Liberty Extended Day Program
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Contact Information
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About the Provider
LEDP is a place where "play" will be your child's work. Through play, children experience and learn many wonderful things about socialization with others and experience their own personal success during before and after school hours. At LEDP, we are committed to fostering the development of the whole child in a safe, creative, and stimulating environment. Talented and nurturing staff nourish the children's social-emotional development, provide continuous opportunities to learn life-long skills, and foster a true sense of community for all children and families.
At LEDP we recognize that each child is an individual who possesses unique gists, talents, interests, and abilities. Each child is encouraged to develop a positive self-image, as well as appreciate the personal worth of other individuals.
LEDP provides a healthy snack for the after school children, and access to the breakfast program in the morning. We offer small group activities, outdoor play, gym time, arts/crafts, fun and games, science, creative play, a reading area, and special programming events. There is a separate homework area where children can quietly complete their assignments and staff members are available for assistance.
Hours of Operation
- Days of Operation Monday–Friday
- Open HoursBefore School Hours (Mon-Fri): 7:00 a.m. - 9:10 a.m. After School Hours (Mon-Fri): School Dismissal - 6:00 p.m.
Inspection/Report History
Where possible, ChildcareCenter provides inspection reports as a service to families. This information is deemed reliable but is not guaranteed. We encourage families to contact the daycare provider directly with any questions or concerns. Reports can also be verified with your local daycare licensing office.
| Inspection Date | Reason | Description | Status |
|---|---|---|---|
| 2026-02-20 | Unannounced Monitoring | 3270.123(a) - Signed | Compliant - Finalized |
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Regulation: 3270.123(a) Description: Signed Noncompliance Area: CONTINUING NONCOMPLIANCE: The Agreements for Child #1, #2, #3, #4, and #5 lacked the operator and parent's signature. Previously cited 11/12/25. Correction Required: An agreement shall be signed by the operator and the parent. |
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Provider Response: (Contact the State Licensing Office for more information.) New agreements for children will include parent and operator signatures. |
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| 2026-02-20 | Unannounced Monitoring | 3270.123(a)(4) - Arrival/departure times | Compliant - Finalized |
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Regulation: 3270.123(a)(4) Description: Arrival/departure times Noncompliance Area: CONTINUING NONCOMPLIANCE: The files for Child #1, #2, #3, #4, and #5 contained Agreements which did not specify the child's arrival and departure times. Previously cited 11/12/25. Correction Required: An agreement shall specify the child's arrival and departure times. |
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Provider Response: (Contact the State Licensing Office for more information.) New agreements for children will include the child's arrival and departure times. |
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| 2026-02-20 | Unannounced Monitoring | 3270.123(a)(5) - Designated release persons | Compliant - Finalized |
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Regulation: 3270.123(a)(5) Description: Designated release persons Noncompliance Area: CONTINUING NONCOMPLIANCE: The Agreements for Child #1, #2, #3, #4, and #5 lacked the persons designated by a parent to whom the child may be released. Previously cited 11/12/25. Correction Required: An agreement shall specify the persons designated by a parent to whom the child may be released. |
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Provider Response: (Contact the State Licensing Office for more information.) New agreements for children will include the persons designated by a parent to whom the child may be released. |
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| 2026-02-20 | Unannounced Monitoring | 3270.123(a)(6)/3270.182(2) - Admission date/Application, admission, withdrawal dates | Compliant - Finalized |
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Regulation: 3270.123(a)(6)/3270.182(2) Description: Admission date/Application, admission, withdrawal dates Noncompliance Area: CONTINUING NONCOMPLIANCE: The Agreements for Child #1, #2, #3, #4 and #5 lacked the date of the child's admission. Previously cited 11/12/25. Correction Required: An agreement shall specify the date of the child's admission. A child's record shall contain the dates of application, admission and withdrawal of the child. |
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Provider Response: (Contact the State Licensing Office for more information.) New agreements for children will include the student's admission date. |
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| 2026-02-20 | Unannounced Monitoring | 3270.151(a)/3270.192(3) - 12 months prior to service and every 24 months thereafter/Health assessment, TB test | Compliant - Finalized |
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Regulation: 3270.151(a)/3270.192(3) Description: 12 months prior to service and every 24 months thereafter/Health assessment, TB test Noncompliance Area: CONTINUING NONCOMPLIANCE: The file for Staff #1 lacked a health assessment. Previously cited 11/12/25. 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. |
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Provider Response: (Contact the State Licensing Office for more information.) Staff #1 will obtain health assessment before returning to facility. Staff person #1 is no longer employed. |
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| 2026-02-20 | Unannounced Monitoring | 3270.151(c)(2)/3270.192(3) - Mantoux TB/Health assessment, TB test | Compliant - Finalized |
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Regulation: 3270.151(c)(2)/3270.192(3) Description: Mantoux TB/Health assessment, TB test Noncompliance Area: CONTINUING NONCOMPLIANCE: The file for Staff #1 lacked tuberculosis screening by the Mantoux method. Previously cited 11/12/25. Correction Required: An adult health assessment must include tuberculosis screening by the Mantoux method at initial employment. Subsequent tuberculosis screening is not required unless directed by a physician, physician's assistant, CRNP, the Department of Health or a local health department. A facility person's record shall include a written report of initial and subsequent health assessments, including the results of initial and subsequent tuberculin skin tests, x-rays or other medical documentation necessary to confirm freedom from communicable tuberculosis. |
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Provider Response: (Contact the State Licensing Office for more information.) Staff #1 will obtain tuberculosis screening by the Mantoux method before returning to the facility. Staff person #1 is no longer employed. |
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| 2026-02-20 | Unannounced Monitoring | 3270.192(2)(iv) - Transcript, diploma and letters | Compliant - Finalized |
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Regulation: 3270.192(2)(iv) Description: Transcript, diploma and letters Noncompliance Area: The file for Staff #1, lacked verification of experience and education or training. Staff was present on the day of inspection acting as an aide. 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. |
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Provider Response: (Contact the State Licensing Office for more information.) Staff #1 will provide verification of experience and education or training. Staff person #1 is no longer employed. |
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| 2026-02-20 | Unannounced Monitoring | 3270.192(5) - Two written references | Compliant - Finalized |
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Regulation: 3270.192(5) Description: Two written references Noncompliance Area: The file for Staff #1, 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. |
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Provider Response: (Contact the State Licensing Office for more information.) Staff person #1 will obtain two written, non-family references before returning to a child-care position at the facility. Staff person #1 is no longer employed. |
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| 2026-02-20 | Unannounced Monitoring | 3270.27(c) - Training regarding plan | Compliant - Finalized |
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Regulation: 3270.27(c) Description: Training regarding plan Noncompliance Area: CONTINUING NONCOMPLIANCE: The file for Staff #2 lacked an Emergency Plan training that was conducted within the past 12 months. Previously cited 11/12/25. 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. |
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Provider Response: (Contact the State Licensing Office for more information.) Staff #2 will receive Emergency Plan training on the first day returning to the center. Staff #2 is no longer employed. |
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| 2026-02-20 | Unannounced Monitoring | 3270.27(f) - Emergency plan | Compliant - Finalized |
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Regulation: 3270.27(f) Description: Emergency plan Noncompliance Area: CONTINUING NONCOMPLIANCE: Based upon documentation, the operator did not send a copy of the emergency plan to the local or county municipality. Previously cited 11/12/25. 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. |
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Provider Response: (Contact the State Licensing Office for more information.) The operator will send a copy of the emergency plan and subsequent plan updates to the local municipality and to the county emergency management agency. |
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| 2026-02-20 | Unannounced Monitoring | 3270.31(e)(4)(i) - Age and Training | Compliant - Finalized |
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Regulation: 3270.31(e)(4)(i) Description: Age and Training Noncompliance Area: CONTINUING NONCOMPLIANCE: Staff person #2 has not completed Pediatric first aid and CPR training on or before expiration of the most current certification. This is evidenced by the previously documented Pediatric first aid and CPR training in file expiring (10/2025). Documentation of updated Pediatric first aid and CPR training is not on file. Previously cited 11/12/25. 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. 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. |
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Provider Response: (Contact the State Licensing Office for more information.) Staff #2 will complete pediatric first aid and CPR Training. Staff #2 is no longer employed. |
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| 2026-02-20 | Unannounced Monitoring | 3270.31(e)(4)(ii) - Fire safety - 1 yr. | Compliant - Finalized |
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Regulation: 3270.31(e)(4)(ii) Description: Fire safety - 1 yr. Noncompliance Area: CONTINUING NONCOMPLIANCE: The file for Staff #2 lacked Fire Safety Training. Previously cited 11/12/25. 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. |
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Provider Response: (Contact the State Licensing Office for more information.) Staff #2 will complete fire safety training upon returning to the facility. Staff #2 is no longer employed. |
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| 2026-02-20 | Unannounced Monitoring | 3270.31(f) - Health and Safety Training | Compliant - Finalized |
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Regulation: 3270.31(f) Description: Health and Safety Training Noncompliance Area: Staff person #1 has not completed the following required pre- service training within 90 days of their date of hire (see LIS code sheet): (Pediatric First Aid and CPR and Health and Safety Basics). Correction Required: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10. Until such time as the required training has been completed, staff person #1 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 #1, staff person #1 may not work in a child-care position at the facility. |
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Provider Response: (Contact the State Licensing Office for more information.) Staff person #1 will complete Pediatric First Aid and CPR and Health and Safety Basics before returning to a child-care position at the facility. Staff person #1 is no longer employed. |
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| 2026-02-20 | Unannounced Monitoring | 3270.32(a) - Comply with CPSL | Compliant - Finalized |
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Regulation: 3270.32(a) Description: Comply with CPSL Noncompliance Area: Staff person #1 has not completed mandated reporter training within 90 days of their date of hire (see LIS code sheet). Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to Child Protective Services). Until such time as the required training has been completed, staff person #1 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 #1 staff person #1 may not work in a child- care position at the facility. |
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Provider Response: (Contact the State Licensing Office for more information.) Staff person #1 will complete mandated reporter training before returning to a child-care position at the facility. Staff person #1 is no longer employed. |
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| 2026-02-20 | Unannounced Monitoring | 3270.32(a)/3270.192(4) - Comply with CPSL/CPSL information | Compliant - Finalized |
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Regulation: 3270.32(a)/3270.192(4) Description: Comply with CPSL/CPSL information Noncompliance Area: CONTINUING NONCOMPLIANCE: The file for Staff #1 contained a National Sex Offender Certificate at the time of inspection, but it was observed they did not have a National Sex Offender Certificate prior to their first day working in childcare. Previously cited 11/12/25. 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. Upon completion of the Existing Provider Training, the Director/ responsible person(s) shall participate in an in-person technical assistance session focused on staff onboarding, staff file and CPSL requirements and staff file organization with ELRC #5. (The operator shall provide a date for when this training will be complete.) |
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Provider Response: (Contact the State Licensing Office for more information.) The operator shall comply with the CPSL and with Chapter 3490 and ensure all appropriate documentation is filed in staff records. |
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| 2026-02-20 | Unannounced Monitoring | 3270.34(a)(6) - Staff evaluations | Compliant - Finalized |
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Regulation: 3270.34(a)(6) Description: Staff evaluations Noncompliance Area: CONTINUING NONCOMPLIANCE: The file for Staff #2 lacked an annual written evaluations that was conducted within the past 12 months. Previously cited 11/12/25. Correction Required: A director is responsible for written evaluation of staff persons on a regular basis, a minimum of one evaluation every 12 months. |
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Provider Response: (Contact the State Licensing Office for more information.) Staff #2 will receive a written evaluation upon returning to the facility. Staff #2 is no longer employed. |
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| 2026-02-20 | Unannounced Monitoring | 3270.94(a)(1) - Every 60 days | Compliant - Finalized |
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Regulation: 3270.94(a)(1) Description: Every 60 days Noncompliance Area: Based on documentation at the facility, fire drills are not being held at least every 60 days. The last documented fire drill took place on 10/14/25. Correction Required: The Director or designated staff person who is responsible for compliance with this chapter ensure fire drills are conducted at least once every 60 days. |
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Provider Response: (Contact the State Licensing Office for more information.) A fire drill will be conducted and logged. |
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| 2025-11-12 | Renewal | 3270.113(a) - Supervised at all times | Non Compliant - Finalized |
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Regulation: 3270.113(a) Description: Supervised at all times Noncompliance Area: A child was observed leaving the Liberty Extended Program and entering the school hallway alone and unsupervised at approximately 4:00 PM. 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. |
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Provider Response: (Contact the State Licensing Office for more information.) Ensure that all students are accompanied and supervised by a staff member at all times during program hours. |
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| 2025-11-12 | Renewal | 3270.113(a)(1) - Staff assigned to specific children | Non Compliant - Finalized |
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Regulation: 3270.113(a)(1) Description: Staff assigned to specific children Noncompliance Area: A child was observed leaving the Liberty Extended Program and entering the school hallway alone and unsupervised at approximately 4:00 PM. A staff was not present with a member of their assigned group during this time. Correction Required: Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises. |
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Provider Response: (Contact the State Licensing Office for more information.) Ensure that all students are accompanied and supervised by a staff member at all times during program hours. |
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| 2025-11-12 | Renewal | 3270.123(a) - Signed | Non Compliant - Finalized |
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Regulation: 3270.123(a) Description: Signed Noncompliance Area: The Agreements for Child #1, #2, #3, #4, and #5 lacked the operator and parent's signature. Correction Required: An agreement shall be signed by the operator and the parent. |
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Provider Response: (Contact the State Licensing Office for more information.) Gain operator and parent signature for the Agreements for Child #1, #2, #3, #4, and #5. |
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| 2025-11-12 | Renewal | 3270.123(a)(4) - Arrival/departure times | Non Compliant - Finalized |
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Regulation: 3270.123(a)(4) Description: Arrival/departure times Noncompliance Area: The files for Child #1, #2, #3, #4, and #5 contained Agreements which did not specify the child's arrival and departure times. Correction Required: An agreement shall specify the child's arrival and departure times. |
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Provider Response: (Contact the State Licensing Office for more information.) Gain arrival and departure times for the Agreements for Child #1, #2, #3, #4, and #5. |
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| 2025-11-12 | Renewal | 3270.123(a)(5) - Designated release persons | Non Compliant - Finalized |
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Regulation: 3270.123(a)(5) Description: Designated release persons Noncompliance Area: The Agreements for Child #1, #2, #3, #4, and #5 lacked the persons designated by a parent to whom the child may be released. Correction Required: An agreement shall specify the persons designated by a parent to whom the child may be released. |
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Provider Response: (Contact the State Licensing Office for more information.) Gain documentation of the persons designated by a parent to whom the child may be released to for the Agreements for Child #1, #2, #3, #4, and #5. |
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| 2025-11-12 | Renewal | 3270.123(a)(6)/3270.182(2) - Admission date/Application, admission, withdrawal dates | Non Compliant - Finalized |
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Regulation: 3270.123(a)(6)/3270.182(2) Description: Admission date/Application, admission, withdrawal dates Noncompliance Area: The Agreements for Child #1, #2, #3, #4 and #5 lacked the date of the child's admission. Correction Required: An agreement shall specify the date of the child's admission. A child's record shall contain the dates of application, admission and withdrawal of the child. |
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Provider Response: (Contact the State Licensing Office for more information.) Gain date of admission for the Agreements for Child #1, #2, #3, #4, and #5. |
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| 2025-11-12 | Renewal | 3270.14/3270.21 - Pertinent Laws & Regulations/General Health and Safety | Non Compliant - Finalized |
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Regulation: 3270.14/3270.21 Description: Pertinent Laws & Regulations/General Health and Safety Noncompliance Area: The files for Staff #3 and #4 contained Health and Safety Basic training at the time of the Renewal Inspection, but it was observed they did not obtain Health and Safety Basic training within 90 days of hire. 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. |
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Provider Response: (Contact the State Licensing Office for more information.) Staff # and #4 have current Health and Safety Basic training. Provide Staff #3 and #4 a designated time to complete the Health and Safety Basic training. |
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| 2025-11-12 | Renewal | 3270.151(a) - 12 months prior to service and every 24 months thereafter | Non Compliant - Finalized |
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Regulation: 3270.151(a) Description: 12 months prior to service and every 24 months thereafter Noncompliance Area: The files for Staff #1 and #3 contained Health Assessments at the time of inspection, but it was observed they did not have Health Assessments before their first day working in childcare. 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. |
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Provider Response: (Contact the State Licensing Office for more information.) Ensure all future staff members have completed health assessments before their first day working in childcare. |
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| 2025-11-12 | Renewal | 3270.151(c)(2) - Mantoux TB | Non Compliant - Finalized |
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Regulation: 3270.151(c)(2) Description: Mantoux TB Noncompliance Area: The Health Assessments for Staff #1 and #3 contained tb screening by the Mantoux method at the time of inspection, but it was observed they did not have tb screening by the Mantoux method before their first day working in childcare. 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. |
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Provider Response: (Contact the State Licensing Office for more information.) Ensure all future staff members have a completed tb screening before their first day working in childcare. |
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| 2025-11-12 | Renewal | 3270.171(c) - Safe routes posted | Non Compliant - Finalized |
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Regulation: 3270.171(c) Description: Safe routes posted Noncompliance Area: Observed the facility did not have written notification of safe routes shall be posted by the operator at a conspicuous location in the childcare facility. Correction Required: Written notification of safe routes shall be posted by the operator at a conspicuous location in the child care facility. |
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Provider Response: (Contact the State Licensing Office for more information.) Post written notification of Safe routes at a conspicuous location in the childcare facility. |
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| 2025-11-12 | Renewal | 3270.18(a) - On file at facility | Non Compliant - Finalized |
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Regulation: 3270.18(a) Description: On file at facility Noncompliance Area: The facility did not provide documentation of general liability insurance. Correction Required: The legal entity shall have comprehensive general liability insurance to cover the persons who are on the premises. A current copy of the insurance policy shall be on file at the facility. |
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Provider Response: (Contact the State Licensing Office for more information.) Print and file a current copy of the insurance policy at the facility. |
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| 2025-11-12 | Renewal | 3270.24(a) - Immediate access | Non Compliant - Finalized |
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Regulation: 3270.24(a) Description: Immediate access Noncompliance Area: On November 11, 2025, at 4:00 PM, Cert Rep arrived at facility to conduct a Renewal Inspection. Staff were able to provide the child files, but it was stated that the staff files were taken out of the facility and not present for review. Multiple requests were made to obtain the staff files, but only partial information was shared. Untimely responses to the requests resulted in a delay to the inspection process and violations for lack of documentation. Correction Required: A staff person shall provide to agents of the Department immediate access to the facility, the children and the files and records. |
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Provider Response: (Contact the State Licensing Office for more information.) Staff files will be returned to the facility and appropriately stored. |
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| 2025-11-12 | Renewal | 3270.25(a) - Availability of certificate of compliance and applicable regulations | Non Compliant - Finalized |
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Regulation: 3270.25(a) Description: Availability of certificate of compliance and applicable regulations Noncompliance Area: The provider did not have their current certificate of compliance posted in a conspicuous location used by parents. The operator did not provide the parents of each child enrolled with information on how to electronically access the regulations. Correction Required: The facility's current certificate of compliance shall be posted in a conspicuous location used by parents. The operator shall provide the parent of each child enrolled with information on how to access the regulations in this chapter electronically and with instructions for contacting the appropriate regional child care office. |
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Provider Response: (Contact the State Licensing Office for more information.) The facility's current certificate of compliance shall be posted in a conspicuous location used by parents. The operator shall provide the parent of each child enrolled with information on how to access the regulations in this chapter electronically and with instructions for contacting the appropriate regional child care office. |
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| 2025-11-12 | Renewal | 3270.27(c) - Training regarding plan | Non Compliant - Finalized |
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Regulation: 3270.27(c) Description: Training regarding plan Noncompliance Area: The files for Staff #2, #4, and #5 lacked an Emergency Plan training that was conducted within the past 12 months. 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. |
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Provider Response: (Contact the State Licensing Office for more information.) Conduct Emergency Plan Training with Staff #2, #4, and #5. |
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| 2025-11-12 | Renewal | 3270.27(f) - Emergency plan | Non Compliant - Finalized |
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Regulation: 3270.27(f) Description: Emergency plan Noncompliance Area: Based upon documentation, the operator did not send a copy of the emergency plan to the local or county municipality. 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. |
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Provider Response: (Contact the State Licensing Office for more information.) The operator will send a copy of the emergency plan to the local municipality's emergency management agency. |
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| 2025-11-12 | Renewal | 3270.31(e) - Age and Training | Non Compliant - Finalized |
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Regulation: 3270.31(e) Description: Age and Training Noncompliance Area: The file for Staff #2 lacked 12 hours of childcare training within the previous year. Correction Required: A staff person shall obtain an annual minimum of 12 clock hours of child care training. |
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Provider Response: (Contact the State Licensing Office for more information.) Designate time and space for Staff #2 to complete 12 hours of childcare training. |
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| 2025-11-12 | Renewal | 3270.31(e)(4)(i) - Age and Training | Non Compliant - Finalized |
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Regulation: 3270.31(e)(4)(i) Description: Age and Training Noncompliance Area: Staff person #2 has not completed Pediatric first aid and CPR training on or before expiration of the most current certification. This is evidenced by the previously documented Pediatric first aid and CPR training on file expiring (10/2025). Documentation of updated Pediatric first aid and CPR training is not on file. 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. |
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Provider Response: (Contact the State Licensing Office for more information.) Register staff #2 to complete Pediatric First Aid and CPR training. |
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| 2025-11-12 | Renewal | 3270.31(e)(4)(ii) - Fire safety - 1 yr. | Non Compliant - Finalized |
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Regulation: 3270.31(e)(4)(ii) Description: Fire safety - 1 yr. Noncompliance Area: The file for Staff #2 lacked 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. |
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Provider Response: (Contact the State Licensing Office for more information.) Register staff #2 for Fire Safety Training. |
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| 2025-11-12 | Renewal | 3270.31(f)(10) - Health and Safety Training - Pediatric First Aid and CPR | Non Compliant - Finalized |
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Regulation: 3270.31(f)(10) Description: Health and Safety Training - Pediatric First Aid and CPR Noncompliance Area: Staff person #5 has not completed the following required pre- service training within 90 days of their date of hire (see LIS code sheet): (Pediatric First Aid and CPR). Correction Required: Staff persons shall complete professional development in the topic of pediatric first aid and pediatric cardiopulmonary resuscitation within 90 days of hire. |
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Provider Response: (Contact the State Licensing Office for more information.) Register staff #5 to complete Pediatric First Aid and CPR training. |
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| 2025-11-12 | Renewal | 3270.32(a)/3270.192(4) - Comply with CPSL/CPSL information | Non Compliant - Finalized |
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Regulation: 3270.32(a)/3270.192(4) Description: Comply with CPSL/CPSL information Noncompliance Area: The file for Staff #1 contained a National Sex Offender Certificate at the time of inspection, but it was observed they did not have a National Sex Offender Certificate prior to their first day working in childcare. The file for Staff #6 contained a Volunteer Child Abuse Clearance. The file for Staff #5 contained a Nation Sex Offender Registry certificate that had not been updated in the previous 60 months. Correction Required: TIERED LIS: 1. 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 #5 and #6 may not work in a childcare position at the facility. (This portion of the plan shall have an immediate correction date.) 2. The facility director will attend in-person Existing Provider Training on January 21, 2026. (The operator shall provide a date for when this training will be complete.) 3. Upon completion of the Existing Provider Training, the Director/ responsible person(s) shall participate in an in-person technical assistance session focused on staff onboarding, staff file and CPSL requirements and staff file organization with ELRC #5. (The operator shall provide a date for when this training will be complete.) |
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Provider Response: (Contact the State Licensing Office for more information.) 1. Staff #5 and Staff #6 will not work in a childcare position until clearances are obtained. (11/12/25) Staff #6 has employee child abuse clearance (12/1/25). Staff #5 has a current National Sex Offender Certificate. (12/11/25) (Implemented 12/11/25) 2. The facility director will attend in-person Existing Provider Training on January 21, 2026. (1/21/26) (Implemented 1/21/26) 3. The facility director will participate in an in-person technical assistance session focused on staff onboarding, staff file and CPSL requirements and staff file organization with ELRC #5. (1/30/26) (Not Implemented 2/20/26) |
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| 2025-11-12 | Renewal | 3270.34(a)(6) - Staff evaluations | Non Compliant - Finalized |
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Regulation: 3270.34(a)(6) Description: Staff evaluations Noncompliance Area: The files for Staff #2 and #4 lacked annual written evaluations that were 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. |
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Provider Response: (Contact the State Licensing Office for more information.) Conduct a written evaluation of Staff #2 and #4 |
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| 2025-11-12 | Renewal | 3270.52 - Mixed Age Level | Non Compliant - Finalized |
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Regulation: 3270.52 Description: Mixed Age Level Noncompliance Area: At approximately 4:05 PM, Staff #1 was observed alone in the cafeteria space with 19 school aged children; therefore, at this time ratio was 1:19. When asked if another staff person was present, it was shared that Staff #4 had left to go get something from their car. Staff #4 arrived at the facility at approximately 4:10 PM. 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). |
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Provider Response: (Contact the State Licensing Office for more information.) Ensure that at all times the facility maintains a staff:student ratio of 1:12 at all times. |
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| 2025-11-12 | Renewal | 3270.94(a) - Director or designated staff person responsibility | Non Compliant - Finalized |
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Regulation: 3270.94(a) Description: Director or designated staff person responsibility Noncompliance Area: The facility lacked a fire drill log to ensure specific criteria in §3270.95Ia)(1)- (a)(9) is being met Correction Required: The Director or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that the critera specified in §3270.95Ia)(1)- (a)(9) are met |
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Provider Response: (Contact the State Licensing Office for more information.) Print fire drill log and update any time a drill is conducted. |
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| 2024-11-11 | Renewal | 3270.123(a) - Signed | Compliant - Finalized |
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Regulation: 3270.123(a) Description: Signed Noncompliance Area: The Agreement in the file for Child #1 lacked the operator's signature. Correction Required: An agreement shall be signed by the operator and the parent. |
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Provider Response: (Contact the State Licensing Office for more information.) Director signed Child #1 Agreement |
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| 2024-11-11 | Renewal | 3270.123(a)(6)/3270.182(2) - Admission date/Application, admission, withdrawal dates | Compliant - Finalized |
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Regulation: 3270.123(a)(6)/3270.182(2) Description: Admission date/Application, admission, withdrawal dates Noncompliance Area: The Agreement for Child #1 lacked the date of the child's admission. Correction Required: An agreement shall specify the date of the child's admission. A child's record shall contain the dates of application, admission and withdrawal of the child. |
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Provider Response: (Contact the State Licensing Office for more information.) Director added Child #1 date of admission |
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| 2024-11-11 | Renewal | 3270.133(5) - Original label | Compliant - Finalized |
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Regulation: 3270.133(5) Description: Original label Noncompliance Area: The Epi Pen observed at the facility for Child #2 was expired. Correction Required: Medication shall be stored in accordance with the manufacturer's or health professional's instructions on the original label. |
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Provider Response: (Contact the State Licensing Office for more information.) We have received a new EPI Pen from the parents of Child #2, which is not expired |
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| 2024-11-11 | Renewal | 3270.133(6) - Written consent | Compliant - Finalized |
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Regulation: 3270.133(6) Description: Written consent Noncompliance Area: Observed the medication at the facility for Child #1 and Child #2 lacked written parental consent for administration of the medication. Correction Required: A parent shall provide written consent for administration of medication or a special diet. |
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Provider Response: (Contact the State Licensing Office for more information.) Child #1 has no medication at the facility. Child #2 now has parental consent for the administration of the medication. |
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| 2024-11-11 | Renewal | 3270.14/3270.21 - Pertinent Laws & Regulations/General Health and Safety | Compliant - Finalized |
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Regulation: 3270.14/3270.21 Description: Pertinent Laws & Regulations/General Health and Safety Noncompliance Area: The facility's written Shaken Baby Policy did not address the recognition of potential signs and symptoms of shaken baby syndrome and abusive head trauma, strategies for coping with a crying, fussing, or distraught child; and addressing the prevention and identification of child maltreatment. Correction Required: A facility shall be operated in conformity with applicable Federal and State laws and regulations.State agencies whose regulations may relate to the operation of a facility include the Department of Environmental Resources, the Department of Labor and Industry, the Department of Health, the Department of Education and the Department of Transportation. Conditions at the facility may not pose a threat to the health or safety of the children. |
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Provider Response: (Contact the State Licensing Office for more information.) We have conducted research and updated the Shaken Baby Policy to further address the recognition of potential signs and symptoms of shaken baby syndrome and abusive head trauma, strategies for coping with a crying, fussing, or distraught child; and addressing the prevention and identification of child maltreatment |
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| 2024-11-11 | Renewal | 3270.14/3270.21 - Pertinent Laws & Regulations/General Health and Safety | Compliant - Finalized |
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Regulation: 3270.14/3270.21 Description: Pertinent Laws & Regulations/General Health and Safety Noncompliance Area: Trash that has been contaminated by human secretions or excrement was observed in a non-lidded, open trash receptacle in the two bathrooms and in the cafeteria space. 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. |
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Provider Response: (Contact the State Licensing Office for more information.) We have added trash cans with lids in the two bathrooms and the cafeteria space. |
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| 2024-11-11 | Renewal | 3270.151(a) - 12 months prior to service and every 24 months thereafter | Compliant - Finalized |
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Regulation: 3270.151(a) Description: 12 months prior to service and every 24 months thereafter Noncompliance Area: The file for Staff #3 lacked a Health Assessment. The last two health assessments in the file for Staff #5 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. |
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Provider Response: (Contact the State Licensing Office for more information.) Staff #3 has been suspended until the Health Assessment with TB is completed |
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| 2024-11-11 | Renewal | 3270.151(c)(2) - Mantoux TB | Compliant - Finalized |
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Regulation: 3270.151(c)(2) Description: Mantoux TB Noncompliance Area: The file for Staff #3 lacked tuberculosis screening by the Mantoux method. Correction Required: An adult health assessment must include tuberculosis screening by the Mantoux method at initial employment. Subsequent tuberculosis screening is not required unless directed by a physician, physician's assistant, CRNP, the Department of Health or a local health department. |
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Provider Response: (Contact the State Licensing Office for more information.) Staff #3 has been suspended until the tuberculosis screening by the Mantoux method. |
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| 2024-11-11 | Renewal | 3270.192(5) - Two written references | Compliant - Finalized |
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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 person's suitability to serve as a facility person. Correction Required: A facility person's record shall include two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person. |
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Provider Response: (Contact the State Licensing Office for more information.) Staff #3 has been suspended until two references that are nonfamily are received |
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| 2024-11-11 | Renewal | 3270.27(a)(5) - Emergency plan | Compliant - Finalized |
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Regulation: 3270.27(a)(5) Description: Emergency plan Noncompliance Area: The facility's emergency plan lacked accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions. Correction Required: The facility shall have an emergency plan that provides for accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions. |
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Provider Response: (Contact the State Licensing Office for more information.) We have updated our Emergency Plan to include a statement that states we currently do not provide care for infants, toddlers, children with disabilities, and children with chronic medical conditions |
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| 2024-11-11 | Renewal | 3270.27(c) - Training regarding plan | Compliant - Finalized |
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Regulation: 3270.27(c) Description: Training regarding plan Noncompliance Area: The file for Staff #4 did not contain documentation of receiving training regarding the emergency plan within the past 12 months. The file for Staff #5 contained Emergency Plan trainings that were dated more than 12 months apart. 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. |
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Provider Response: (Contact the State Licensing Office for more information.) We have ensured that Staff #4 and Staff #5 have signed their Emergency Plan Training sign-off sheet. |
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| 2024-11-11 | Renewal | 3270.27(f) - Emergency plan | Compliant - Finalized |
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Regulation: 3270.27(f) Description: Emergency plan Noncompliance Area: Based on conversations with the operator, the operator did not send a copy of the emergency plan to the local or county municipalities. 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. |
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Provider Response: (Contact the State Licensing Office for more information.) We sent a copy of the Emergency Plan to the Local Municipality and County Emergency Management Agency on Sept 3 2024, and signed the Documentation of Emergency Plan Delivery on Oct 29 2024 |
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| 2024-11-11 | Renewal | 3270.31(e) - Age and Training | Compliant - Finalized |
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Regulation: 3270.31(e) Description: Age and Training Noncompliance Area: The file for Staff #4 and #5, lacked documentation of the annual 12 clock hours of childcare training for the 12/22-12/23 training year. Correction Required: A staff person shall obtain an annual minimum of 12 clock hours of child care training. |
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Provider Response: (Contact the State Licensing Office for more information.) We have Staff #4 and Staff #5 working on their 12 clock hours of training for this year. |
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| 2024-11-11 | Renewal | 3270.31(e)(4)(ii) - Fire safety - 1 yr. | Compliant - Finalized |
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Regulation: 3270.31(e)(4)(ii) Description: Fire safety - 1 yr. Noncompliance Area: The files for Staff #4 and #5 did not contain documentation of training in fire safety in the last year. 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. |
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Provider Response: (Contact the State Licensing Office for more information.) We have Staff #4 and Staff #5 completing Fire Safety training for this year. |
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| 2024-11-11 | Renewal | 3270.31(f) - Health and Safety Training | Compliant - Finalized |
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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): (Health and Safety Basic 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 12/10/24 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. |
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Provider Response: (Contact the State Licensing Office for more information.) Staff #4 completed Health and Safety Basic Training when hired. We sent this documentation |
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| 2024-11-11 | Renewal | 3270.31(f) - Health and Safety Training | Compliant - Finalized |
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Regulation: 3270.31(f) Description: Health and Safety Training Noncompliance Area: Although the file for Staff #2 contained Pediatric First Aid/CPR at the time of inspection, it was observed that the file for Staff #2 did not contain Pediatric First Aid/CPR within 90 days of hire. Correction Required: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10. |
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Provider Response: (Contact the State Licensing Office for more information.) Staff #2 has completed First Aid/CPR training |
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| 2024-11-11 | Renewal | 3270.32(a) - Comply with CPSL | Compliant - Finalized |
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Regulation: 3270.32(a) Description: Comply with CPSL Noncompliance Area: Although Staff #5 had current Mandated reporter Training at the time of the Renewal Inspection, it was observed that Staff #5 updated Mandated Reporter Training in an interval greater than 60 months. Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). |
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Provider Response: (Contact the State Licensing Office for more information.) Staff #5 completed Mandated Reporter Training |
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| 2024-11-11 | Renewal | 3270.32(a)/3270.192(4) - Comply with CPSL/CPSL information | Compliant - Finalized |
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Regulation: 3270.32(a)/3270.192(4) Description: Comply with CPSL/CPSL information Noncompliance Area: The disclosure statement in the file for Staff #1 lacked a date. Although the file for Staff #2 contained a National Sex Offender Certificate at the time of inspection, it was observed that Staff #2 did not obtain the certificate within 45 days of hire and therefore was incorrectly provisionally hired. The file for Staff #3 lacked a PA State Police Clearance or request for the Clearance. The file for Staff #3 who has lived outside of Pennsylvania in the last five years lacked Maryland's clearances or request for the clearances. Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Facility Person #3 may not work in a childcare position at the facility. |
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Provider Response: (Contact the State Licensing Office for more information.) Staff #1 has added a date for the disclosure statement. Staff #2 has completed the NSOR. Staff #3 has been suspended until PA State Police Clearance and Maryland clearances are received. |
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| 2024-11-11 | Renewal | 3270.34(a)(6) - Staff evaluations | Compliant - Finalized |
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Regulation: 3270.34(a)(6) Description: Staff evaluations Noncompliance Area: The file for Staff 4 did not contain an evaluation completed within the previous 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. |
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Provider Response: (Contact the State Licensing Office for more information.) The director has reviewed the self-evaluation and completed a written evaluation on Staff #4 |
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| 2023-11-14 | Renewal | 3270.123(a) - Signed | Compliant - Finalized |
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Regulation: 3270.123(a) Description: Signed Noncompliance Area: The agreement forms in the file for child #1 through #5 were not signed by the operator. Correction Required: An agreement shall be signed by the operator and the parent. |
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Provider Response: (Contact the State Licensing Office for more information.) We have signed the operator section of the agreement forms. |
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| 2023-11-14 | Renewal | 3270.123(a)(6) - Admission date | Compliant - Finalized |
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Regulation: 3270.123(a)(6) Description: Admission date Noncompliance Area: The agreement forms in the file for child #1 through #5 did not specify the child's date of admission. Correction Required: An agreement shall specify the date of the child's admission. |
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Provider Response: (Contact the State Licensing Office for more information.) We have added the child's date of admission to the agreement forms. |
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| 2023-11-14 | Renewal | 3270.124(b)(7) - Name/address/phone release person | Compliant - Finalized |
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Regulation: 3270.124(b)(7) Description: Name/address/phone release person Noncompliance Area: The emergency contact information in the file for child #4 did not include the addresses for all 4 release persons. 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. |
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Provider Response: (Contact the State Licensing Office for more information.) We will have the parent add the information for the 4 release persons |
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| 2023-11-14 | Renewal | 3270.133(4) - Locked | Compliant - Finalized |
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Regulation: 3270.133(4) Description: Locked Noncompliance Area: The following medications were observed as accessible to children, as they were stored on the steps of the facility's storage area next to the girls' bathroom: an epi-pen, albuterol and OTC allergy medications. The door to the storage area was unlocked at the time. Correction Required: Medication shall be stored in a locked area of the facility or in an area that is out of the reach of children. |
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Provider Response: (Contact the State Licensing Office for more information.) The storage area with the medication is locked |
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| 2023-11-14 | Renewal | 3270.133(5) - Original label | Compliant - Finalized |
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Regulation: 3270.133(5) Description: Original label Noncompliance Area: The albuterol for child #7 was expired. The box containing the medication listed 5/31/24 as the expiration date, however, the actual canister listed the expiration date of July 2023. Correction Required: Medication shall be stored in accordance with the manufacturer's or health professional's instructions on the original label. |
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Provider Response: (Contact the State Licensing Office for more information.) We contacted the parent to get a new canister & the parent provided us with a canister that expires 12-31-2024 |
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| 2023-11-14 | Renewal | 3270.133(6) - Written consent | Compliant - Finalized |
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Regulation: 3270.133(6) Description: Written consent Noncompliance Area: There was no written parental consent for albuterol belonging to child #6. Correction Required: A parent shall provide written consent for administration of medication or a special diet. |
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Provider Response: (Contact the State Licensing Office for more information.) We requested the form to be filled out by the parent - we received the filled out form |
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| 2023-11-14 | Renewal | 3270.14/3270.21 - Pertinent Laws & Regulations/General Health and Safety | Compliant - Finalized |
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Regulation: 3270.14/3270.21 Description: Pertinent Laws & Regulations/General Health and Safety Noncompliance Area: Staff person #1 and #3 were observed to be caring for children unsupervised. Staff person #1 has not completed the following pre-service training required prior to caring for children unsupervised: Health and safety training. Staff person #3 has not completed the following pre-service training required prior to caring for children unsupervised: Health and safety training and First-aid/CPR training. Correction Required: : A facility shall be operated in conformity with applicable Federal and State laws and regulations. State agencies whose regulations may relate to the operation of a facility include the Department of Environmental Resources, the Department of Labor and Industry, the Department of Health, the Department of Education and the Department of Transportation. Conditions at the facility may not pose a threat to the health or safety of the children. Until such time as the required pre-service trainings are completed, staff person #1 and #3 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 person(s) available to supervise staff person #1 and staff person #3 may not work in a child-care position at the facility. |
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Provider Response: (Contact the State Licensing Office for more information.) Until the required pre-service trainings were completed, staff person #1 and #3 were supervised, when interacting with children, by a staff member (an AGS) who completed the required training related to this citation. Staff member #1 and #3 completed their pre-service training (health and safety training & First-aid/CPR training. |
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| 2023-11-14 | Renewal | 3270.151(a)/3270.192(3) - 12 months prior to service and every 24 months thereafter/Health assessment, TB test | Compliant - Finalized |
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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 health assessment in the file for staff person #1, #2 and #3 was dated after the individual began working with children. The last health assessment in the file for staff person #4, #5 and #7 was dated more than 24 months ago. 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. |
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Provider Response: (Contact the State Licensing Office for more information.) We have requested staff person #4, #5, and #7 submit their new health form. |
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| 2023-11-14 | Renewal | 3270.151(c)(2) - Mantoux TB | Compliant - Finalized |
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Regulation: 3270.151(c)(2) Description: Mantoux TB Noncompliance Area: The TB screening in the file for staff person #1 was dated after the staff person began working with children. 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. |
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Provider Response: (Contact the State Licensing Office for more information.) We will continue to do our best in ensure that new hires complete all necessary health assessments prior to working with children |
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| 2023-11-14 | Renewal | 3270.182(7) - Reports of accidents, injuries and illnesses. Original report - parent same day Copy - facility accident file. Copy - child's file | Compliant - Finalized |
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Regulation: 3270.182(7) Description: Reports of accidents, injuries and illnesses. Original report - parent same day Copy - facility accident file. Copy - child's file Noncompliance Area: Based on conversation with the operator and review of the files for child #3 and #4, a third copy of all injury/illness reports were not being retained in the children's files. Correction Required: A child's record shall contain reports of accidents, injuries and illnesses involving a child in care at the facility. The original report shall be given to the parent on the day of the incident. The second copy of the report shall be retained at the facility in an accident file. The third copy of the report shall be retained at the facility in the child's file. |
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Provider Response: (Contact the State Licensing Office for more information.) We have copied the injury reports and put it in the appropriate files |
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| 2023-11-14 | Renewal | 3270.27(f) - Emergency plan | Compliant - Finalized |
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Regulation: 3270.27(f) Description: Emergency plan Noncompliance Area: Based on conversation with the operator, there was not proof that the most recent updates to the facility's emergency plan were sent to the local and county emergency management agencies. 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. |
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Provider Response: (Contact the State Licensing Office for more information.) We have sent the updates to the local and county emergency management agencies with a letter |
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| 2023-11-14 | Renewal | 3270.31(f) - Health and Safety Training | Compliant - Finalized |
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Regulation: 3270.31(f) Description: Health and Safety Training Noncompliance Area: The health and safety training and the First-aid/CPR training in the file for staff person #6 were dated beyond their first 90 days working with children. Correction Required: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10. |
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Provider Response: (Contact the State Licensing Office for more information.) We will continue to do our best in ensure that new hires complete all necessary health and safety trainings prior to the 90 day period. |
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| 2023-11-14 | Renewal | 3270.32(a) - Comply with CPSL | Compliant - Finalized |
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Regulation: 3270.32(a) Description: Comply with CPSL Noncompliance Area: The mandated reporter in the file for staff person #6 was dated beyond their first 90 days working with children. Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). |
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Provider Response: (Contact the State Licensing Office for more information.) We will continue to do our best in ensure that new hires complete all trainings prior to the 90 day period. |
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| 2023-11-14 | Renewal | 3270.32(a)/3270.192(4) - Comply with CPSL/CPSL information | Compliant - Finalized |
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Regulation: 3270.32(a)/3270.192(4) Description: Comply with CPSL/CPSL information Noncompliance Area: The file for staff person #1, hired provisionally on (SEE LIS CODE DATE) and past their 45-day provisional period, did not include an NSOR clearance. The file for staff person #3, hired provisionally on (SEE LIS CODE SHEET), did not include clearances for North Carolina. Based on review of the file, they had a driver's license from North Carolina issued in 2021 and reference letters regarding experience in North Carolina in 2023. When the operator was asked when the individual moved to Pennsylvania, they stated it was within the last year. At approximately 4:40 pm, staff person #1 and #3 were the only staff outside with a group of children. Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Facility Person #1 and #2 may not work in a child care position at the facility. |
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Provider Response: (Contact the State Licensing Office for more information.) Until the required paperwork was completed, staff person #1 and #3 were not working in a child care position until all paperwork was in. Staff person #1 completed/submitted their NSOR & staff person #3 completed/submitted their North Caroline clearances |
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| 2023-11-14 | Renewal | 3270.35(b)(1)/3270.192(2)(ii) - Bachelor's/Exp, educ., training prior to facility | Compliant - Finalized |
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Regulation: 3270.35(b)(1)/3270.192(2)(ii) Description: Bachelor's/Exp, educ., training prior to facility Noncompliance Area: The file for staff person #2, holding the title of group supervisor, did not include evidence of a bachelor's degree in a related field. Correction Required: A group supervisor shall have a bachelor's degree 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 verification of child care experience, education and training prior to service at the facility. |
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Provider Response: (Contact the State Licensing Office for more information.) Staff member #2 no longer works with us. |
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| 2023-11-14 | Renewal | 3270.36(b)(5)/3270.192(2)(ii) - HS/GED + 2 yrs/Exp, educ., training prior to facility | Compliant - Finalized |
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Regulation: 3270.36(b)(5)/3270.192(2)(ii) Description: HS/GED + 2 yrs/Exp, educ., training prior to facility Noncompliance Area: The file for staff person #1 and #6, both holding the title of assistant group supervisor, included a high school diploma, but did not include evidence of 2500 hours of 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. |
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Provider Response: (Contact the State Licensing Office for more information.) Staff member #1 is now an aid as she continues to build experience and her education. Staff member #6 is now an aid as we were unable to confirm if fostering counts towards "2 years experience with children" |
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| 2023-11-14 | Renewal | 3270.94(a)(1) - Every 60 days | Compliant - Finalized |
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Regulation: 3270.94(a)(1) Description: Every 60 days Noncompliance Area: Based on review of the facility's fire drill log, there was one time when fire drills were conducted more than 60 days apart: 11/3/22 and 1/11/23. The drill listed on 12/1/22 was a tornado emergency drill. Correction Required: The Director or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that fire drills are conducted at least once every 60 days. |
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Provider Response: (Contact the State Licensing Office for more information.) We have & will continue to do a fire drill at least once every 60-days. |
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| 2023-11-14 | Renewal | 3270.94(a)(4) - Hypothetical locations | Compliant - Finalized |
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Regulation: 3270.94(a)(4) Description: Hypothetical locations Noncompliance Area: Based on review of the facility's fire drill log, the hypothetical location of the fire for consecutive drills on 2/6/23 and 3/8/23 was the cafeteria. Correction Required: The Director or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that the hypothetical locations of the fire are rotated around the facility for each drill such that the hypothetical location is never the same for consecutive drills. |
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Provider Response: (Contact the State Licensing Office for more information.) We have & will continue to do a fire drill in a different hypothetical locations - never the same location for consecutive drills. |
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| 2023-11-14 | Renewal | 3270.94(a)(9) - Written record | Compliant - Finalized |
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Regulation: 3270.94(a)(9) Description: Written record Noncompliance Area: Based on review of the facility's fire drill log, there was not an evacuation time listed for drills on 1/11/23 and 2/6/23. Correction Required: The Director or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that a written record is maintained on file at the facility indicating the specific time of day of the drill, the hypothetical location of the fire, the evacuation time, and the names of the facility persons and the number of children who participate in the fire drill. |
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Provider Response: (Contact the State Licensing Office for more information.) We have & will continue to do a fire drills and note the evacuation time in the fire drill log |
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| 2023-03-20 | Unannounced Monitoring | 3270.131(c) - Completed or signed by physician, PA, or CRNP | Compliant - Finalized |
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Regulation: 3270.131(c) Description: Completed or signed by physician, PA, or CRNP Noncompliance Area: The updated health report for child #1, which included a statement that the child is able to participate in child care and appears to be free from communicable disease, did not include a name, title or written or electronic signature of the individual who completed the form. Correction Required: A health report must be written and signed by a physician, physician's assistant or a CRNP. The signature must include the individual's professional title. |
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Provider Response: (Contact the State Licensing Office for more information.) Although the health report and immunizations were given to us, it was unclear if the physician signed the report. We have asked the parents to resubmit their health report and immunizations for child #1. We have asked the family to fill out the Child Health Report as required by 55 PA Code again. |
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| 2023-03-20 | Unannounced Monitoring | 3270.14/3270.21 - Pertinent Laws & Regulations/General Health and Safety | Compliant - Finalized |
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Regulation: 3270.14/3270.21 Description: Pertinent Laws & Regulations/General Health and Safety Noncompliance Area: 2nd citation: The facility's emergency plan was updated with a statement that they had a plan for continuity of operations, but the actual plan was not addressed. The facility's shaken baby sydrome policy did not address the signs/symptoms of shaken baby, how to cope with a crying/distarught child and the identification and prevention of child maltreatment. Previously cited on 12/16/22. 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. |
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Provider Response: (Contact the State Licensing Office for more information.) We will update our Emergency Plan to include additional, specific, information regarding continuity of operations and added a separate, specific, Shaken Baby Syndrome Policy. |
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| 2023-03-20 | Unannounced Monitoring | 3270.151(c)(3)/3270.151(c)(5) - Exam communicable disease/Physician/CRNP assessment | Compliant - Finalized |
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Regulation: 3270.151(c)(3)/3270.151(c)(5) Description: Exam communicable disease/Physician/CRNP assessment Noncompliance Area: 2nd citation: The health assessment for staff person #7 did not include an examination for communicable diseases and the results of that examination or the physician's or CRNP's assessment of the person's suitability to provide childcare. Previously cited on 12/16/22. Correction Required: An adult health assessment must include an examination for communicable diseases and the results of that examination. An adult health assessment must include the physician's or CRNP's assessment of the person's suitability to provide child care. |
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Provider Response: (Contact the State Licensing Office for more information.) We have asked the staff members to have their physician fill out our specific Staff Member Health Report ¿ they have made an appointment. We will not allow this staff member back to work until the Health Report is complete. This Health Report has information regarding communicable diseases and ensure that the staff member is suitable to provide child care. |
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| 2023-03-20 | Unannounced Monitoring | 3270.94(a)(4) - Hypothetical locations | Compliant - Finalized |
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Regulation: 3270.94(a)(4) Description: Hypothetical locations Noncompliance Area: The hypothetical location was listed as "cafe" for consecutive drills on 1/11/23 and 2/6/23. Correction Required: The Director or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that the hypothetical locations of the fire are rotated around the facility for each drill such that the hypothetical location is never the same for consecutive drills. |
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Provider Response: (Contact the State Licensing Office for more information.) We have updated the fire drills log to include time of day and hypothetical location of the fire. We conducted another fire drill on 3/20/2023 which had a hypothetical location of the gym. We used the correct form that included time of day and hypothetical location of the fire ¿ we ensured it was not ¿café¿ again. |
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| 2022-11-29 | Renewal | 3270.113(a) - Supervised at all times | Non Compliant - Finalized |
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Regulation: 3270.113(a) Description: Supervised at all times Noncompliance Area: At approximately 5:05 pm, an older schoolager was observed leaving the cafeteria unsupervised. When asked where the child was going, staff stated that the child was walking to the gym, which is at the other end of the first floor hallway. 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. |
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Provider Response: (Contact the State Licensing Office for more information.) We had a conversation with our staff about students walking from one side of the hallway to the next and explained, again, that children need to be always supervised. We will ensure that no student is left alone. Plus, we have created a new system of supervision. Each student¿s name is on an individual postcard. Before the students are released into our care, the staff member is given the postcards for the individual students they are supervising. While any student is in our care, the supervising staff member has a postcard coordinating with the students under their care. |
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| 2022-11-29 | Renewal | 3270.113(a)(1) - Staff assigned to specific children | Non Compliant - Finalized |
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Regulation: 3270.113(a)(1) Description: Staff assigned to specific children Noncompliance Area: At approximately 4 pm, staff person #2 and #4 were observed in the cafeteria with 22 schoolagers. When asked to identify for whom they were responsible, staff person #2 identified 8 children and staff person #4 identified 11 children, leaving 3 children unidentified. Staff were not able to identify which 3 children were missed. The staff were asked to identify their groups again and the children's names were read back to them for clarification. 3 children were still unidentified and staff were not able to identify which 3 children were missed. This certification representative pointed to each child in the cafeteria and asked their names and at that time, the certification representative was able to identify the 3 children who were not identified. At approximately 5:05 pm, an older schoolager was observed leaving the cafeteria unsupervised. When asked where the child was going, staff stated that the child was walking to the gym, which is at the other end of the first floor hallway. Correction Required: Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises. |
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Provider Response: (Contact the State Licensing Office for more information.) We had a conversation with our staff about students walking from one side of the hallway to the next and explained, again, that children need to be always supervised. We also reminded them of the correct ratio and the importance of knowing each students¿ name and whereabouts. Plus, we have created a new system of supervision. Each student¿s name is on an individual postcard. This will assist our staff in knowing students¿ names. Before the students are released into our care, the staff member is given the postcards for the individual students they are supervising. While any student is in our care, the supervising staff member has a postcard coordinating with the students under their care. |
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| 2022-11-29 | Renewal | 3270.123(a)(1) - Amount of fee | Non Compliant - Finalized |
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Regulation: 3270.123(a)(1) Description: Amount of fee Noncompliance Area: The agreement in the file for child #1 did not specify the amount of the fee to be charged per day or per week. Correction Required: An agreement shall specify the amount of the fee to be charged per day or per week. |
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Provider Response: (Contact the State Licensing Office for more information.) The amount was stated in the agreement, however, may be hard to see. We have highlighted the section on the agreement for easy review. |
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| 2022-11-29 | Renewal | 3270.123(a)(2) - Date fee to be paid | Non Compliant - Finalized |
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Regulation: 3270.123(a)(2) Description: Date fee to be paid Noncompliance Area: The agreement in the file for child #1 did not specify the date on which the fee is to be paid. Correction Required: An agreement shall specify the date on which the fee is to be paid. |
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Provider Response: (Contact the State Licensing Office for more information.) The due date was stated in the agreement, however, may be hard to see as it is stapled to the agreement on page 2. We have gone through and ensured that this important page is stapled to the agreement. |
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| 2022-11-29 | Renewal | 3270.124(b)(4)/3270.182(3) - Written consent/Consent for emergency medical care required prior to admission | Non Compliant - Finalized |
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Regulation: 3270.124(b)(4)/3270.182(3) Description: Written consent/Consent for emergency medical care required prior to admission Noncompliance Area: The file for child #2 did not include the 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. |
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Provider Response: (Contact the State Licensing Office for more information.) We have reprinted the Emergency Contact Form which includes the written consent for emergency medical care. We have asked the parents to sign the correct page. |
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| 2022-11-29 | Renewal | 3270.131(d)(7) - Free from contagious/communicable disease | Non Compliant - Finalized |
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Regulation: 3270.131(d)(7) Description: Free from contagious/communicable disease Noncompliance Area: The health report in the file for child #1 did not include a statement that the child is able to participate in child care and appears to be free from contagious or communicable disease. Correction Required: A health report shall include a statement that the child is able to participate in child care and appears to be free from contagious or communicable disease. |
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Provider Response: (Contact the State Licensing Office for more information.) We have the health report and immunizations for child #1. However, it is not on the 55 PA Code ¿Child Health Report.¿ We have asked the family to fill out the correct Child Health Report as required by 55 PA Code. |
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| 2022-11-29 | Renewal | 3270.133(2) - Written instructions | Non Compliant - Finalized |
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Regulation: 3270.133(2) Description: Written instructions Noncompliance Area: There was no written instructions or prescription for the epi-pen belonging to child #3. Correction Required: A staff person shall administer a prescription medication only if written instructions are provided from the individual who prescribed the medicine. Instructions for administration contained on a prescription label are acceptable. |
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Provider Response: (Contact the State Licensing Office for more information.) We have created a new Epi-Pen form for students that need it. We have asked the family to fill out this new form which provides instructions for Epi-Pen. We have instructed the family that a doctor must provide the instructions or provide us with the prescription with the doctor¿s information. |
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| 2022-11-29 | Renewal | 3270.133(5) - Original label | Non Compliant - Finalized |
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Regulation: 3270.133(5) Description: Original label Noncompliance Area: The epi-pen belonging to child #2 was expired. Correction Required: Medication shall be stored in accordance with the manufacturer's or health professional's instructions on the original label. |
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Provider Response: (Contact the State Licensing Office for more information.) We have asked the family to provide us with non-expired Epi-Pen. This Epi-Pen must come complete with the manufacturer¿s or health professional¿s instructions on the original label. |
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| 2022-11-29 | Renewal | 3270.133(6) - Written consent | Non Compliant - Finalized |
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Regulation: 3270.133(6) Description: Written consent Noncompliance Area: There was no written parental consent for the epi-pen belonging to child #2 and #3. Correction Required: A parent shall provide written consent for administration of medication or a special diet. |
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Provider Response: (Contact the State Licensing Office for more information.) We have created a new Epi-Pen form for students that need it. We have asked the family to fill out this new form which provides written consent for the Epi-Pen. |
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| 2022-11-29 | Renewal | 3270.14/3270.21 - Pertinent Laws & Regulations/General Health and Safety | Non Compliant - Finalized |
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Regulation: 3270.14/3270.21 Description: Pertinent Laws & Regulations/General Health and Safety Noncompliance Area: The facility's emergency plan did not include information regarding continuity of operations. The facility did not have a shaken baby sydrome policy. 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. |
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Provider Response: (Contact the State Licensing Office for more information.) We have updated our Emergency Plan to include information regarding continuity of operations and added a Shaken Baby Syndrome Policy. |
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| 2022-11-29 | Renewal | 3270.14/3270.21 - Pertinent Laws & Regulations/General Health and Safety | Non Compliant - Finalized |
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Regulation: 3270.14/3270.21 Description: Pertinent Laws & Regulations/General Health and Safety Noncompliance Area: On 11/29/22, staff person #2 and #4 were observed to be caring for children unsupervised. Staff person #2 and #4 has not completed the following pre-service training required prior to caring for children unsupervised: Mandated reporter. Correction Required: A facility shall be operated in conformity with applicable Federal and State laws and regulations. State agencies whose regulations may relate to the operation of a facility include the Department of Environmental Resources, the Department of Labor and Industry, the Department of Health, the Department of Education and the Department of Transportation. Conditions at the facility may not pose a threat to the health or safety of the children. Until such time as the required pre-service trainings are completed, staff person #2 and #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 person(s) available to supervise staff person #2 and #4, staff person #2 and #4 may not work in a child-care position at the facility. |
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Provider Response: (Contact the State Licensing Office for more information.) Following Federal and State laws and regulations, until such time as the required pre-service trainings were completed, staff person #2 and #4 were supervised, when interacting with children, by an AGS who has completed the required training related to this citation. If there are no staff person(s) available to supervise staff person #2 and #4, staff person #2 and #4 may not work in a childcare position at the facility. Staff member #2 and #4 have renewed their Mandated Report training and completed all required pre-service training. |
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| 2022-11-29 | Renewal | 3270.151(c)(3) - Exam communicable disease | Non Compliant - Finalized |
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Regulation: 3270.151(c)(3) Description: Exam communicable disease Noncompliance Area: The health assessment for staff person #7 did not include an examination for communicable diseases and the results of that examination. Correction Required: An adult health assessment must include an examination for communicable diseases and the results of that examination. |
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Provider Response: (Contact the State Licensing Office for more information.) We have asked the staff members to have their physician fill out our specific Staff Member Health Report. This Health Report has information regarding communicable diseases. |
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| 2022-11-29 | Renewal | 3270.151(c)(5) - Physician/CRNP assessment | Non Compliant - Finalized |
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Regulation: 3270.151(c)(5) Description: Physician/CRNP assessment Noncompliance Area: The file for staff person #7 did not include the physician's or CRNP's assessment of the person's suitability 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. |
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Provider Response: (Contact the State Licensing Office for more information.) We have asked the staff members to have their physician fill out our specific Staff Member Health Report. This Health Report has information regarding the person¿s suitability to provide childcare. |
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| 2022-11-29 | Renewal | 3270.18(a) - On file at facility | Non Compliant - Finalized |
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Regulation: 3270.18(a) Description: On file at facility Noncompliance Area: The liability insurance on file at the facility at the time of the inspection expired 8/21/22. 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. |
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Provider Response: (Contact the State Licensing Office for more information.) We have printed out our Liability Insurance and filed it. |
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| 2022-11-29 | Renewal | 3270.182(5) - Consent for administration of minor first-aid required prior to admission | Non Compliant - Finalized |
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Regulation: 3270.182(5) Description: Consent for administration of minor first-aid required prior to admission Noncompliance Area: The file for child #2 did not include the written consent signed by a parent for minor 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. |
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Provider Response: (Contact the State Licensing Office for more information.) We have reprinted the Emergency Contact Form which includes the written consent for minor first-aid. We have asked the parents to sign the correct page. |
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| 2022-11-29 | Renewal | 3270.27(b) - Plan reviewed/updated annually | Non Compliant - Finalized |
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Regulation: 3270.27(b) Description: Plan reviewed/updated annually Noncompliance Area: The last documented review of the emergency plan was more than 12 months ago. Correction Required: The operator shall review the emergency plan at least annually and update the plan as needed. The operator shall document in writing each review and update of the emergency plan and kept on file at the facility. |
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Provider Response: (Contact the State Licensing Office for more information.) We have reviewed the emergency plan and documented it in writing. |
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| 2022-11-29 | Renewal | 3270.27(c) - Training regarding plan | Non Compliant - Finalized |
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Regulation: 3270.27(c) Description: Training regarding plan Noncompliance Area: The last emergency plan training in the file for staff person #2 and #3 was 9/15/21. The last emergency plan training in the file for staff person #4 was 9/16/19. There was no emergency plan training in the file for staff person #5, #6 and #7, all working with children more than 90 days. 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. |
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Provider Response: (Contact the State Licensing Office for more information.) Our staff members received Emergency Plan Training at the beginning of the school year. Our staff has signed off that, yes, they did receive this training. We have now documented the training by having the staff members sign the paper confirming the said training ¿ this document is on file at the facility. |
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| 2022-11-29 | Renewal | 3270.31(e) - Age and Training | Non Compliant - Finalized |
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Regulation: 3270.31(e) Description: Age and Training Noncompliance Area: The file for staff person #2 included 10 hours of child care training between 12/19/20 and 12/19/21. Correction Required: A staff person shall obtain an annual minimum of 12 clock hours of child care training. |
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Provider Response: (Contact the State Licensing Office for more information.) We will have Staff #2 complete two additional hours of training. We will create a list of child care training opportunities and provide them to staff members. We will provide this list to our staff members so that they may complete their 12 clock hours of child care training. |
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