Lightbridge Academy Hampton Township

Regulation: 3270.107

Description: Refrigerator

Noncompliance Area: The refrigerator in the Orange Giraffe classroom lacked an operating thermometer.

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

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The file for staff person #1 who was hired on (See LIS Code Sheet) lacked a state police clearance.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL.

Regulation: 3270.82(h)

Description: Handwashing signs

Noncompliance Area: In the Khaki Kangaroos classroom handwashing signs were not observed to be posted above the two toilets in the restroom.

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)

Description: Supervised at all times

Noncompliance Area: Per the facility's self-report and staff statements, on 6/3/25, Staff #1 and Staff #2 were transitioning 19 preschoolers from their classroom to outside when Child #1 was left in the restroom which is located inside of the classroom. Child #1 then left the room unaccompanied and went down the stairs where the child rejoined their group. Staff Person #1 and Staff Person #2 reported that they did not realize Child #1 was not with the class until Child #1 rejoined them downstairs Staff Person #3 witnessed the child returning to the group and reported that the child was upset. Staff #3 took Child #1 into office to calm down before reuniting them with their class. Child #1 was alone for less than one minute before reuniting with their class.

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. TIERED LIS: 1. Children must be supervised at all times. 2. The Legal Entity will require the operator, director and any staff persons who have a leadership role to participate in monthly, on site, Technical Assistance (TA) sessions with ELRC 5 for a minimum of 4 months. The TA sessions will include defining staff leadership roles in the childcare, identifying methods that each role can utilize to ensure staff understand and are implementing proper supervision of all of the children in care. Documentation of each TA session will be submitted to the Department within 10 days of the completion of the session. 3. The director and any staff person who have a leadership role will attend the live virtual Supervision 101 training conducted by the ELRC 5 on August 7, 2025. 4. All new staff employed after the accepted date of this plan of correction will complete 2 hours of online supervision training within the first 14 calendar days of employment for a minimum of 4 months. The legal entity will submit the training for approval prior to completing the training. Certificates of completion will be submitted to the department within 5 calendar days of completion.

Regulation: 3270.113(a)(1)

Description: Staff assigned to specific children

Noncompliance Area: Per the facility's self-report and staff statements, on 6/3/25, Staff #1 and Staff #2 were transitioning 19 preschoolers from their classroom to outside when Child #1 was left in the restroom which is located inside of the classroom. Child #1 then left the room unaccompanied and went down the stairs where the child rejoined their group. Staff Person #1 and Staff Person #2 reported that they did not realize Child #1 was not with the class until Child #1 rejoined them downstairs Staff Person #3 witnessed the child returning to the group and reported that the child was upset. Staff #3 took Child #1 into office to calm down before reuniting them with their class. Child #1 was alone for less than one minute before reuniting with their class.

Correction Required: Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises.

Regulation: 3270.51

Description: Similar Age Level

Noncompliance Area: Per the facility's self-report and staff statements, on 6/3/25, Staff #1 and Staff #2 were transitioning 19 preschoolers from their classroom to outside when Child #1 was left in the restroom which is located inside of the classroom. Child #1 then left the room unaccompanied and went down the stairs where the child rejoined their group. Staff Person #1 and Staff Person #2 reported that they did not realize Child #1 was not with the class until Child #1 rejoined them downstairs Staff Person #3 witnessed the child returning to the group and reported that the child was upset. Staff #3 took Child #1 into office to calm down before reuniting them with their class. Child #1 was alone for less than one minute before reuniting with their class.

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.

Regulation: 3270.95(a)/3270.95(b)

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

Noncompliance Area: The 30-day fire detection log on file at the facility included dates of testing from 1/8/25-2/24/25, 2/24/25-3/2725, and 4/24/25-5/27/25, which are all over 30 days between testing.

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: 3270.113(a)

Description: Supervised at all times

Noncompliance Area: Per the facility's self-report and staff statements, on 2/10/25 Staff #1 and #2 took their group of 10 preschool children from the Khaki Kangaroo room directly across the hall to the multi-purpose room. Staff person #2 went to the restroom. Child #1 was found in the hallway by staff person #3. Staff person #4 walked out of her classroom and found staff person #3 and child #1 in the hallway. Staff person #3 and #4 took child #1 back to the multi-purpose room. Staff person #1 did not realize that child #1 was not in the multi-purpose room. Child #1 was unsupervised for approximately 1 minute before staff returned child #1 to the multi-purpose room.

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. 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. 1. Children must be supervised at all times. 2. The legal entity must arrange for all facility staff to take the 2-hr, in person training from ELRC 5, "Creating Safe Environments Through Active Supervision." The training must be approved by DHS. The training may count towards the mandatory 12 training hours required by 3270.31(e).

Regulation: 3270.113(a)(1)

Description: Staff assigned to specific children

Noncompliance Area: Per the facility's self-report and staff statements, on 2/10/25 Staff #1 and #2 took their group of 10 preschool children from the Khaki Kangaroo room directly across the hall to the multi-purpose room. Staff person #2 went to the restroom. Child #1 was found in the hallway by staff person #3. Staff person #4 walked out of her classroom and found staff person #3 and child #1 in the hallway. Staff person #3 and #4 took child #1 back to the multi-purpose room. Staff person #1 did not realize that child #1 was not in the multi-purpose room. Child #1 was unsupervised for approximately 1 minute before staff returned child #1 to the multi-purpose room.

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. 1. Each staff person shall be assigned the responsibility for supervision of specific children. 2. The facility is required to develop and maintain a hands-free method for identifying the specific children for which each staff person is responsible. It will include, minimally, the name and a picture of the child and staff will utilize the identification method appropriately at all times while on duty at the facility. When a new child enrolls at the facility, a supervision card will be present at the facility before the child's first day of attendance.

Regulation: 3270.51

Description: Similar Age Level

Noncompliance Area: Per the facility's self-report and staff statements, on 2/10/25 Staff #1 and #2 took their group of 10 preschool children from the Khaki Kangaroo room directly across the hall to the multi-purpose room. Staff person #2 went to the restroom. Child #1 was found in the hallway by staff person #3. Staff person #4 walked out of her classroom and found staff person #3 and child #1 in the hallway. Staff person #3 and #4 took child #1 back to the multi-purpose room. Staff person #1 did not realize that child #1 was not in the multi-purpose room. Child #1 was unsupervised for approximately 1 minute before staff returned child #1 to the multi-purpose room.

Correction Required: When children are grouped in similar age levels, the following maximum child group sizes and ratios of staff persons apply: Infants 1:4 with a maximum group size of 8; Young toddlers 1:5 with a maximum group size of 10; Older toddlers 1:6 with a maximum group size of 12; Preschool children 1:10 with a maximum group size of 20; Young school-age children 1:12 with a maximum group size of 24; Older school-age children 1:15 with a maximum group size of 30.

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: The file for staff person #1 lacked Pediatric First-Aid and CPR training that was completed within 90 days of hire (See the LIS Code Sheet). The Pediatric First-Aid and CPR training in the file was dated 9/12/24.

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

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The file for staff person #2 who was hired as an assistant group supervisor on (See LIS Code Sheet) lacked a child abuse clearance prior to the start date. The child abuse clearance in the file was dated 6/14/24. The file for staff person #3 who was hired as an aide on (See LIS Code Sheet) lacked a child abuse clearance prior to the start date. The child abuse clearance in the file was dated 8/9/24.

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.

Regulation: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: In the Yellow Ducks classroom broken magnetic plastic blocks were observed to be broken causing rough edges, sharp corners, and pinch and crush points.

Correction Required: Toys, play equipment and other indoor and outdoor equipment used by the children shall be clean, in good repair and free from rough edges, sharp corners, pinch and crush points, splinters and exposed bolts.

Regulation: 3270.123(a)(3)

Description: Services proceeded

Noncompliance Area: The file for child #8 lacked a child service report that was completed 6 months from the previous child service report. The child service reports in the file were dated 10/31/22 and 11/15/23.

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

Regulation: 3270.123(b)/3270.182(8)

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

Noncompliance Area: In the files for children #1 - #10 it was observed that the original agreement was in the files and was not given to the parents.

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

Regulation: 3270.124(b)(7)

Description: Name/address/phone release person

Noncompliance Area: In the files for children #2 and #4 the emergency contact information did not include the address information of the individual designated by the parent to whom the child may be released.

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

Regulation: 3270.124(f)/3270.181(c)

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

Noncompliance Area: The file for child #4 lacked an update in writing to the emergency contact information six months from the previous update. The emergency contact information was updated on 7/31/23 and 2/5/24. The file for child #8 lacked an update in writing to the emergency contact information six months from the previous update. The emergency contact information was updated on 7/1/23 and 2/1/24. The file for child #10 lacked an update in writing to the emergency contact information six months from the previous update. The emergency contact information was updated on 7/3/23 and 2/14/24.

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)/3270.182(1)

Description: Health information/Initial and subsequent health reports

Noncompliance Area: The file for child #8 lacked an initial child health report that was completed within 60 days of the first day of attendance at the facility (See LIS Code Sheet). The child health report in the file was dated 10/18/22.

Correction Required: The operator shall require the parent of an enrolled child, including a child, a foster child and a relative of an operator or a facility person, to provide an initial health report no later than 60 days following the first day of attendance at the facility. A child's record shall contain initial and subsequent health reports.

Regulation: 3270.31(e)(4)(ii)/3270.192(2)(iii)

Description: Fire safety - 1 yr./Exp, educ., training at facility

Noncompliance Area: The file for staff person #1 lacked firesafety training that was completed 12 months from the previous firesafety training. The firesafety training in the file was dated 9/13/22 and 10/5/23.

Correction Required: Staff persons shall participate, at least annually, in firesafety training conducted by a fire protection professional. Staff persons and volunteers shall receive training in maintenance of smoke detectors, the duties of facility persons during a fire drill and during a fire and the use of the facility's fire extinguishers, not including discharge of the fire suppressant agent. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The files for staff persons #2 - #13 lacked a valid disclosure statement. The disclosure statements in the files were not completed on the most current disclosure statement form.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL.

Regulation: 3270.66(a)

Description: Locked or inaccessible

Noncompliance Area: In the Yellow Ducks classroom an unlocked cabinet under the sink accessible to the children was observed containing a bottle of sanitizer spray and MPC Sani Spray both labeled "Keep Out of Reach of Children".

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: 3270.82(h)

Description: Handwashing signs

Noncompliance Area: In the Khaki Kangaroos classroom a handwashing sign was observed to not be posted in the right side stall in the restroom.

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: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: In the green frog classroom a broken plastic toy bin was observed causing rough edges, sharp corners, and pinch and crush points.

Correction Required: Toys, play equipment and other indoor and outdoor equipment used by the children shall be clean, in good repair and free from rough edges, sharp corners, pinch and crush points, splinters and exposed bolts.

Regulation: 3270.106(f)

Description: 2 feet apart

Noncompliance Area: During naptime in the purple cats room there were five mats with less than 2 feet of space on three sides of the mat while the equipment was in use.

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

Regulation: 3270.107

Description: Refrigerator

Noncompliance Area: The refrigerator in the purple cats room lacked a thermometer.

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

Regulation: 3270.113(a)

Description: Supervised at all times

Noncompliance Area: **Per the facility's self-report and staff statements, on 9/11/23 Staff #1, 2 & 3 took their group of children to the outdoor playground. Unnoticed by the staff, child #1 had gone into the bathroom and did not accompany the group to the playground. He was unsupervised for approximately 3-5 minutes before a staff returned to the room to retrieve the child.

Correction Required: **The legal entity must arrange for all facility staff to take the 2-hr, in person training from ELRC 5, "Creating Safe Environments Through Active Supervision." The training must be approved by DHS. The training may count towards the mandatory 12 training hours required by 3270.31(e).

Regulation: 3270.113(a)

Description: Supervised at all times

Noncompliance Area: ***Per the facility's self-report and staff statements, on 9/11/23 Staff #1, 2 & 3 took their group of children to the outdoor playground. Unnoticed by the staff, child #1 had gone into the bathroom and did not accompany the group to the playground. He was unsupervised for approximately 3-5 minutes before a staff returned to the room to retrieve the child.

Correction Required: ***The legal entity must submit documentation in a format approved by DHS proving that the facility is maintaining their procedure for counting children and identifying the specific children assigned to each staff. The form to be used to record the checks must be approved by DHS. The Director or another identified staff, should conduct the check and complete the form for each classroom at least 3 times per week. The legal entity will confirm continuing compliance by making copies of the forms available to the DHS Department Representative upon request after DHS approves the form. Forms are to be completed upon approval for a minimum period of 3 months from the date the forms are accepted by the DHS.

Regulation: 3270.113(a)

Description: Supervised at all times

Noncompliance Area: *Per the facility's self-report and staff statements, on 9/11/23 Staff #1, 2 & 3 took their group of children to the outdoor playground. Unnoticed by the staff, child #1 had gone into the bathroom and did not accompany the group to the playground. He was unsupervised for approximately 3-5 minutes before a staff returned to the room to retrieve the child.

Correction Required: *Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Outdoor play space used by the facility is considered part of the facility premises.

Regulation: 3270.113(a)(1)

Description: Staff assigned to specific children

Noncompliance Area: Per the facility's self-report and staff statements, on 9/11/23 Staff #1, 2 & 3 took their group of children to the outdoor playground. Unnoticed by the staff, child #1 had gone into the bathroom and did not accompany the group to the playground. He was unsupervised for approximately 3-5 minutes before a staff returned to the room to retrieve the child.

Correction Required: Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises.

Regulation: 3270.123(a)(3)

Description: Services proceeded

Noncompliance Area: The file for child #1 lacked a child service report that was completed within 6 months of the enrollment date. The child service report was dated 5/26/23. The child's start date was (See LIS Code Sheet). The files for children #4 and #6 lacked an updated child service report. The file for child #4 contained a child service report dated 10/31/22. The file for child #6 contained a child service report dated 11/11/22.

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: The files for children #2, #3, #4, and #5 lacked emergency contact information that included the work addresses and work telephone numbers of the enrolling parent.

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

Regulation: 3270.124(b)(7)

Description: Name/address/phone release person

Noncompliance Area: The file for child #3 lacked emergency contact information that included the address and telephone number of the individual designated by the parent to whom the child may be released.

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

Regulation: 3270.131(b)(1)

Description: Infant: updated health report every 6 months

Noncompliance Area: The file for child #4 a young toddler lacked a health report that was completed 6 months from the previous health report. The health reports in the file were dated 12/28/22 and 9/14/23. The file for child #7 a young toddler lacked a health report that was completed 6 months from the previous health report. The health reports in the file were dated 1/26/23 and 9/20/23.

Correction Required: The operator shall require the parent to provide an updated health report at least every 6 months for an infant or young toddler.

Regulation: 3270.131(b)(2)

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

Noncompliance Area: The file for child #6 a preschooler lacked a health report that was completed more than 12 months from the previous health report. The health reports in the file were dated 2/2/22 and 3/1/23.

Correction Required: The operator shall require the parent to provide an updated health report at least every 12 months for an older toddler or preschool child.

Regulation: 3270.135(a)(3)

Description: Disposable diapers

Noncompliance Area: The hand-free trash can in the khaki kangaroos room diaper changing area was broken. The trash can was not able to be operated hands-free.

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(a)

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

Noncompliance Area: The file for staff person #2 lacked a staff health assessment that was completed 24 months from the previous health assessment. The health assessments in the file were dated 5/20/21 and 7/17/23. The file for staff person #5 whom was hired on (See LIS Code Sheet) lacked a health assessment that was completed 12 months prior to providing initial service in a child care setting. The health assessment in the file was dated 1/13/22.

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: 3270.31(e)(4)(ii)

Description: Fire safety - 1 yr.

Noncompliance Area: The file for staff person #1 lacked firesafety training that was completed 12 months from the previous firesafety training. The firesafety trainings in the file were dated 1/25/22 and 1/27/23. The file for staff person #4 lacked firesafety training that was completed 12 months from the previous firesafety training. The firesafety trainings in the file were dated 3/2/21 and 10/20/22.

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)(10)/3270.192(2)(iii)

Description: Health and Safety Training - Pediatric First Aid and CPR/Exp, educ., training at facility

Noncompliance Area: The file for staff person #3 lacked Pediatric First-Aid and Pediatric CPR training within 90 days of hire (See LIS Code Sheet).

Correction Required: Staff persons shall complete professional development in pediatric first aid and pediatric cardiopulmonary resuscitation within 90 days of hire. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

Regulation: 3270.34(a)(6)

Description: Staff evaluations

Noncompliance Area: The file for staff person #1 lacked a written staff evaluation from the director that was one year from the previous written staff evaluation. The staff evaluations in the file were dated 3/28/22 and 3/29/23.

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

Regulation: 3270.51

Description: Similar Age Level

Noncompliance Area: Per the facility's self-report and staff statements, on 9/11/23 Staff #1, 2 & 3 took their group of children to the outdoor playground. Unnoticed by the staff, child #1 had gone into the bathroom and did not accompany the group to the playground. He was unsupervised for approximately 3-5 minutes before a staff returned to the room to retrieve the child.

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.

Regulation: 3270.65

Description: Protective Outlet Covers 5 yrs. or less

Noncompliance Area: There were two outlets missing protective receptacle covers in the khaki kangaroos room accessible to children 5 years of age or younger.

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

Regulation: 3270.75(c)

Description: Has all items

Noncompliance Area: The first-aid kit in the purple cats room lacked scissors.

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

Regulation: 3270.95(a)/3270.95(b)

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

Noncompliance Area: The Fire Drill and Fire Detection Log was observed for the 30-day smoke detector checks. There were 55 days between 11/2/22 and 12/27/22, 37 days between 1/23/23 and 3/1/23, 36 days 3/1/23 and 4/6/23, 49 days 4/6/23 and 5/25/23, and 55 days between 8/2/23 and 9/26/23.

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

Regulation: 3270.133(5)

Description: Original label

Noncompliance Area: In the Yellow Duck Preschool room an expired Epi pen was observed in the excursion backpack.

Correction Required: Medication shall be stored in accordance with the manufacturer's or health professional's instructions on the original label.

Regulation: 3270.133(6)

Description: Written consent

Noncompliance Area: An Epi Pen was observed in the Yellow Duck Preschool Room in the excursion backpack that did not have written parental consent for administration of medication.

Correction Required: A parent shall provide written consent for administration of medication or a special diet.

Regulation: 3270.113(a)

Description: Supervised at all times

Noncompliance Area: During an interview with staff person #1 on 3/21/22 staff person #1 stated at approximately 4:35pm on 3/16/22 staff person #1 did a head count and realized that child #1 was not on the playground. A parent brought child #1 back out to the playground from inside the facility. Child #1 was missing from the playground for approximately one minute.

Correction Required: Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Outdoor play space used by the facility is considered part of the facility premises.

Regulation: 3270.113(a)(1)

Description: Staff assigned to specific children

Noncompliance Area: During an interview with staff person #1 on 3/21/22 staff person #1 stated at approximately 4:35pm on 3/16/22 staff person #1 did a head count and realized that child #1 was not on the playground. A parent brought child #1 back out to the playground from inside the facility. Child #1 was missing from the playground for approximately one minute.

Correction Required: Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises.

Regulation: 3270.51

Description: Similar Age Level

Noncompliance Area: During an interview with staff person #1 on 3/21/22 staff person #1 stated at approximately 4:35pm on 3/16/22 staff person #1 did a head count and realized that child #1 was not on the playground. A parent brought child #1 back out to the playground from inside the facility. Child #1 was missing from the playground for approximately one minute.

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.

Regulation: 3270.106(f)

Description: 2 feet apart

Noncompliance Area: One crib with a sleeping infant was observed to lack 2 feet of space on 3 sides.

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

Regulation: 3270.113(a)(1)

Description: Staff assigned to specific children

Noncompliance Area: Upon assessment of supervision and ratio in the Infant Room at 12:05 PM, Staff #1 named 4 Infants. Staff #3 was asked to name her supervisory group and did not answer cert rep. Staff #1 asked Staff #2 to name her group before Staff #3. Staff #2 named 2 infants.. Staff #1 then said to Staff #3 that there were 10 children in the room. Staff #3 named 3 children. When asked who was responsible for the child who was not named, Staff #3 found the sleeping infant and named the child.

Correction Required: Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises.

Regulation: 3270.106(f)

Description: 2 feet apart

Noncompliance Area: During assessment of supervision and ratio on 11/29/21 at 11:15 AM in the Infant Room, two infants were observed sleeping in cribs which lacked 2 feet of space on three sides.

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

Regulation: 3270.113(b)

Description: No physical punishment

Noncompliance Area: *In a video recording from the facility's video camera, which was viewed as part of a complaint investigation, Staff #1 is observed pulling a child down off a shelf by both legs, causing him to land roughly on his bottom on the floor.

Correction Required: A facility person may not use any form of physical punishment, including spanking a child.

Regulation: 3270.113(b)

Description: No physical punishment

Noncompliance Area: **In a video recording from the facility's video camera, which was viewed as part of a complaint investigation, Staff #1 is observed pulling a child down off a shelf by both legs, causing him to land roughly on his bottom on the floor.

Correction Required: A facility person may not use any form of physical punishment, including spanking a child. The legal entity must arrange for all facility staff to receive a minimum of two hours of in-person training conducted by the ELRC in the area of positive discipline.

Regulation: 3270.135(a)(3)

Description: Disposable diapers

Noncompliance Area: SECOND VIOLATION. During a diaper change in the Mobile Infant Room, staff was observed placing the soiled diaper on the diaper changer surface until all wipes were used, and then the diaper and wipes were placed in the hands-free can.Cited previously on SIN-00192830 on 9/13/21.

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: 3270.25(b)

Description: Post the inspection summary

Noncompliance Area: During the implementation visit to verify corrections for SIN-00192830 , it was observed that the Inspection Summary was not posted in a conspicuous location used by parents.

Correction Required: The operator shall post a copy of each inspection summary issued by the Department in a conspicuous location used by parents. The inspection summary shall remain posted until an agent of the Department verifies that each regulatory noncompliance item cited on the inspection summary has been corrected.

Regulation: 3270.31(f)(10)/3270.192(2)(iii)

Description: Health and Safety Training - Pediatric First Aid and CPR/Exp, educ., training at facility

Noncompliance Area: SECOND VIOLATION. The file for Staff #3, with a hire date of 4/14/21, Staff #5, with a hire date of 3/1/21, Staff #8, with a hire date of 5/24/21, and Staff #10, with a hire date of 1/28/2, lacked documentation of certification in pediatric first-aid and CPR. The file for Staff #6, with a hire date of 6/5/21, lacked documentation of certification in pediatric CPR. Certification was due 90 days from hire. Previously cited on SIN-00192830 on 9/13/21.

Correction Required: Pediatric first aid and pediatric cardiopulmonary resuscitation. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

Regulation: 3270.113(a)

Description: Supervised at all times

Noncompliance Area: During assessment of ratio and supervision at naptime in the Kangaroo Room at 1:15 PM on 9/14/21, , Staff #4 was observed supervising 10 OT. Staff #4 was unable to see or assess 3 of the children in her care from her seated position on the floor next to a child. Two children were behind bookcases and one child was behind a diaper changing station.

Correction Required: Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Outdoor play space used by the facility is considered part of the facility premises.

Regulation: 3270.113(a)(1)

Description: Staff assigned to specific children

Noncompliance Area: Upon assessment of supervision and ratio in the Mobile Infant Room at 11:05 AM on 9/13/21, Staff #1 named 4 YT, Staff #11named 3 infants and Staff #10 named 3 children - 1 YT and 2 INF - for a total of 10 children. There were 12 children in the room at this time. When asked to re-name their supervisory groups, all 3 staff named the same groups. When asked whom was responsible for the remaining 2 children, Staff #11 and Staff #10 added 1 INF each to their group. Upon assessment of supervision on the Older PG at 11:25 AM on 9/13/21, Staff #13 named 4 PS children and Staff #8 named 4 PS children. There were 10 children on the Older PG at this time. When asked to re-name their supervisory groups, both staff named the same groups. When asked whom was responsible for the 2 remaining children, each staff added 1 PS child to their group.

Correction Required: Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises.

Regulation: 3270.123(a)(5)

Description: Designated release persons

Noncompliance Area: The files for Child #1, #2 and #3 contained agreements which lacked the release persons.

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

Regulation: 3270.124(b)(7)

Description: Name/address/phone release person

Noncompliance Area: The file for Child #1 contained an emergency contact form which lacked the telephone number of a 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: 3270.133(5)

Description: Original label

Noncompliance Area: An Auvi-Q labeled for Child #4 in the Kangaroos Room was observed to be expired.

Correction Required: Medication shall be stored in accordance with the manufacturer's or health professional's instructions on the original label.

Regulation: 3270.135(a)(3)

Description: Disposable diapers

Noncompliance Area: During a diaper change in the Mobile Infant Room, staff was observed placing the soiled diaper and wipes on the diaper changer surface until all wipes were used, and then the diaper and wipes were placed in the hands-free can.

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

Regulation: 3270.151(a)/3270.192(3)

Description: 12 months prior to service and every 24 months thereafter/Health assessment, TB test

Noncompliance Area: The file for Staff #4 lacked an initial health assessment. The files for Staff #5 and #7 contained initial health assessments dated after the first days of employment in child care positions.

Correction Required: A facility person providing direct care who comes into contact with the children or who works with food preparation shall have a health assessment conducted within 12 months prior to providing initial service in a child care setting and every 24 months thereafter. A health assessment is valid for 24 months following the date of signature, if the person does not contract a communicable disease or develop a medical problem.A facility person's record shall include a written report of initial and subsequent health assessments, including the results of initial and subsequent tuberculin skin tests, x-rays or other medical documentation necessary to confirm freedom from communicable tuberculosis.

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

Description: Mantoux TB/Health assessment, TB test

Noncompliance Area: The file for Staff #4 lacked documentation of tuberculosis screening by the Mantoux method. The files for Staff #5 and #7 contained initial tuberculosis screenings by the Mantoux method dated after the first days of employment in child care positions.

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.

Regulation: 3270.192(5)

Description: Two written references

Noncompliance Area: The files for Staff #3 ,#4, #6, #8, #10, #11 and #12 lacked two written, nonfamily references. The file for Staff #5 contained one of two required written, nonfamily references.

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: The file for Staff #7 contained documentation of most current certification in pediatric first-aid and CPR which had expired.

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

Regulation: 3270.31(f)(10)/3270.192(2)(iii)

Description: Health and Safety Training - Pediatric First Aid and CPR/Exp, educ., training at facility

Noncompliance Area: The file for Staff #2, with a hire date of 3/29/21, Staff #3, with a hire date of 4/14/21, Staff #5, with a hire date of 3/1/21, Staff #6, with a hire date of 6/5/21, Staff #8, with a hire date of 5/24/21, and Staff #10, with a hire date of 1/28/21, lacked documentation of certification in pediatric first-aid and CPR. Certification was due 90 days from hire.

Correction Required: Pediatric first aid and pediatric cardiopulmonary resuscitation.A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

Regulation: 3270.31(h)/3270.192(2)(iii)

Description: Health and Safety Training/Exp, educ., training at facility

Noncompliance Area: The files for Staff #2, with a hire date of 3/29/21, Staff #5, with a hire date of 3/1/21, Staff #6 with a hire date of 6/5/21, Staff #8, with a hire date of 5/24/21, and Staff #10, with a hire date of 1/28/21,lacked documentation of health and safety training numbers 1 - 9, as listed in the regulation 3270.31(f). Training was required within 90 days of employment in child care.

Correction Required: All staff persons shall complete the professional development under subsection (f). A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

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

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

Noncompliance Area: The files for Staff #8, with a hire date of 5/4/21 and Staff #10, with a hire date of 1/28/21, lacked documentation of required mandated reporter training.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services).A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The file for Staff #3, with a hire date of 4/14/21, contained an NSOR clearance dated 4/28/21 and lacked an application for NSOR. The file for Staff #4 lacked a disclosure statement for the present employer. The file for Staff #5, with a hire date of 3/1/21, contained an NSOR clearance dated 3/8/21 and lacked an application for NSOR. The file for Staff #7 contained most current state police and child abuse clearances which were dated more than 60 months ago. The file for Staff #9, with a hire date of 7/7/21, contained an NSOR application dated 6/17/21 and an NSOR clearance dated 8/31/21. Staff #9's provisional hire period ended 8/21/21 and was not removed from child care between that date and when the NSOR was obtained. The file for Staff #10 lacked an NSOR clearance or application for NSOR. The file for Staff #11, with a hire date of 6/28/21, contained receipt for FBI fingerprinting dated 6/21/21 yet lacked documentation of valid FBI clearance. Staff #11's provisional hire period ended 8/12/21 and was not removed from child care after that date. Staff #11 was observed supervising children 9/14/21 after being removed the previous day.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services).A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Facility Person #4, #7, #10 and #11 - may not work in a child care position at the facility.

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

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

Noncompliance Area: The file for Staff #1, designated as a GS, contained documentation of 14 related credit hours and 688 hours of previous experience, qualifying her as an Aide. The file for Staff #3, designated as a GS, contained documentation of 12 related credit hours, qualifying her as an Aide. The file for Staff #4, designated as a GS, lacked documentation of education or experience. The file for Staff #8, designated as a GS, contained documentation of a bachelor's degree which lacked the major field of study, making it unable to be determined if the field of study was human services related. The file for Staff #9, designated as an AGS, contained documentation of an associate's degree in general studies which lacked a transcript of courses, qualifying the individual as an Aide. The file for Staff #11, designated as an AGS, contained documentation of more than 2 years of child care experience yet lacked documentation of education.

Correction Required: A staff person or a substitute staff person shall meet one of the applicable staff qualifications for the position in which the person is performing .A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

Regulation: 3270.34(a)(6)

Description: Staff evaluations

Noncompliance Area: The file for Staff #7 contained an initial staff evaluation dated more than 12 months after the date of hire.

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: 3270.37(c)

Description: Aides supervised all times

Noncompliance Area: Staff #4, whose file did not qualify her as an AGS or above, was observed supervising a group of 10 OT alone during naptime on 9/14/21 at 1:10 PM, unsupervised by another staff person.

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

Regulation: 3270.66(a)

Description: Locked or inaccessible

Noncompliance Area: Toxic shaving cream labeled keep out of reach of children, was observed in the Purple Cats Room, described by staff as being used for crafts with the children.

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: 3270.66(b)

Description: Original container

Noncompliance Area: Toxic disinfectant and sanitizer bottles were observed setting on the counter in the Purple Cats Room, where lunch was being prepped for the children.

Correction Required: Cleaning materials and other toxic materials shall be stored in an original labeled container or in a container that specifies the content. Toxics shall be stored away from food, food preparation areas and child care spaces.

Regulation: 3270.75(b)

Description: Inaccessible to children

Noncompliance Area: The first-aid kit on the Older PG was observed to be accessible to children, setting on top of a lidded waste can.

Correction Required: A first-aid kit must be inaccessible to children.

Regulation: 3270.75(c)

Description: Has all items

Noncompliance Area: The first-aid kit in the Orange Giraffe Room was observed to lack 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 far stall in the bathroom of the Kangaroos Room, and both stalls in the bathrooms of the Green Frogs and Orange Giraffe Rooms were observed to lack handwashing signs.

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: 3270.95(a)/3270.95(b)

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

Noncompliance Area: The operator lacked documentation of proof of purchase for the demonstrated interconnected fire detection system.

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.