Lightbridge Academy

Regulation: 3270.123(a)(5)/3270.124(b)(7)

Description: Designated release persons/Name/address/phone release person

Noncompliance Area: A renewal inspection was conducted on 7/20/26 and 7/21/26. At that time, the child files were reviewed. The emergency contact form for Child #1 did not include the address of the release persons. The fee agreement for Child #1 did not include the release persons designated by the parent.

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

Regulation: 3270.124(f)/3270.181(c)

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

Noncompliance Area: A renewal inspection was conducted on 7/20/26 and 7/21/26. At that time, the child files were reviewed. The emergency contact form and fee agreement for Child #2 had not been updated since 3/25/25, more than 6 months prior to the date of the inspection.

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

Regulation: 3270.131(a)/3270.131(e)

Description: Health information/ACIP recommended immunization record

Noncompliance Area: A renewal inspection was conducted on 7/20/26 and 7/21/26. At that time, the child files were reviewed. The files for Child #1, Child #3, Child #4, and Child #5 did not include health assessments or immunization records. All four children have been enrolled at the facility more than 60 days.

Correction Required: The operator shall require the parent of an enrolled child, including a child, a foster child and a relative of an operator or a facility person, to provide an initial health report no later than 60 days following the first day of attendance at the facility. The facility may not accept or retain an infant 2 months of age or older, a toddler or a preschool child at the facility for more than 60 days following the first day of attendance at the facility unless the parent provides written verification from a physician, physician's assistant, CRNP, the Department of Health or a local health department of the dates (month, day and year) the child was administered immunizations in accordance with the recommendations of the ACIP. Child #1, Child #3, Child #4, and Child #5 must be dismissed from care by close of business 7/20/26 and may only return to care when the health assessment and immunization record is on updated and in the child's file.

Regulation: 3270.151(a)

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

Noncompliance Area: A renewal inspection was conducted on 7/20/26 and 7/21/26. At that time, the staff files were reviewed. The file for Staff Person #7 contained health assessments dated 5/8/23 and 7/11/26, more than 24 months between updates.

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

Regulation: 3270.182(5)

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

Noncompliance Area: A renewal inspection was conducted on 7/20/26 and 7/21/26. At that time, the child files were reviewed. The emergency contact form for Child #4 did not include signed parental consent for administration of minor first-aid procedures by facility staff.

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

Regulation: 3270.192(5)

Description: Two written references

Noncompliance Area: A renewal inspection was conducted on 7/20/26 and 7/21/26. At that time, the staff files were reviewed. The file for Staff Person #4 contained only one written letter of reference.

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

Regulation: 3270.27(a)(5)/3270.27(e)

Description: Emergency plan/Letter to parents

Noncompliance Area: A renewal inspection was conducted on 7/20/26 and 7/21/26. At that time, the emergency plan was reviewed. The letter provided to the parents regarding the emergency plan did not include accommodations for the infants and toddlers enrolled at the facility.

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

Regulation: 3270.27(c)

Description: Training regarding plan

Noncompliance Area: A renewal inspection was conducted on 7/20/26 and 7/21/26. At that time, the staff files were reviewed. The most recent emergency plan training for Staff Person #7 was completed 9/6/24, more than twelve months prior to the inspection.

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

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

Description: Fire safety - 1 yr.

Noncompliance Area: A renewal inspection was conducted on 7/20/26 and 7/21/26. At that time, the staff files were reviewed. The most recent fire safety training for Staff Person #7 was completed 8/25/24, more than twelve months prior to the inspection.

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

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: A renewal inspection was conducted on 7/20/26 and 7/21/26. At that time, the staff files were reviewed. The file for Staff Person #2 contained a NY CARI (child abuse clearance) dated 5/7/26, after the staff's start date of working with children. The file for Staff Person #5 contained an FBI Clearance requested and completed 12/30/26, after the staff's start date of working with children. The file for Staff Person #6 contained an FBI Clearance completed 1/8/26, after the staff's start date of working with children. The file did not include the request for the FBI Clearance. The file for Staff Person #7 contained PA State Police Clearances dated 8/3/21 and 7/22/25. Both PA State Police Clearances were in "under review" status. A complete PA State Police Clearance was not in the staff's file. The file for Staff Person #7 contained PA Child Abuse Clearance dated 7/11/26. The clearance was not updated within 60 months of the previous PA Child Abuse clearance on file dated 7/8/21.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Staff Person #7 may not work in a child care position at the facility until a complete PA State Police Clearance is on file. 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. Staff Person #7 may not work in a child care position at the facility until a complete PA State Police Clearance is on file. This portion of the plan shall have an immediate correction date. 2. The legal entity must create a hiring checklist. The checklist should include an outline of what needs to be in a staff file and by when. The hiring checklist must be submitted to Northeast Regional Office for approval. Once approved, the child care center will use the hiring checklist whenever a new staff is hired. The operator shall provide a correction date for when the hiring checklist will be implemented.

Regulation: 3270.34(a)(6)

Description: Staff evaluations

Noncompliance Area: A renewal inspection was conducted on 7/20/26 and 7/21/26. At that time, the staff files were reviewed. The most recent staff evaluation for Staff Person #7 was completed 8/2024, more than twelve months prior to the inspection.

Correction Required: A director is responsible for written evaluation of staff persons on a regular basis, a minimum of one evaluation every 12 months.

Regulation: 3270.35(b)(1)

Description: Bachelor's

Noncompliance Area: A renewal inspection was conducted on 7/20/26 and 7/21/26. At that time, the staff files were reviewed. The file for Staff Person #1, a group supervisor, contained a Bachelor of Arts degree from West Virginia University. The college transcripts were not in the file and the degree did not indicate the field of study to verify that the staff had a degree in the human services 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.

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

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

Noncompliance Area: A renewal inspection was conducted on 7/20/26 and 7/21/26. At that time, the staff files were reviewed. The file for Staff Person #3, an assistant group supervisor, contained verification of high school education but did not include verification of child care experience. The file for Staff Person #5, an assistant group supervisor, included verification of 6 college credits, but did not include verification of high school education or child care experience.

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

Regulation: 3270.61(h)(2)(i)/3270.61(h)(2)(ii)

Description: No more than two 1/2 hour time periods daily/Designated on facility schedule

Noncompliance Area: An unannounced inspection was conducted 3/26/26. At that time, the measured room capacity in Room 8 was exceeded by 2 children. Room 8 has a measured capacity of 16 children. At 1:00pm, staff stated that they had 18 children in care since about 10:00am, which exceeds 2 half hour periods. Staff stated that there were 18 children in Room 9 from 9:10am-10:00am when a child was moved to another classroom. The measured room capacity for Room 9 is 17 children. The daily schedule does not indicate a time when the capacity of the indoor child care space will be exceeded in either room.

Correction Required: The capacity established for an indoor space may be exceeded for no more than two separate 1/2 hour time periods daily when older toddler, preschool or school-age children are participating in a program activity. When the number of older toddler, preschool or school-age children participating in a program activity exceeds the capacity of the child care space each time period shall be designated on the facility's schedule of daily activities. TIERED LIS 1. The capacity established for an indoor space may be exceeded for no more than two separate 1/2 hour time periods daily when older toddler, preschool or school-age children are participating in a program activity. When the number of older toddler, preschool or school-age children participating in a program activity exceeds the capacity of the child care space each time period shall be designated on the facility's schedule of daily activities. This portion of the plan shall have an immediate correction date. 2. The legal entity must post the classroom capacities in a conspicuous location in all child care spaces and staff must be made aware of the room capacities. The operator shall provide a correction date for when the room capacities will be posted in each child care space.

Regulation: 3270.103

Description: Small Toys and Objects

Noncompliance Area: A renewal inspection was conducted on 7/18/25 and 7/22/25. On 7/18/25, Ziplock bags were observed in a cubby approximately 30 inches high in the Orange Giraffes Room and Purple Cats Room where they were accessible to the toddler children in the room who staff said are still placing objects in their mouths.

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

Regulation: 3270.123(a)(3)

Description: Services proceeded

Noncompliance Area: A renewal inspection was conducted on 7/18/25 and 7/22/25. On 7/18/25, the child files were reviewed. The most recent child service report on file for Child #2 was dated 12/6/24.

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

Regulation: 3270.124(b)(3)

Description: Parent home/work address, phone

Noncompliance Area: A renewal inspection was conducted on 7/18/25 and 7/22/25. On 7/18/25, the child files were reviewed. The emergency contact forms for Child #1, Child #3, Child #4, Child #5, Child #6, Child #7, and Child #10 did not include the business phone number of the parents. The emergency contact forms for Child #2 and Child #8 did not include the business phone number and business address of the parents.

Correction Required: Emergency contact information must include the home and work addresses and telephone numbers of the enrolling parent.

Regulation: 3270.124(b)(7)

Description: Name/address/phone release person

Noncompliance Area: A renewal inspection was conducted on 7/18/25 and 7/22/25. On 7/18/25, the child files were reviewed. The emergency contact forms for Child #8 and Child #9 did not include the address of the release person.

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

Regulation: 3270.124(f)/3270.181(c)

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

Noncompliance Area: A renewal inspection was conducted on 7/18/25 and 7/22/25. On 7/18/25, the child files were reviewed. The emergency contact form and fee agreement of Child #6 had not been updated within six months. This was evidenced by the dates of the updates on the forms: 6/9/24 and 3/1/25.

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

Regulation: 3270.192(5)

Description: Two written references

Noncompliance Area: A renewal inspection was conducted on 7/18/25 and 7/22/25. On 7/22/25, the staff files were reviewed. The file for Staff Person #5 only contained one letter of reference.

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

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

Description: Age and Training

Noncompliance Area: A renewal inspection was conducted on 7/18/25 and 7/22/25. On 7/22/25, the staff files were reviewed. Staff Person #4 did not update their pediatric first aid and cpr training prior to the expiration date of 4/2025. This was evidenced by the pediatric first aid and cpr trainings on file being dated 4/28/23 and 6/14/25.

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.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: A renewal inspection was conducted on 7/18/25 and 7/22/25. On 7/22/25, the staff files were reviewed. The current PA State Police Clearance on file for Staff Person #3 dated 8/3/21 was in review status. The completed clearance was not on file.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Staff Person #3 may not work in a child care position at the facility until a complete PA State Police Clearance is on file.

Regulation: 3270.34(a)(6)

Description: Staff evaluations

Noncompliance Area: A renewal inspection was conducted on 7/18/25 and 7/22/25. On 7/22/25, the staff files were reviewed. The following staff did not have staff evaluations completed within their past year of employment: Staff Person #5 and Staff Person #6.

Correction Required: A director is responsible for written evaluation of staff persons on a regular basis, a minimum of one evaluation every 12 months.

Regulation: 3270.35(b)(1)

Description: Bachelor's

Noncompliance Area: A renewal inspection was conducted on 7/18/25 and 7/22/25. On 7/22/25, the staff files were reviewed. The file for Staff Person #1, a group supervisor, had a Bachelor's Degree on file, but it was unknown what field of study the degree was in and whether or not it would qualify the staff as a group supervisor. The file for Staff Person #2, a group supervisor, had a Bachelor's Degree on file, but it was unknown what field of study the degree was in and whether or not it would qualify the staff as a group supervisor. The file for Staff Person #6, a group supervisor, had a high school diploma on file, but no verification of high education or experience to qualify the staff as a group supervisor.

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.

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

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

Noncompliance Area: A renewal inspection was conducted on 7/18/25 and 7/22/25. On 7/22/25, the staff files were reviewed. The file for Staff Person #7, an assistant group supervisor, had a high school diploma on file, but no verification of experience to qualify the staff as an assistant group supervisor.

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

Regulation: 3270.65

Description: Protective Outlet Covers 5 yrs. or less

Noncompliance Area: A renewal inspection was conducted on 7/18/25 and 7/22/25. On 7/18/25, an uncovered electrical outlet approximately twelve inches high was observed in the Yellow Ducks Room, where it was accessible to the preschool children in care.

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

Regulation: 3270.66(a)

Description: Locked or inaccessible

Noncompliance Area: A renewal inspection was conducted on 7/18/25 and 7/22/25. On 7/18/25, Banana Boat Sunscreen was observed in a cubby approximately 30 inches high in the Blue Horses Room where it was accessible to the children in the room. ThinkBaby Sunscreen and Coppertone Sunscreen were observed in a cubby approximately 30 inches high in the Brown Bears Room where they were accessible to the children in the room. Hello flouride toothpaste was observed in a cubby approximately 30 inches high in the Teal Turtles Room where it was accessible to the four five-year-old children in the room. Neutrogena sunscreen was observed in a cubby approximately 30 inches high in the Orange Giraffes Room where it was accessible to the children in the room. All sunscreen was labeled "keep out of reach of children." The toothpaste was labeled "keep out of reach of children under age six."

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

Regulation: 3270.67(d)

Description: Contaminated trash in closed plastic-lined receptacle

Noncompliance Area: A renewal inspection was conducted on 7/18/25 and 7/22/25. On 7/18/25, an unlidded trash can was observed in the Yellow Ducks Room. The trash can contained discarded tissues and food items.

Correction Required: Trash that has been contaminated by human secretions or excrement shall be contained in closed, plastic-lined receptacles.

Regulation: 3270.72(c)

Description: Good repair

Noncompliance Area: A renewal inspection was conducted on 7/18/25 and 7/22/25. On 7/18/25, a hole was observed in the screen of the middle window in the Khaki Kangaroos. The staff stated that this window is open for ventilation on nice days.

Correction Required: Screens shall be in good repair.

Regulation: 3270.113(b)/3270.113(d)

Description: No physical punishment /No harsh language

Noncompliance Area: On 3/21/25, a parent viewed a live action video showing two children playing under a table. Staff Person #1 shoved the table away from the children. When Child #1 stood up and leaned against the table, Staff Person #1 roughly grabbed Child #1 by the arm and pulled the child to another area of the room. During the investigation of this incident at the facility, it was found that Staff Person #1 has on other occasions, roughly grabbed the children by the wrist or bicep and pulled them to another area of the room while the child stumbled to keep up and has yelled harshly enough for the older toddlers to cry or seek out another staff for comfort.

Correction Required: A facility person may not use any form of physical punishment, including spanking a child. A facility person may not use harsh, demeaning or abusive language in the presence of children. TIERED LIS: 1. A facility person may not use any form of physical punishment, including spanking a child. A facility person may not use harsh, demeaning or abusive language in the presence of children. This portion of the plan shall have an immediate correction date. 2. The legal entity must arrange for Staff Person #1 to complete two hours of training on managing your emotions and/or positive guidance/appropriate discipline for children. The legal entity must receive approval of the training from the Regional Office prior to the staff completing the training. The operator shall provide a correction date for when the training will be completed.

Regulation: 3270.103

Description: Small Toys and Objects

Noncompliance Area: A renewal inspection was conducted 7/15/24. At that time, plastic bags and plastic gloves were observed on the floor in the Khaki Kangaroos bathroom where they were accessible to the toddlers in care at that time. Plastic bags were observed in an open backpack in a floor level cubby in the Purple Cats room where they were accessible to the toddler children in the room.

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

Regulation: 3270.123(a)(3)

Description: Services proceeded

Noncompliance Area: A renewal inspection was conducted 7/15/24. At that time, the child files were reviewed. The child service reports on file for Child #1, Child #3, Child #4, and Child #5 were not an OCDEL Approved Child Assessment.

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

Regulation: 3270.124(b)(7)

Description: Name/address/phone release person

Noncompliance Area: A renewal inspection was conducted 7/15/24. At that time, the child files were reviewed. The emergency contact form for Child #2, Child #4, and Child #5 did not include the address of the 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.

Regulation: 3270.124(c)

Description: Each child care space

Noncompliance Area: A renewal inspection was conducted 7/15/24. At that time, there was no emergency contact information for the children in the infant group on the playground during the inspection.

Correction Required: When children are in the facility, emergency contact information shall be present in a child care space for children receiving care in the space.

Regulation: 3270.124(e)

Description: Written emergency plan posted

Noncompliance Area: A renewal inspection was conducted 7/15/24. At that time, an emergency transportation plan, including staffing provisions, was not displayed in each child care space or in the emergency backpacks.

Correction Required: A written plan identifying the means of transporting a child to emergency care and staffing provisions in the event of an emergency shall be displayed conspicuously in every child care space and shall accompany a staff person who leaves on an excursion with children.

Regulation: 3270.133(4)

Description: Locked

Noncompliance Area: A renewal inspection was conducted 7/15/24. At that time, diaper cream, labeled "keep out of reach of children" was observed in an open cubby in the Orange Giraffes Room, where it was accessible to the preschool children in the room.

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.

Regulation: 3270.135(a)(3)

Description: Disposable diapers

Noncompliance Area: A renewal inspection was conducted 7/15/24. At that time, the trash cans used for diapering were not hands-free in the infant room, the mobile infant room, the purple cats room, the orange giraffes room, the khaki kangaroos room, or the yellow ducks room.

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

Regulation: 3270.151(c)(3)/3270.151(c)(5)

Description: Exam communicable disease/Physician/CRNP assessment

Noncompliance Area: A renewal inspection was conducted 7/29/24. At that time, the staff files were reviewed. Staff Person #9 did not have a health assessment on file that included whether the staff was free from communicable diseases or suitable to provide child care.

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.

Regulation: 3270.192(5)

Description: Two written references

Noncompliance Area: A renewal inspection was conducted 7/29/24. At that time, the staff files were reviewed. Staff Person #6 had only one letter of reference on file.

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

Regulation: 3270.25(a)

Description: Availability of certificate of compliance and applicable regulations

Noncompliance Area: A renewal inspection was conducted 7/15/24. At that time, information on how to access the regulations electronically had not been provided to parents.

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.

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: A renewal inspection was conducted 7/29/24. At that time, the staff files were reviewed. Staff Person #5, who was employed more than 90 days, has not yet completed the one hour health and safety training.

Correction Required: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10. Staff person #5 will have until 8/15/24 to complete the required training. Until such time as the required training has been completed, staff person #5 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 #5, then staff person #-- may not work in a child-care position at the facility.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: A renewal inspection was conducted 7/15/24 and 7/29/24. At that time, the staff files were reviewed. The mandated reporter training for Staff Person #1 had not been updated within 60 months. The mandated reporter training on file for Staff Person #1 is 9/22/18. The PA state police clearance, PA child abuse clearance, and the DHS FBI Clearance for Staff Person #2 had not been updated within 60 months. The dates of the PA state police clearance for Staff Person #2 were 8/31/18 and 3/12/24. The dates of the PA child abuse clearance for Staff Person #2 were 9/10/18 and 3/12/24. The dates of the FBI Clearance for Staff Person #2 were 9/13/18 and 3/14/24. The PA state police clearance for Staff Person #3 had not been updated within 60 months. The dates of the PA state police clearance were 2/22/19 and 6/17/24. The FBI Clearance on file for Staff Person #3 was dated 2/27/19, which is more than 60 months old. There was no NSOR on file for Staff Person #5, who has been employed longer than 45 days. The NSOR certificate on file was not dated within 45 days of hire of Staff Person #8. The NSOR was dated 6/21/24. The requests for the NSOR were 3/25/24 and 4/22/24.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Staff Person #3 may not work in a child care position at the facility until an updated FBI Clearance is on file at the facility. Staff Person #5 may not work in a child care position at the facility until an updated NSOR certificate is on file at the facility.

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

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

Noncompliance Area: A renewal inspection was conducted 7/29/24. At that time, the staff files were reviewed. Staff Person #6 had verification of high school education on file but did not have verification of any child care experience to qualify as an assistant group supervisor. Staff Person #7 had verification of high school education on file but did not have verification of any child care experience to qualify as an assistant group supervisor. Staff Person #9 had verification of high school education on file but only had verification of 1.25 years of child care experience. Staff Person #9 needs an additional .75 years of child care experience to qualify as an assistant group supervisor.

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

Regulation: 3270.37(b)(1)

Description: HS/GED

Noncompliance Area: A renewal inspection was conducted 7/29/24. At that time, the staff files were reviewed. Staff Person #8 had education on file from El Salvador that had not been evaluated by a service that is a member of the National Association of Credential Evaluation Services (NACES) or the Association of International Credential Evaluators (AICE).

Correction Required: An aide shall have a high school diploma or a general educational development certificate.

Regulation: 3270.66(a)

Description: Locked or inaccessible

Noncompliance Area: A renewal inspection was conducted 7/15/24. At that time, Hello Bello sunscreen, labeled "keep out of reach of children" was observed in an open backpack in a floor level cubby of the Purple Cats Room, where it was accessible to the toddler children in the room.

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

Regulation: 3270.121(a)/3270.121(b)

Description: Review policies and procedures/Given parents in writing

Noncompliance Area: Child # 1 & # 2 enrolled and attending the facility did not have emergency contact forms completed at time of enrollment.

Correction Required: The operator shall review with the parent, at the time of application, the facility's general daily schedule, hours for which care is provided, fees, responsibilities for meals, clothing, health policies, supervision policies, night care policies, dismissal policies, transportation and pick-up arrangements. At the time of enrollment, a parent shall receive in writing the facility's general daily schedule, hours for which care is provided, fees, responsibilities for meals, clothing, health policies, supervision policies, night care policies, dismissal policies, transportation and pick-up arrangements.

Regulation: 3270.123(a)(3)

Description: Services proceeded

Noncompliance Area: Child # 7 did not have a child service report completed in over 6 months from 10/24/22 o 5/1/23. The child service report on file does not have a parent or guardian signature.

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

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

Description: ACIP recommended immunization record /Exemption documentation from parent/guardian

Noncompliance Area: Child # 2, 5 & 6 have influenza immunizations on file that are over 12 months old from 2020. Child # 2,5 & 6 do not have a note on file that they do not receive the influenza shot due to strong personal or religious reasons.

Correction Required: The facility may not accept or retain an infant 2 months of age or older, a toddler or a preschool child at the facility for more than 60 days following the first day of attendance at the facility unless the parent provides written verification from a physician, physician's assistant, CRNP, the Department of Health or a local health department of the dates (month, day and year) the child was administered immunizations in accordance with the recommendations of the ACIP. The facility shall require the parent to provide updated written verification from a physician, physician's assistant, CRNP, the Department of Health or a local health department of ongoing vaccines administered to an infant, toddler or preschool child in accordance with the schedule recommended by the ACIP.

Regulation: 3270.133(3)/3270.133(5)

Description: Name on bottle/Original label

Noncompliance Area: Child # 3 has albuterol at facility that is not labeled. Child # 4 has Children's Allertec that expired in May 2023. Child # 8 has an Epi Pen at facility that has no prescription or label on the medication for the child.

Correction Required: The label of a medication container shall identify the name of the medication and the name of the child for whom the medication is intended. Medication shall be administered to only the child whose name appears on the container. Medication shall be stored in accordance with the manufacturer's or health professional's instructions on the original label.

Regulation: 3270.171(a)

Description: Pick-up and drop-off points

Noncompliance Area: The facility has not notified the local traffic safety authority the facilities use of pedestrian and vehicular routes around the facility in over 12 months since 10/1/21.

Correction Required: An operator shall notify local traffic safety authorities annually in writing of the location of the facility and the program's use of pedestrian and vehicular routes around the child care facility.

Regulation: 3270.27(f)

Description: Emergency plan

Noncompliance Area: The emergency plan was not sent to the emergency management agency or a local municipality in over 12 months since 10/1/21.

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

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

Description: Age and Training

Noncompliance Area: Staff person # 1 did not renew their pediatric first aid and cpr before expiration on 1/30/23. Staff person # 1 received pediatric first aid and cpr on 2/25/23. Staff person # 2 did not renew their pediatric first aid and cpr before expiration on 6/19/23. Staff person # 2 received pediatric first aid and cpr on 7/7/23.

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

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: Staff person # 3 did not completed mandated reporter training in 60 months from 5/4/18 to 5/27/23. Staff person # 4 did not completed mandated reporter training in 60 months from 2/22/16 to 7/15/22. Staff person #5 did not completed mandated reporter training in 60 months from 5/5/18 to 6/10/23.

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

Regulation: 3270.66(a)

Description: Locked or inaccessible

Noncompliance Area: There is hand sanitizer spray on top of the paper towel dispenser accessible to the children in the teal turtle's classroom.

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

Regulation: 3270.76

Description: Building Surfaces

Noncompliance Area: There are steak knives in an unlocked cabinet above a handwashing sink in the blue horse classroom accessible to the children.

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

Regulation: 3270.106(a)

Description: Clean, age appropriate

Noncompliance Area: The toddler classroom and young toddler classroom do not have cot list for assigned cot numbers.

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

Regulation: 3270.123(a)(6)

Description: Admission date

Noncompliance Area: Child # 3 does not have date of admission listed on file.

Correction Required: An agreement shall specify the date of the child's admission.

Regulation: 3270.124(b)(6)

Description: Insurance coverage information

Noncompliance Area: Child # 1 does not have medical policy number on file. Child # 4 does not have medical policy number on file. Child # 5 does not have the medical insurance policy name or number on file.

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

Regulation: 3270.131(a)/3270.131(e)(4)

Description: Health information/Annual immunization reporting to DOH

Noncompliance Area: Child # 2 & # 3 enrolled and attending facility, did not have a health assessment on file for over 60 days from date of enrollment.

Correction Required: The operator shall require the parent of an enrolled child, including a child, a foster child and a relative of an operator or a facility person, to provide an initial health report no later than 60 days following the first day of attendance at the facility. The facility shall comply with the annual immunization reporting requirements in accordance with the Department of Health regulation in 28 Pa. Code §27.77.

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: Facility does not have a policy developed and implemented for understanding staff role and responsibility in prevention of shaken baby syndrome, abusive head trauma and 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.

Regulation: 3270.151(a)

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

Noncompliance Area: Facility staff # 1 has a health assessment on file that is more than 24 months old from 7/23/20.

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

Regulation: 3270.182(3)/3270.182(5)

Description: Consent for emergency medical care required prior to admission/Consent for administration of minor first-aid required prior to admission

Noncompliance Area: Child # 1,2 & 5 do not have signed consent on file for emergency medical care or minor first aid treatment.

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

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

Description: Transcript, diploma and letters/Two written references

Noncompliance Area: Facility staff # 7 hired and working in child care does not have proof of education on file nor do they have 2 references on file. Facility staff # 8 hired and working in childcare only has 1 reference on file.

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

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

Description: Fire safety - 1 yr.

Noncompliance Area: Facility staff # 1 did not complete fire safety training in over 12 months from 7/23/19 to 9/22/21.

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

Regulation: 3270.31(f)/3270.31(f)(10)

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

Noncompliance Area: Staff person # 2 & # 3 have not completed the following pre-service training within 90 days of their date of hire: pediatric first aid and cpr. Facility staff # 3 did not complete professional development in health and safety within 90 days from time of hire.

Correction Required: Staff persons shall complete professional development in the topics of PQAS approved pediatric first aid and cpr within 90 days of hire as listed in subsections (f)1-10.Staff persons shall complete professional development in pediatric first aid and pediatric cardiopulmonary resuscitation within 90 days of hire. Staff person # 2 & # 3 will have until August 13, 2022 to complete the required training. Until such time as the required training has been completed, staff person # 2 & # 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 available to supervise staff # 2 & # 3 , staff person # 2 & # 3 will not work in a child care position at the facility.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: Staff person # 4 has not completed mandated reporter training within the last 60 months. This is evidenced by the previously documented mandated reporter training on file being dated 2/17/16. Staff person # 6 has not completed mandated reporter training within the last 60 months. This is evidenced by the previously documented mandated reporter training on file being dated 2/22/16. Facility staff # 3 who has not lived in PA the past 5 years and is working in child care does not have out of state clearances on file. Facility staff # 5 who has not lived in PA the past 5 years and is working in child care does not have out of state clearances on file.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Staff person # 4 & 6 will have until 8/13/22 to complete the mandated reporter training . Until such time as the required training has been completed, staff person # 4 & # 6 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 persons available to supervise staff person # 3 & # 5 may not work in a child care position at facility. Facility staff # 3 & # 5 may not work in a child care position at facility. A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Facility Person #-3 & 5 may not work in a child care position at the facility.

Regulation: 3270.75(c)

Description: Has all items

Noncompliance Area: The first aid kit in the toddler classroom does not have gloves.

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

Regulation: 3270.82(h)

Description: Handwashing signs

Noncompliance Area: The toddler classroom does not have a hand washing sign posted at the classroom sink to wash hands.

Correction Required: A facility person and an able child shall wash his hands after toileting and before eating. A sign on which this requirement is written shall be posted at each toilet, training chair, diapering area and sink in the facility.

Regulation: 3270.113(a)/3270.113(a)(1)

Description: Supervised at all times /Staff assigned to specific children

Noncompliance Area: A complaint investigation was conducted on 12/20/21. Certification rep spoke with facility staff regarding a concern that 7 school aged children were alone on the play ground outside sometime in Oct or Nov 2021 by another staff. Facility staff reported she did not witness it, however was told and was aware of it taking place. Cert rep then spoke with another facility staff member who reported they were made aware of the allegations but were told a staff member was watching the children on the playground from inside the facility peeking their head out to the playground.

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. Children must be supervised at all times.

Regulation: 3270.113(a)/3270.113(a)(1)

Description: Supervised at all times /Staff assigned to specific children

Noncompliance Area: A complaint investigation was conducted on 12/20/21. Certification rep spoke with facility staff regarding a concern that 7 school aged children were alone on the play ground outside sometime in Oct or Nov 2021 by another staff. Facility staff reported she did not witness it, however was told and was aware of it taking place. Cert rep then spoke with another facility staff member who reported they were made aware of the allegations but were told a staff member was watching the children on the playground from inside the facility peeking their head out to the playground.

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. Children must be supervised at all times. Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises.

Regulation: 3270.113(a)/3270.113(a)(1)

Description: Supervised at all times /Staff assigned to specific children

Noncompliance Area: A complaint investigation was conducted on 12/20/21. Certification rep spoke with facility staff regarding a concern that 7 school aged children were alone on the play ground outside sometime in Oct or Nov 2021 by another staff. Facility staff reported she did not witness it, however was told and was aware of it taking place. Cert rep then spoke with another facility staff member who reported they were made aware of the allegations but were told a staff member was watching the children on the playground from inside the facility peeking their head out to the playground.

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. The legal entity must arrange for all facility staff to receive a minimum of two hours PQAS approved in person training regarding supervision of children. It does not matter if the PQAS approved training is through the ELRC's. The legal entity must receive DHS approval of the training content prior to scheduling the training.

Regulation: 3270.135(e)

Description: 2 hour diaper check

Noncompliance Area: A complaint investigation was conducted 12/20/21. Upon entering the infant and mobile infant classrooms, certification rep asked to see the diaper logs of a child in each classroom that arrived first for the day. Cert rep observed child #1's log and observed they arrived at 7:01 am, were diapered at 8:26 am last. It was 11:07 am when rep observed the log. In the mobile infant classroom, child # 2 arrived at 7:16 am and was just being diapered at 11 am when rep asked to see log. Both infants diapers were not checked or changed in over 2 hours.

Correction Required: A staff person shall check a child's diaper at least every 2 hours and whenever the child indicates discomfort or exhibits behavior that suggests a soiled diaper. A staff person shall change a child's diaper when the diaper is soiled.

Regulation: 3270.51

Description: Similar Age Level

Noncompliance Area: A complaint investigation was conducted on 12/20/21. Upon arrival to the Pre K classroom (4 and 5 year old children), certification rep observed 1 staff with 16 children. Immediately following cert rep, facility person # 1 entered the classroom. When rep asked facility person # 1 where they came from, facility person # 1 stated the bathroom that is outside of the classroom.

Correction Required: When children are grouped in similar age levels, the following maximum child group sizes and ratios of staff persons apply: Infants 1:4 with a maximum group size of 8; Young toddlers 1:5 with a maximum group size of 10; Older toddlers 1:6 with a maximum group size of 12; Preschool children 1:10 with a maximum group size of 20; Young school-age children 1:12 with a maximum group size of 24; Older school-age children 1:15 with a maximum group size of 30. IF USING TIERED LIS: The required staff:child ratios must be maintained at all times. The legal entity must submit documentation in a format approved by DHS proving that the facility is maintaining the required staff:child ratios at all times. The legal entity will confirm continuing compliance by sending copies of the documentation to the -------- Region Office on a weekly basis for a period of three months after DHS approves the documentation format.

Regulation: 3270.95(a)/3270.95(b)

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

Noncompliance Area: On 12/20/21 a unannounced inspection was conducted on site. At the time of the inspection, fire alarm system testing and fire drill logs were reviewed. Facility has not tested the alarm system in over 30 days since 10/24/21 , which is the last documented alarm testing on file at facility.

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

Regulation: 3270.161(a)

Description: Wholesome

Noncompliance Area: There is milk that expired 11/13/21 for the children in the Kacky Kangaroos classroom refrigerator.

Correction Required: Food stored, prepared or served shall be clean, wholesome, free from spoilage, free from adulteration and safe for human consumption.

Regulation: 3270.27(c)/3270.34(a)(6)

Description: Training regarding plan/Staff evaluations

Noncompliance Area: Facility person # 1 has been employed at facility since 5/22/18 and does not have a staff evaluation on file and has not had emergency plan training in over a year since 5/29/18.

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. A director is responsible for written evaluation of staff persons on a regular basis, a minimum of one evaluation every 12 months.

Regulation: 3270.95(a)/3270.95(b)

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

Noncompliance Area: Facility did not test alarm system in over 30 days from 2/7/21 to 4/2/21.

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