfast and lunch and the menu is not posted.

Correction Required: An operator shall conspicuously post the menu at least 1 week in advance or provide a menu to each family.

Noncompliance Area: Bottles were not labeled.

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

Noncompliance Area: Facility did not have policy on file at the center.

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

Noncompliance Area: Children # 1, 2, 3, & 4 do not have parent signature for first aid in their records.

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.

Noncompliance Area: Facility person # 6, identified as a business manager of the facility, does not have a record on file. OCDEL must see his completed CPSL clearances. In addition, if he has child care duties or comes into contact with the children, he must have a complete file.

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

Noncompliance Area: Staff persons # 4 & 5 only have one reference in their record.

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

Noncompliance Area: Facility does not have a qualified director employed 30 hours per week.

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

Noncompliance Area: The indoor large muscle area measures for 4 children. Nine (9) children were observed playing in the room. In addition, the room is crowded with toys that are not large muscle related. Children cannot safely engage in large muscle activity.

Correction Required: Outdoor or indoor play space shall be measured at 65 square feet per child. Outdoor or indoor play space shall be safe for large muscle activity.

Noncompliance Area: Facility person #2 does not have a physical. Staff person # 5 does not have a physical.

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.

Noncompliance Area: Staff person #1 does not have a TB test.

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.

Noncompliance Area: Facillity person #6, identified as a business manager of the facility, does not have a record on file. OCDEL must see his completed CPSL clearances. In addition to those, if he has child care duties or comes into contact with the children, he must have a complete file.

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

Noncompliance Area: Staff persons #1, 4, & 5 do not have references in their record.

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

Noncompliance Area: Staff persons # 4 & 5 do not have proof of age in their record.

Correction Required: A staff person shall be 18 years of age or older.A facility person`s record shall include verification of age.

Noncompliance Area: Facility persons # 1, 2, 4, & 5 do not have a signed disclosure statement in their record. This is a required document for all employees and an employee may not work as a provisional employee without this document.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). LACKING REQUIRED HIRING DOCUMENTS: Facility Persons # 1, 2, 4, & 5 may not work in a child care position at the facility. A facility person`s record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL.

Noncompliance Area: Staff are considered provisional employees until and unless they have 3 completed clearances on file, a signed disclosure statement, and have completed mandated reporter training, all within their first 90 days of employment. Staff persons # 1, 4, & 5 are provisional employees. Staff person # 2 is a volunteer. Provisional employees must be supervised by a permanent employee, not a volunteer. Volunteers may not be supervised by provisional employees. On 10/3/17, at around 10:15 am, Staff person #1, a provisional employee, and Facility person #2, who identified herself as a volunteer, were observed with 7 children. No other staff were in the building. They cannot supervise each other.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). PROVISIONAL HIRE UNSUPERVISED: A provisional employee may not be permitted to work alone with children and must work within the vicinity of a permanent employee. A volunteer shall be supervised by a staff person who is qualified at minimum as an assistant group supervisor.

Noncompliance Area: Facility persons # 1, 2, & 3 do not have verification of education and/or experience in their records.

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.

Noncompliance Area: On 10/3/17, at around 10:15 am, Staff person #1 and Facility person #2, who identified herself as a volunteer, were observed with 7 children. Neither have 1st aid training and no other staff were in the building.

Correction Required: One or more facility persons competent in first-aid techniques shall be at the facility when one or more children are in care.

Noncompliance Area: A director has not been present at least 30 hours per week for the last 3 weeks.

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