Little Achievers

Regulation: 3280.102(a)

Description: Clean and good repair

Noncompliance Area: The handle to the small trampoline in the front classroom was loose and unstable, creating a tipping or fall hazard for children. A toy truck and dollhouse in the outdoor play area were found to be visibly unclean and in need of sanitizing. The table in the playhouse in the preschool play space was cracked.

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: 3280.103

Description: Small Toys and Objects

Noncompliance Area: Mulch from the adjacent preschool play space was spilling through the fence into the toddler play area and small stones were observed on the play surface in the toddler area. The mulch and stones, which were less than an inch in diameter, were accessible to children 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: 3280.131(b)(2)/3280.182(1)

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

Noncompliance Area: The file of Child #3, identified as a preschool age child (see LIS code sheet), did not contain a health assessment conducted in the last 12 months. The most recent assessment on file was dated 6/20/2025.

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

Regulation: 3280.181(c)

Description: Emergency info/agreement updated 6 mos

Noncompliance Area: The financial agreement for Child #2 was reviewed/updated more than 6 months apart (9/15/2025 and 4/12/2026).

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

Regulation: 3280.182(3)

Description: Consent for emergency medical care required prior to admission

Noncompliance Area: The file of Child #1 did not include signed parental consent for emergency medical care for the child.

Correction Required: A child's record must contain signed parental consent for emergency medical care for the child. Written consent is required prior to admission.

Regulation: 3280.182(5)

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

Noncompliance Area: The file of Child #1 did not include signed parental consent for administration of minor first-aid procedures by facility staff.

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

Regulation: 3280.20

Description: General Health and Safety

Noncompliance Area: In the outdoor preschool play space, a large dollhouse and the back of a Cozy Coupe car conatined standing water. In the outdoor infant/toddler play area, standing water was observed in the back of a dump truck and in the bucket attached to a tricycle.

Correction Required: Conditions at the facility may not pose a threat to the health or safety of the children.

Regulation: 3280.26(a)(3)

Description: Contact when arises

Noncompliance Area: The emergency plan did not include a method for facility persons to contact parents as soon as reasonably possible when an emergency situation arises.

Correction Required: The facility shall have an emergency plan that provides for a method for facility persons to contact parents as soon as reasonably possible when an emergency situation arises.

Regulation: 3280.26(a)(4)

Description: Contact when ended

Noncompliance Area: The emergency plan did not include a method for facility persons to inform parents that the emergency has ended and to provide instruction as to how parents can safely be reunited with their children

Correction Required: The facility shall have an emergency plan that provides for a method for facility persons to inform parents that the emergency has ended and to provide instruction as to how parents can safely be reunited with their children.

Regulation: 3280.32(a)/3280.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The file of Staff #1 did not contain documentation of a current FBI clearance with the previous being dated 6/15/2021, more than 60 months prior to the inspection. The disclosure statement on file for Staff #2 was a previous version of the form dated 11/8/2024 and not the current version dated 1/1/2025.

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

Regulation: 3280.66(b)

Description: Toxic use- no contamination

Noncompliance Area: Cleaning materials were being stored directly on top of the refrigerator and not in a bin to prevent leaking and contaminating the food in the refrigerator.

Correction Required: Cleaning materials and other toxic materials shall be used in a way that does not contaminate play surfaces, food, food preparation areas and does not constitute a hazard to the children.

Regulation: 3280.76

Description: Building Surfaces

Noncompliance Area: Three sections of wall paneling in the activities room, plus an area behind the door, are detached. This creates a pinch and cut hazard for children who might insert their fingers. A lock to a door beneath the steps is detaching from the wall in the activity room. The lower section of the fencing on the gate in the outdoor preschool area had sharp, protruding edges that pose an injury to children and staff. The wall in the corner of the bathroom by the vanity had discoloration and the trim was loose. After a conversation with the Staff #3, it was determined water had caused the damage.

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: 3280.94(a)(2)

Description: Different times of day

Noncompliance Area: Based on documentation on the fire drill logs, all drills conducted since 8/14/2025 were in the morning between 10:00 am and 11:40 am.

Correction Required: Fire drills are conducted at different times of the day or night, or both, if applicable.

Regulation: 3280.94(a)(4)

Description: Hypothetical locations

Noncompliance Area: The playroom was documented consecutively as the hypothetical location of the fire on 9/25/2025 and 10/10/2025.

Correction Required: The hypothetical locations of the fire are rotated around the facility for each drill such that the hypothetical location is never the same for consecutive drills.

Regulation: 3280.95(a)/3280.95(b)

Description: FIRE DETECTION/Staff responsibility

Noncompliance Area: Based on documentation, testing of the fire detection system exceeded 30 days when tested on 12/2/2025 and the next testing on 1/2/2026.

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 primary staff person or designated staff person who is responsible for compliance with this chapter shall ensure the requirements in subsection (a) are met

Regulation: 3280.102(a)

Description: Clean and good repair

Noncompliance Area: A clear plastic bin containing play cars in the preschool classroom had a hole exposing children to sharp, rough edges. The changing pad on the changing table had a tear in the vinyl which exposed the foam inside.

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: 3280.103

Description: Small Toys and Objects

Noncompliance Area: The changing pad on the changing table had a tear in the vinyl which exposed the foam inside to children 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: 3280.123(a)(3)

Description: Services proceeded

Noncompliance Area: The child service reports (the Department's approved form) for child #1 were dated more than 6 months apart (7/1/2024 and 5/2025). The file of child #3 and #5 contained a child service report dated 5/2025 which was more than 6 months from their start date at the facility (see LIS code sheet). The child service reports for child #4 were dated more than 6 months apart (3/14/2024 and 5/2025).

Correction Required: An agreement shall specify 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 at § 3280.124(f).

Regulation: 3280.124(b)(3)

Description: Parent home/work address, phone

Noncompliance Area: The emergency contact information of child #2 and #5 did not contain the address of an enrolling parent.

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

Regulation: 3280.124(b)(5)

Description: Information re: special needs

Noncompliance Area: The emergency contact information of child #5 did not contain information on the child's special needs, as specified by the child's parent, physician, physician's assistant or CRNP, which is needed in an emergency situation or documentation this is not applicable to the child.

Correction Required: Emergency contact information must include information on the child's special needs, as specified by the child's parent, physician, physician's assistant or CRNP, which is needed in an emergency situation.

Regulation: 3280.124(b)(7)

Description: Name/address/phone release person

Noncompliance Area: The emergency contact information of child #1 and #3 did not contain the addresses of the persons 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: 3280.181(c)

Description: Emergency info/agreement updated 6 mos

Noncompliance Area: The emergency contact information review and/or update for child #1 were dated more than 6 months apart (2/18/2024 and 3/24/2025) and the last documented review and/or update of the financial agreement was dated more than 6 months ago on 7/1/2024. Documentation of the last review and/or update of the financial agreement for child #4 was dated 3/30/2024, more than 6 months prior to the inspection. Documentation of the last review and/or update of the financial agreement and emergency contact information for child #5 was dated 6/27/2024, more than 6 months prior to the inspection.

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

Regulation: 3280.182(8)

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

Noncompliance Area: The file of child #2 and #3 did not contain financial agreements.

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

Regulation: 3280.26(a)(6)

Description: Emergency plan

Noncompliance Area: Though the facility had documented an annual emergency drill, the documented information did not include information of any special accommodations used, or if any problems were encountered or observed during the emergency drill.

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

Regulation: 3280.32(a)

Description: Comply with CPSL

Noncompliance Area: The file of staff #1 contained an NSOR verification certificate dated 7/3/2025 which was updated more than 60 months from the prior certificate dated 6/8/2020. The file of staff #2, who was observed working with children, did not contain a completed NSOR verification certificate.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). LACKING REQUIRED HIRING DOCUMENTS: Facility Person #2 may not work in a child care position at the facility.

Regulation: 3280.67(d)

Description: Contaminated trash in closed plastic-lined receptacle

Noncompliance Area: The trash can in the kitchen area contained partially eaten food which contained human secretions and did not have a lid.

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

Regulation: 3280.95(a)/3280.95(b)

Description: FIRE DETECTION/Staff responsibility

Noncompliance Area: Documentation of the testing of the fire detection system exceeded 30 days on the following occasions: 3/1/2025 to 4/1/2025 and 5/1/2025 to 6/2/2025.

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 primary staff person or designated staff person who is responsible for compliance with this chapter shall ensure the requirements in subsection (a) are met.

Regulation: 3280.32(a)/3280.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The file of staff #1 did not contain an updated NSOR verification certificate within 60 months of the prior certificate dated 11/19/2019.

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

Regulation: 3280.95(a)/3280.95(b)

Description: FIRE DETECTION/Staff responsibility

Noncompliance Area: Testing the fire detection system exceeded 30 days on the following occasions: 7/16/2024 to 8/16/2024 and 1/3/2025 to 2/3/2025.

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 primary staff person or designated staff person who is responsible for compliance with this chapter shall ensure the requirements in subsection (a) are met.

Regulation: 3280.103

Description: Small Toys and Objects

Noncompliance Area: In the Activities Room, 2 children, identified as older toddlers, were playing with playdough which had removable parts less than an inch in diameter. Shortly after, the 2 older toddlers were using markers with lids that were less than an inch in diameter. The playdough and marker lids were less than an inch in diameter making them a choking hazard to children 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: 3280.123(a)(3)

Description: Services proceeded

Noncompliance Area: The Child Service Report of child #1 was dated 2/14/2024 which was more than 6 months from their start date at the facility (see LIS code sheet). The Child Services Reports of Child #2 were dated 7/1/2023 and 2/14/2024, exceeding 6 months. The Child Service Report of child #3 was dated 2/28/2023, and child #4 was dated 7/1/2023, more than 6 months from the date of the inspection.

Correction Required: An agreement shall specify 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 at § 3280.124(f).

Regulation: 3280.124(b)(5)

Description: Information re: special needs

Noncompliance Area: The emergency contact form of child #2 did not contain on the child's special needs, as specified by the child's parent, physician, physician's assistant or CRNP, which is needed in an emergency situation.

Correction Required: Emergency contact information must include information on the child's special needs, as specified by the child's parent, physician, physician's assistant or CRNP, which is needed in an emergency situation.

Regulation: 3280.131(a)

Description: Health Information

Noncompliance Area: The initial health assessment of child #1 was dated 6/28/2024, more than 60 days from their start date at the facility (see LIS code sheet).

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

Regulation: 3280.131(b)(2)/3280.182(1)

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

Noncompliance Area: The files contained documentation of health assessments updated more than 12 months apart for child #3 (6/3/2022 and 6/11/2024) and child #4 (2/5/2022 and 4/25/2024), both identified as preschool age children (see LIS code sheet).

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

Regulation: 3280.151(b)/3280.192(3)

Description: Conducted by physician, PA or CRNP/Health assessment, TB test

Noncompliance Area: The health assessment of staff #2 did not include the signature or professional title of the physician, physician's assistant or CRNP which conducted the examination.

Correction Required: A health assessment shall be conducted and a report shall be written and signed by a physician, physician's assistant or CRNP. The signature must include the individual's professional title. 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: 3280.192(4)

Description: CPSL information

Noncompliance Area: The file of staff #1 did not include documentation of a current child abuse clearance at the time of the inspection.

Correction Required: A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL.

Regulation: 3280.52(c)

Description: Mixed age levels

Noncompliance Area: *At approximately 10:07 AM, staff #1 was the only person at the facility and identified 9 children they were supervising. In the group, staff #1 stated there were 2 older toddlers and 7 preschoolers present. Staff #1 exceeded the staff to child ratio of 1:6 (based on the youngest child in the group) until staff #2 arrived at approximately 10:12 AM.

Correction Required: The legal entity must arrange for all staff to receive a minimum of two hours of training regarding mixed ratios. The legal entity must receive OCDEL approval of the training content prior to scheduling the training. Proof of training will be submitted to the Department upon completion.

Regulation: 3280.52(c)

Description: Mixed age levels

Noncompliance Area: At approximately 10:07 AM, staff #1 was the only person at the facility and identified 9 children they were supervising. In the group, staff #1 stated there were 2 older toddlers and 7 preschoolers present. Staff #1 exceeded the staff to child ratio of 1:6 (based on the youngest child in the group) until staff #2 arrived at approximately 10:12 AM.

Correction Required: When children are grouped in mixed age levels, the age of the youngest child in the group determines the staff:child ratio and maximum group size in accordance with the requirements at §3280.52(b).

Regulation: 3280.76

Description: Building Surfaces

Noncompliance Area: The gate prohibiting children to the kitchen area from the Activities Room was broken creating a potential pinching hazard.

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: 3280.94(a)(4)

Description: Hypothetical locations

Noncompliance Area: The hypothetical location of the fire documented on the fire drill log was consecutive on 2 occasions (12/1/2023 and 1/2/2024 = main room and 4/1/2024 and 5/1/2024 = kitchen).

Correction Required: The primary staff person or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that the hypothetical locations of the fire are rotated around the facility for each drill such that the hypothetical location is never the same for consecutive drills.

Regulation: 3280.95(a)/3280.95(b)

Description: FIRE DETECTION/Staff responsibility

Noncompliance Area: Documentation of testing the fire detection system exceeded 30 days on 5 occasions in the past 12 months (8/4/2023 to 9/4/2023, 12/1/2023 to 1/2/2024 to 2/2/2024, 3/1/2024 to 4/1/2024 and 5/1/2024 to 6/3/2024).

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 primary staff person or designated staff person who is responsible for compliance with this chapter shall ensure the requirements in subsection (a) are met.

Regulation: 3280.102(e)/3280.103

Description: Infant/toddler - no material less than 1 inch/Small Toys and Objects

Noncompliance Area: According to staff statements, staff have taken older toddlers to play on the preschool play space that has embedded equipment and mulch. The older toddlers, who are still placing objects in their mouths, used the swing and slide on the preschool play space and had access to mulch that was less than 1 inch in diameter.

Correction Required: Pea gravel and other materials with a diameter of less than 1 inch may not be used in spaces where infants or toddlers receive care. 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: 3280.131(b)(2)/3280.182(1)

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

Noncompliance Area: The file for child #2, a preschooler, lacked a current health assessment updated within the last 12 months.

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

Regulation: 3280.131(d)(5)/3280.131(e)(3)

Description: Immunization record/Dismissal policy

Noncompliance Area: The files for child #2, a 3 year old, child #3, a 5 year old, and child #4, a 4 year old, had an immunization record that lacked verification of the Influenza vaccination being administered within the last calendar year in accordance with the schedule recommended by the ACIP and lacked exemption documentation.

Correction Required: A health report shall include a review of the child's immunized status according to recommendations of the ACIP. The facility shall implement dismissal policies in accordance with the Department of Health regulation in 28 Pa. Code § 27.77 (relating to immunization requirements for children in child care group settings). Children #2, #3, and #4 must be dismissed from care by close of business on 7-25-23 and may only return to care when the immunization record is updated or when a parent provides a written, signed exemption letter.

Regulation: 3280.181(c)

Description: Emergency info/agreement updated 6 mos

Noncompliance Area: The files for child #3 and #4 lacked a current agreement updated within the last 6 months. The file for child #1 had an emergency contact form and agreement that exceeded 6 months between updates. The file for child #2 had an agreement that exceeded 6 months between updates.

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

Regulation: 3280.26(a)(6)

Description: Emergency plan

Noncompliance Area: The facility lacked documentation on file of an emergency drill being conducted within the last year.

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

Regulation: 3280.94(a)(4)

Description: Hypothetical locations

Noncompliance Area: According to the fire drill log, the hypothetical location of the fire was the same for two consecutive drills on multiple occasions.

Correction Required: The primary staff person or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that the hypothetical locations of the fire are rotated around the facility for each drill such that the hypothetical location is never the same for consecutive drills.

Regulation: 3280.95(a)/3280.95(b)

Description: FIRE DETECTION/Staff responsibility

Noncompliance Area: According to the log, the operator did not manually test the smoke detectors in the facility at least once every 30 days on multiple occasions within the last year.

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 primary staff person or designated staff person who is responsible for compliance with this chapter shall ensure the requirements in subsection (a) are met.

Regulation: 3280.134(a)

Description: Child's hands washed

Noncompliance Area: On 10-4-22 at approximately 1:22 p.m. in the infant room, staff person #1 was observed changing a 2 year old child's diaper and then immediately placing the child in their crib for naptime without washing the child's hands after being diapered.

Correction Required: A staff person shall ensure that a child's hands are washed before meals and snacks, after toileting and after being diapered.

Regulation: 20.71(a)(7)

Description: Fraud or deceit in obtaining or attempting to obtain a certificate of compliance

Noncompliance Area: The file for staff person #1 contained a health and safety training document that was observed to be altered. On the document, the first and last name of staff person #1 were handwritten on the certificate, and the date was partially handwritten with the month, day, and the last number of the year handwritten. At the time of the renewal inspection on 7-26-22, staff person #1 was asked if they had completed the health and safety training, and staff person #1 said, "No."

Correction Required: The Department may deny, refuse to renew or revoke a certificate of compliance for fraud or deceit in obtaining or attempting to obtain a certificate of compliance.

Regulation: 3280.104

Description: High Chairs

Noncompliance Area: In the kitchen, there was a high chair with green fabric that lacked a T-shaped safety strap and was observed to be used by a child during the renewal inspection.

Correction Required: High chairs shall have a wide base and a T-shaped safety strap.

Regulation: 3280.113(a)

Description: Supervised at all times

Noncompliance Area: On 7-26-22 at approximately 9:20 a.m., staff person #3 was observed answering the front door to the facility leaving 6 preschoolers alone in the large child care room without staff supervision, resulting in the children being out of ratio. On 7-26-22 at approximately 9:31 a.m., staff person #1 was observed leaving the kitchen and walking through the activities room into the hallway around the corner for approximately 10 seconds before returning to the kitchen, leaving 3 children, including 2 young toddlers and an older toddler, alone in the kitchen in high chairs without staff supervision. On 7-26-22 at approximately 9:40 a.m., staff person #3 was in the activities room with 6 preschoolers and staff person #1 was in the kitchen that is located next to the activities room with 3 children, including 2 young toddlers and an older toddler, and staff person #3 was observed leaving the activities room to answer the front door of the facility, resulting in staff person #1 being out of ratio with an older toddler, 2 young toddlers, and 6 preschoolers.

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: 3280.113(a)(1)

Description: Staff assigned to specific children

Noncompliance Area: On 7-26-22 at approximately 9:20 a.m., staff person #3 was observed answering the front door to the facility leaving 6 preschoolers alone in the large child care room without staff supervision, resulting in the children being out of ratio. On 7-26-22 at approximately 9:31 a.m., staff person #1 was observed leaving the kitchen and walking through the activities room into the hallway around the corner for approximately 10 seconds before returning to the kitchen, leaving 3 children, including 2 young toddlers and an older toddler, alone in the kitchen in high chairs without staff supervision. On 7-26-22 at approximately 9:40 a.m., staff person #3 was in the activities room with 6 preschoolers and staff person #1 was in the kitchen that is located next to the activities room with 3 children, including 2 young toddlers and an older toddler, and staff person #3 was observed leaving the activities room to answer the front door of the facility, resulting in staff person #1 being out of ratio with an older toddler, 2 young toddlers, and 6 preschoolers.

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: 3280.131(b)(1)/3280.182(1)

Description: Infant: updated health report every 6 months/Initial and subsequent health assessments

Noncompliance Area: The file for child #1, a young toddler, lacked an updated health assessment within the last 6 months.

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

Regulation: 3280.131(e)(1)/3280.182(1)

Description: Exemption documentation from parent/guardian/Initial and subsequent health assessments

Noncompliance Area: The file for child #2, a 5 year old, had an immunization record that lacked verification of the Influenza vaccination being administered within the last calendar year in accordance with the schedule recommended by the ACIP and lacked exemption documentation. The file for child #1, a 15 month old, had an immunization record that lacked documentation of the 2nd and 3rd doses of the DTAP and Pneumococcal vaccinations by age 6 months and the 2nd dose of the HIB and Polio vaccinations by age 4 months in accordance with the schedule recommended by the ACIP and lacked exemption documentation.

Correction Required: The facility shall require the parent to provide updated written verification from a physician, physician's assistant, CRNP, the Department of Health or a local health department of ongoing vaccines administered to an infant, toddler or preschool child in accordance with the schedule recommended by the ACIP. A child's record must contain initial and subsequent health reports.

Regulation: 3280.14/3280.20

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: The emergency plan lacked requirements for practice drills and continuity of operations according to federal requirements at 45 CFR § 98.41(a)(1)(vii).

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: 3280.14/3280.20

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: Staff person 1 was observed to be caring for children unsupervised. Staff person 1 has not completed the following pre-service trainings required prior to caring for children unsupervised: Mandated Reporter Training, Health and Safety Training in the topics of 3270.31(f)(1-9).

Correction Required: A facility shall be operated in conformity with applicable Federal and State laws and regulations. State agencies whose regulations may relate to the operation of a facility include the Department of Environmental Resources, the Department of Labor and Industry, the Department of Health, the Department of Education and the Department of Transportation. Conditions at the facility may not pose a threat to the health or safety of the children. Until such time as the required pre-service trainings are completed, staff person #1 must be supervised, when interacting with children, by a primary staff person who has completed the required training related to this citation. If there are no staff person(s) available to supervise staff person #1, staff person #1 may not work in a child-care position at the facility.

Regulation: 3280.151(a)

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

Noncompliance Area: The file for staff person #1 had an initial health assessment that was dated after their start date providing initial service in a child care setting at the facility.

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: 3280.151(c)(2)

Description: Mantoux TB

Noncompliance Area: The file for staff person #1 lacked a tuberculosis screening by the Mantoux method at initial employment, and requires a current tuberculosis screening by the Mantoux method.

Correction Required: An adult health assessment must include tuberculosis screening by the Mantoux method at initial employment. Subsequent tuberculosis screening is not required unless directed by a physician, physician's assistant, CRNP, the Department of Health or a local health department.

Regulation: 3280.32(a)/3280.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The file for staff person #1 lacked an NSOR verification certificate and had an FBI clearance that was dated after their start date. The file for staff person #2 had a Department of Education FBI clearance and lacked a DHS FBI clearance. The files for staff person #1 and #2 had a disclosure statement that lacked the date and the signature of a witness.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Staff Person #1 and Staff Person #2 may not work at the facility.

Regulation: 3280.34(b)(5)/3280.192(2)(ii)

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

Noncompliance Area: The files for staff person #1 and #2, functioning as a primary staff person, lacked verification of experience to qualify as a primary staff person.

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

Regulation: 3280.52(b)

Description: Similar age levels

Noncompliance Area: On 7-26-22 at approximately 9:20 a.m., staff person #3 was observed answering the front door to the facility leaving 6 preschoolers alone in the large child care room without staff supervision, resulting in the children being out of ratio.

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 12; Young toddlers 1:5 with a maximum group size of 12; Older toddlers 1:6 with a maximum group size of 12; Preschool children 1:10 with a maximum group size of 12; Young school-age children 1:12 with a maximum group size of 12; Older school-age children 1:15 with a maximum group size of 15.

Regulation: 3280.52(c)

Description: Mixed age levels

Noncompliance Area: On 7-26-22 at approximately 9:31 a.m., staff person #1 was observed leaving the kitchen and walking through the activities room into the hallway around the corner for approximately 10 seconds before returning to the kitchen, leaving 3 children, including 2 young toddlers and an older toddler, alone in the kitchen in high chairs without staff supervision. On 7-26-22 at approximately 9:40 a.m., staff person #3 was in the activities room with 6 preschoolers and staff person #1 was in the kitchen that is located next to the activities room with 3 children, including 2 young toddlers and an older toddler, and staff person #3 was observed leaving the activities room to answer the front door of the facility, resulting in staff person #1 being out of ratio with an older toddler, 2 young toddlers, and 6 preschoolers. On 8-17-22 at approximately 9:29 a.m. in the large child care room, staff person #3 was observed supervising 9 children, including 2 older toddlers and 7 preschoolers, resulting in staff person #3 being out of ratio.

Correction Required: When children are grouped in mixed age levels, the age of the youngest child in the group determines the staff:child ratio and maximum group size in accordance with the requirements at §3280.52(b).

Regulation: 3280.61(c)

Description: 40 square feet wall-to-wall

Noncompliance Area: On 7-26-22, the activities room, with a capacity of 5 children, was observed overcapacity from 9:30 a.m. to 12 p.m. with a total of 7 children in the room.

Correction Required: Indoor child care space is measured within permanent stationary partitions or walls. The allowable number of children in a space is determined by dividing the total square feet in a space by 40.

Regulation: 3280.71

Description: Heat Source

Noncompliance Area: On 7-26-22 at approximately 9:50 a.m. during breakfast, preschoolers were observed walking into the kitchen with the gate open that separates the kitchen and activities room, resulting in the knobs on the stove being accessible to children.

Correction Required: Hot water pipes and other sources of heat exceeding 110° F that are accessible to children shall be equipped with protective guards or shall be insulated to prevent direct contact.

Regulation: 3280.94(a)(5)

Description: Evacuation routes posted

Noncompliance Area: The evacuation routes were not posted on the 1st floor of the facility.

Correction Required: The primary staff person or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that evacuation routes are posted in a conspicuous location on each floor of the facility.

Regulation: 3280.95(a)/3280.95(b)

Description: FIRE DETECTION/Staff responsibility

Noncompliance Area: On 7-26-22, there were 3 smoke detectors that the operator identified as interconnected smoke detectors that were observed operable in the facility, with 2 detectors on the bottom floor and 1 detector on the 1st floor. The smoke detectors were not functioning as an interconnected fire detection system as required. On 8-17-22, the smoke detectors were tested by the operator, and the 2 smoke detectors on the bottom floor were observed to be operating as interconnected, and the 1st floor smoke detector was not operating as interconnected with the 2 smoke detectors on the bottom floor.

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 primary staff person or designated staff person who is responsible for compliance with this chapter shall ensure the requirements in subsection (a) are met.