Mechanic Grove Church of the Brethren DC

Regulation: 3270.123(a)

Description: Signed

Noncompliance Area: The agreement on file for child #6 was not signed by the parent. The agreements on file for children #7, #8, and #9 were not signed by the operator.

Correction Required: An agreement shall be signed by the operator and the parent.

Regulation: 3270.123(a)(5)

Description: Designated release persons

Noncompliance Area: The agreement on file for child #6 did not specify the persons designated by a parent to whom the child may be released.

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

Regulation: 3270.123(a)(6)

Description: Admission date

Noncompliance Area: The agreements on file for children #6, #7, #8 and #9 did not specify the date of the child's admission.

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

Regulation: 3270.124(b)(3)/3270.124(b)(7)

Description: Parent home/work address, phone/Name/address/phone release person

Noncompliance Area: The emergency contact information on file for child #5 did not include the enrolling parent's work address and also did not include addresses for 2 of the listed release persons. The emergency contact information on file for child #7 did not include the enrolling parent's work address and phone number.

Correction Required: Emergency contact information must include the home and work addresses and telephone numbers of the enrolling parent. 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)/3270.131(b)(2)

Description: Infant: updated health report every 6 months/Toddler/preschool: updated health report every 12 months

Noncompliance Area: The health assessments on file for child #1 (infant) were dated in December of 2024 and subsequently more than 6 months later in July of 2025. The health assessments on file for child #4 were dated in June of 2024 and subsequently more than 6 months later in June of 2025. The child was a young toddler at the time of the lapse. The health assessments on file for child #5 (preschooler) were dated in January of 2023 and subsequently more than 12 months later in August of 2024.

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. 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: 3270.133(2)

Description: Written instructions

Noncompliance Area: An inhaler was on site for child #2. The medication was loose in a bag and did not include written instructions from the individual who prescribed the medicine, or a prescription label. An epi pen was on site for child #3. The medication was loose in a bag and did not include written instructions from the individual who prescribed the medicine, or a prescription label.

Correction Required: A staff person shall administer a prescription medication only if written instructions are provided from the individual who prescribed the medicine. Instructions for administration contained on a prescription label are acceptable.

Regulation: 3270.133(7)

Description: Medication log

Noncompliance Area: Two inhalers were on site for child #2. The facility only had a completed medication log on file for one of the two inhalers.

Correction Required: An operator is responsible to establish and maintain a medication log if prescription or nonprescription medication is administered.

Regulation: 3270.151(a)

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

Noncompliance Area: The health assessments on file for staff person #2 were dated July of 2023 and more than 24 months later in August of 2025. The health assessments on file for staff person #3 were date in August of 2022 and more than 24 months later in September of 2024. The health assessments on file for staff person #10 were date in January of 2023 and more than 24 months later in February of 2025. The health assessments on file for staff person #15 were date in September of 2022 and more than 24 months later in July of 2025.

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: 3270.151(c)(3)

Description: Exam communicable disease

Noncompliance Area: The health assessment on file for staff person #7 did not include results of an examination for communicable diseases.

Correction Required: An adult health assessment must include an examination for communicable diseases and the results of that examination.

Regulation: 3270.166(1)

Description: Written statement

Noncompliance Area: A written statement giving the formula and feeding schedule had not been obtained for infant child #1

Correction Required: A written statement giving the formula and feeding schedule for an infant shall be obtained from the parent.

Regulation: 3270.18(a)

Description: On file at facility

Noncompliance Area: At the time of inspection, the operator was unable to provide documentation of current general liability insurance policy.

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

Regulation: 3270.181(c)

Description: Emergency info/agreement updated 6 mos

Noncompliance Area: The agreement on file for child #1 was signed/dated by the parent in November of 2024, and subsequently more than 6 months later in July of 2025.

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: 3270.31(e)(4)(i)

Description: Age and Training

Noncompliance Area: The previous pediatric first aid and CPR training on file for staff person #15 expired at the end of January 2025. An updated training was not completed until February 20, 2025.

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

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

Description: Fire safety - 1 yr.

Noncompliance Area: Fire safety trainings on file for staff person #8 were dated in June of 2024, and subsequently more than 12 months later in August of 2025.

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(e)/3270.192(2)(iii)

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

Noncompliance Area: The record for staff person #11 did not include documentation of 12 clock hours of annual child care training for the previous training year (6/2024-6/2025). The record for staff person #12 did not include documentation of 12 clock hours of annual child care training for the previous training year (6/2024-6/2025). Annual training hours have since been completed.

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

Description: Health and Safety Training

Noncompliance Area: Staff person #1 completed the required health and safety trainings (listed in subsections f1-9) 105 days after their date of hire. Staff person #13 completed pediatric first aid and CPR (listed in subsection f10) 172 days after their date of hire.

Correction Required: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10. (1) Prevention and control of infectious diseases (including immunization) and the establishment of a grace period that allows homeless children and children in foster care to receive services under this subchapter while their families (including foster families) are taking necessary action to comply with immunization and other health and safety requirements. (2) Prevention of Sudden Infant Death Syndrome and use of safe sleep practices. (3) Administration of medication, consistent with standards for parental consent. (4) Prevention of and response to emergencies due to food and allergic reactions. (5) Building and physical premises safety, including identification of and protection from hazards that can cause bodily injury such as electrical hazards, bodies of water and vehicular traffic. (6) Prevention of shaken baby syndrome and abusive head trauma. (7) Emergency preparedness and response planning for emergencies resulting from a natural disaster or a man-caused event (such as violence at a child care facility) within the meaning of those terms under section 602(a)(1) of the Robert T. Stafford Disaster Relief and Emergency Assistance Act (42 U.S.C.A. § 5195a(a)(1)). (8) Handling and storage of hazardous materials and appropriate disposal of biocontaminants. (9) Precautions when transporting children. (10) Pediatric first aid and pediatric cardiopulmonary resuscitation.

Regulation: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: The NSOR certificate on file for staff person #4 was more than 60 months old (dated 7/23/2020) and was no longer valid. (CORRECTED ON SITE) The NSOR certificate on file for staff person #5 was more than 60 months old (dated 11/6/2019) and was no longer valid. The NSOR certificates on file for staff person #6 were dated 11/6/2019, and subsequently more than 60months later on 2/24/25. The staff person worked in a child care position without a valid NSOR on file. The mandated reporter trainings on file for staff person #6 were dated 2/14/2020, and subsequently more than 60 months later on 8/5/25. The staff person worked in a child care position without a valid mandated reporter training on file. The mandated reporter trainings on file for staff person #7 were dated 3/6/2020, and subsequently more than 60 months later on 7/23/25. The staff person worked in a child care position without a valid mandated reporter training on file. The disclosure on file for staff person #9 was not witnessed by a representative of the legal entity. According to documentation on file at the time of inspection, when staff person #9 began working with children at the facility the staff record did not contain a completed NSOR certificate as required under the CPSL. The NSOR was dated 30 days after the staff person's first day working in a child care position. The NSOR certificates on file for staff person #10 were dated 1/15/2020 and subsequently more than 60months later on 2/3/25. The staff person worked in a child care position without a valid NSOR on file. The mandated reporter trainings on file for staff person #10 were dated 6/9/2020, and subsequently more than 60 months later on 7/23/25. The staff person worked in a child care position without a valid mandated reporter training on file. Staff person #14 worked with expired clearances on file. The state police clearance expired 1/2/2025 and was not updated until 2/20/25. The child abuse clearance expired 2/12/2025 and was not updated until 3/1/25. The FBI clearance expired 2/4/2025 and was not updated until 3/5/25. The NSOR certificate expired 11/6/19 and was not updated until 2/26/25. The mandated reporter trainings on file for staff person #14 were dated 1/10/2020, and subsequently more than 60 months later on 7/30/25. The staff person worked in a child care position without a valid mandated reporter training on file. The mandated reporter trainings on file for staff person #16 were dated 1/22/2020, and subsequently more than 60 months later on 8/1/25. The staff person worked in a child care position without a valid mandated reporter training on file.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Facility Person #5 may not work in a child care position at the facility.

Regulation: 3270.66(a)/3270.66(d)

Description: Locked or inaccessible/Toxic plants not permitted

Noncompliance Area: A bag of rock salt was observed on the toddler playground in an area accessible to the toddlers using the space. (CORRECTED ON SITE) Toxic cleaning products were observed underneath the bathroom sink in the children's bathroom in the daycare building. (CORRECTED ON SITE) A toxic plant (pokeweed) was observed growing on the toddler playground in an area accessible to the toddlers using the space.

Correction Required: Cleaning materials and other toxic materials shall be kept in an area or container that is locked or made inaccessible to children. Toxic plants are not permitted in a child care space.

Regulation: 3270.75(b)

Description: Inaccessible to children

Noncompliance Area: A backpack containing a first aid kit was observed on the toddler playground in an area accessible to the toddlers using the space. (CORRECTED ON SITE) A backpack containing a first aid kit was observed in the gym in an area accessible to the children using the space. (CORRECTED ON SITE)

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

Regulation: 3270.75(d)

Description: On excursions

Noncompliance Area: The first aid kit that the school-age group takes on excursions did not contain a bottle of water. (CORRECTED ON SITE)

Correction Required: One first-aid kit per child care group must accompany children and facility persons on excursions from the facility. Each first aid kit taken on an excursion must contain a bottle of water in addition to the items specified at §3270.75(c).

Regulation: 3270.82(g)

Description: Clean and good repair

Noncompliance Area: A toilet for the school-age children had signs of not being cleaned daily. The toilet bowl included a ring of pink bacterial residue.

Correction Required: Toilet areas and fixtures shall be cleaned daily and be in good repair.

Regulation: 3270.20(a)(1)

Description: Inpatient hospitalization or ER treatment of child

Noncompliance Area: The operator did not telephone notice the appropriate regional office within 24 hours of a child receiving emergency room treatment. An email was sent in-lieu of a phone call.

Correction Required: The operator shall immediately notify a child's parent and shall telephone notice to the appropriate regional office within 24 hours if a child in care at the facility is hospitalized or receives emergency room treatment.

Regulation: 3270.94(a)(1)

Description: Every 60 days

Noncompliance Area: Fire drills have not been completed at least every 60 days. Fire drills were completed on 8/1/24, 61 days later on 10/1/24, and then 62 days later on 12/2/24.

Correction Required: The Director or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that fire drills are conducted at least once every 60 days.

Regulation: 3270.95(a)

Description: Devices must be compliant

Noncompliance Area: According to the log on file at the time of inspection, more than 30 days lapsed between the following manual tests of the fire detection system: 8/1/24 to 9/2/24, 10/1/24 to 11/1/24 to 12/2/24 to 1/2/25.

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)). To verify operability, a child care center shall manually test all fire detection devices or systems at least once every thirty days and shall maintain a written record of the testing with the facility's fire drill logs.

Regulation: 3270.123(a)(3)

Description: Services proceeded

Noncompliance Area: Children 1, 3, and 4 - Child service reports had been completed in June of 2023, and then subsequently more than 6 months later in May of 2024.

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(e)

Description: Written emergency plan posted

Noncompliance Area: The written plan identifying the means of transporting a child to emergency care and staffing provisions in the event of an emergency was not displayed conspicuously in the CLASP space.

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

Regulation: 3270.131(b)(1)

Description: Infant: updated health report every 6 months

Noncompliance Area: Updated health reports were not obtained timely during the past year for children 1 and 3. Child 1 - Health reports were dated 12/2022 and subsequently more than 6 months later in October of 2023. The child was a young toddler at the time of the lapse. Child 3 - Health reports were dated 9/2022 and subsequently more than 6 months later in 9/2023. The child was a young toddler at the time of the lapse.

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: 3270.133(1)

Description: Original container

Noncompliance Area: Benadryl tablets were observed in loose blister packs. The box/original container was not on site.

Correction Required: A prescription or nonprescription medication may be accepted only in an original container. The medication shall remain in the container in which it was received.

Regulation: 3270.133(7)

Description: Medication log

Noncompliance Area: The facility did not have medication logs on file for three medications that were on site in the CLASP space.

Correction Required: An operator is responsible to establish and maintain a medication log if prescription or nonprescription medication is administered.

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: Staff person #9 was observed to be caring for children unsupervised. Staff person #9 has not completed mandated reporter training within the last 60 months. This is evidenced by the previously documented mandated reporter training on file being dated 10/22/2018. The record for staff person 13 did not include the required 1-hour Pennsylvania Health and safety training update.

Correction Required: A facility shall be operated in conformity with applicable Federal and State laws and regulations. Conditions at the facility may not pose a threat to the health or safety of the children. Until such time as the required trainings are completed, staff person #9 must be supervised, when interacting with children, by ab AGS or GS who has completed the required training related to this citation. If there are no staff person(s) available to supervise staff person #9, staff person #9 may not work in a child-care position at the facility.

Regulation: 3270.151(a)

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

Noncompliance Area: The most recent health assessment on file for staff person 10 was more than 24 months old, and no longer valid. The updated health assessment on file for staff person 14 was not updated timely. The health assessments on file were dated in February of 2022 and then more than 24 months later in March of 2023.

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: 3270.181(c)/3270.181(e)

Description: Emergency info/agreement updated 6 mos/Emergency master file updated

Noncompliance Area: Emergency contact forms located in the toddler, preschool, infant, and CLASP rooms were past due for updates (parent signatures more than 6 months old).

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. If emergency information is updated in a master file, it shall be updated accordingly in other facility records.

Regulation: 3270.192(5)

Description: Two written references

Noncompliance Area: Staff person 11 did not have two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person. Forms were on file that outlined the work she did, but did not attest to her suitability to serve as a facility person.

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

Regulation: 3270.27(c)

Description: Training regarding plan

Noncompliance Area: Staff persons 1, 4, 5, 6, 7, and 14 received emergency plan training in June of 2023 and then subsequently more than 12 months later in July of 2024.

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

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

Description: Fire safety - 1 yr.

Noncompliance Area: Staff persons 2 and 8 each completed fire safety training in October of 2022 and then subsequently more than 12 months later in November of 2023.

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

Regulation: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: Staff person 9 has not completed mandated reporter training within the last 60 months. This is evidenced by the previously documented mandated reporter training on file being dated 10-22-2018. The records for staff persons 11, 15, and 17 included PDE FBI clearances in-lieu of the required DHS FBI clearances. Staff person 12 began working in a child care position without a complete child abuse clearance on file. (CORRECTED) Staff person 16 began working in a child care position without a complete child abuse clearance on file. The clearance was obtained 3 days after start date.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Staff person #9 will have until 8/23/24 to complete the mandated reporter training. Until such time as the required training has been completed, staff person must be supervised, when interacting with children, by an AGS OR GS who has completed the required training related to this citation. If there are no staff person(s) available to supervise staff person/facility person/volunteer #9, staff person #9 may not work in a child-care position at the facility. Staff person 11, 13, 17 may not work in a child care position at the facility until complete clearances are on file.

Regulation: 3270.66(d)

Description: Toxic plants not permitted

Noncompliance Area: A boxwood shrub was observed within reach of the outdoor preschool/school age child care space.

Correction Required: Toxic plants are not permitted in a child care space.

Regulation: 3270.74

Description: Emergency Numbers Posted

Noncompliance Area: The telephone number of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted by the phone in the CLASP room.

Correction Required: The telephone number of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted by each telephone in the facility.

Regulation: 3270.75(b)/3270.133(4)

Description: Inaccessible to children/Locked

Noncompliance Area: The backpack containing the first aid kit and medications (an EPI pen, an inhaler, and benadryl) was observed on a table in an area accessible to the school age children in the space.

Correction Required: A first-aid kit must be inaccessible to children. Medication shall be stored in a locked area of the facility or in an area that is out of the reach of children.

Regulation: 3270.66(a)

Description: Locked or inaccessible

Noncompliance Area: Two bottles of hand sanitizer were observed in areas accessible to the children. (CORRECTED ON SITE)

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: 3270.95(a)/3270.95(b)

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

Noncompliance Area: 31 days lapsed between manual tests of the fire detection systems on 3/1/24 and subsequently 4/1/24.

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. To verify operability, a child care center shall manually test all fire detection devices or systems at least once every thirty days and shall maintain a written record of the testing with the facility's fire drill logs.

Regulation: 3270.124(b)(2)/3270.124(b)(6)

Description: Physician name, address, phone/Insurance coverage information

Noncompliance Area: The emergency contact information on file for child 2 was incomplete. The record did not include the address of the child's Physican, nor the health insurance policy number.

Correction Required: Emergency contact information must include the name, address and telephone number of the child's physician or source of medical care. Emergency contact information must include health insurance coverage and policy number for a child under a family policy or Medical Assistance benefits, if applicable.

Regulation: 3270.131(e)(1)/3270.131(e)(3)

Description: Exemption documentation from parent/guardian/Dismissal policy

Noncompliance Area: The immunization record on file for child 1 was not updated in accordance with the schedule recommended by the ACIP. The record did not contain documentation of the immunizations given at 6 months.

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. 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).

Regulation: 3270.14/3270.31(e)(4)(i)

Description: Pertinent Laws & Regulations/Age and Training

Noncompliance Area: Staff persons 1 and 2 are seasonal staff and have been employed for more than 90 days. Their pediatric first aid and CPR trainings expired and were not updated prior to returning for the summer employment.

Correction Required: A facility shall be operated in conformity with applicable Federal and State laws and regulations. All staff persons shall renew their certification in pediatric first aid and pediatric cardiopulmonary resuscitation (CPR) on or before the expiration of the most current certification. Until such time as the required trainings are completed, staff persons #1 and #2 must be supervised, when interacting with children, by an AGS or GS who has completed the required training related to this citation. If there are no staff person(s) available to supervise staff persons #1 and #2, staff person #1 and #2 may not work in a child-care position at the facility.

Regulation: 3270.181(c)/3270.181(d)

Description: Emergency info/agreement updated 6 mos/Dated signature affixed

Noncompliance Area: The emergency contact information on file for children 2 and 3 were past due for updates. The most recent parent signatures were more than 6 months old (1/23/23 and 12/22).

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. Following review, a parent shall attest to the accuracy of information in the emergency contact information and the financial agreement at each review by affixing a dated signature to the record.

Regulation: 3270.102(c)

Description: Outdoor equip.- protective surfacing

Noncompliance Area: An outdoor Step 2 Skyward Summit climber was not embedded over a loose-fill or unitary playground protective surface covering that meets the recommendations of the United States Consumer Product Safety Commission as required by the manufacturer's instructors.

Correction Required: Outdoor equipment that requires embedded mounting must be mounted over a loose-fill or unitary playground protective surface covering that meets the recommendations of the United States Consumer Product Safety Commission. The equipment must be anchored firmly and be in good repair.

Regulation: 3270.124(b)(3)/3270.124(b)(7)

Description: Parent home/work address, phone/Name/address/phone release person

Noncompliance Area: The emergency contact information on file for children 1 and 3 were incomplete. (CORRECTED ON SITE) -Child 1, did not include address for listed release person -Child 3, did not include enrolling parent's work address and work telephone number

Correction Required: Emergency contact information must include the home and work addresses and telephone numbers of the enrolling parent. 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(e)(1)/3270.131(e)(2)(i)

Description: Exemption documentation from parent/guardian/Exemption documentation from parent/guardian

Noncompliance Area: The immunization record on file for child 2 was not in accordance with the schedule recommended by the ACIP, and also did not include any exemption notes. An annual influenza vaccine from the previous year was not on file.

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.Exemption from immunization for religious belief or strong personal objection equated to a religious belief shall be documented by a written, signed and dated statement from the child's parent or guardian. The statement shall be kept in the child's record.

Regulation: 3270.151(a)/3270.151(c)(2)

Description: 12 months prior to service and every 24 months thereafter/Mantoux TB

Noncompliance Area: The initial health assessment and TB test results on file for staff person 2 were dated more than 12 months prior to start date.

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. 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: 3270.181(c)/3270.181(e)

Description: Emergency info/agreement updated 6 mos/Emergency master file updated

Noncompliance Area: Some of the emergency contact forms present in the school-age space had not been updated during the previous six months.

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. If emergency information is updated in a master file, it shall be updated accordingly in other facility records.

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

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

Noncompliance Area: Staff persons 1, 5, 6, 7, 10, 11, 12 have acceptable pediatric first aid/CPR training in an approved curriculum; however, the trainer has not provided documentation that they are PQAS-certified in that training topic.

Correction Required: Staff persons shall complete professional development in the topics of 3270.31(f)(10) within 90 days of hire. Staff person #1, 5, 6, 7, 10, 11, 12 must do one of the following: provide documentation that the trainer has become PQAS-certified or at least is on the waiting list, request the instructor provide documentation, such as their Pediatric First-Aid/CPR Instructor Card from the PQAS-approved organization or the approved curriculum organization, that the instructor is approved to offer Pediatric First-Aid/CPR training on behalf of their organization, or receive pediatric first-aid/CPR training in an approved curriculum by a PQAS-certified trainer.

Regulation: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: Staff person 2 had volunteer clearances on file in-lieu of employment clearances for a period of 11 calendar days. (CORRECTED ON SITE) The FBI clearance on file for staff person 7 expired 10/24/21, and the updated clearance was not obtained until 8/9/22.

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

Regulation: 3270.61(c)

Description: 40 square feet wall-to-wall

Noncompliance Area: 11 younger and older toddlers were observed in a room measured for 8 children. (CORRECTED ON SITE)

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: 3270.65

Description: Protective Outlet Covers 5 yrs. or less

Noncompliance Area: Electrical outlets in both of the school-age bathrooms off the gym/main lobby were not covered. Five year old children use the space.

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

Regulation: 3270.76

Description: Building Surfaces

Noncompliance Area: The carpet in the school-age space has significant staining that is not coming up during routine cleanings/shampooing.

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

Regulation: 3270.77(a)

Description: No peeling paint or plaster

Noncompliance Area: Peeling paint was observed on the wall behind the trash can in the infant room.

Correction Required: Peeled or damaged paint or damaged plaster is not permitted on indoor or outdoor surfaces in the child care facility.

Noncompliance Area: Upon inspection of child care spaces, it was found that the emergency contact information was not present in 3 rooms where children were receiving care.

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

Noncompliance Area: Upon inspection, multiple plastic shopping bags were observed in a cabinet accessible to young toddlers.

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.

Noncompliance Area: During inspection, it was observed that the refrigerator in the young toddler/infant care space was operating at 48 degrees.

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.

Noncompliance Area: Upon inspection, it was observed that the Emergency Contact Forms were not updated with the master files in 4 child care spaces: Kindercare room, school CLASP classroom, Infant room and Preschool Room.

Correction Required: If emergency information is updated in a master file, it shall be updated accordingly in other facility records.

Noncompliance Area: Upon inspection, it was found that Staff person #1 was operating in an Assistant Group supervisor role, while being currently qualified as an Aide.

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.

Noncompliance Area: Upon inspection of Child #1 records, it was found that the file did not have a signed authorization to administer prescription medications.

Correction Required: A child's record shall contain signed parental consent for administration of medications or special dietary needs.

Noncompliance Area: Upon inspection of Staff #2 employee file, it was found that it did not contain two written non-family 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

Noncompliance Area: Upon inspection of Staff #1 employee file, it was found that the FBI clearance was last done on 5/14/2014.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Staff #1 cannot work with children in the facility until all clearances are up to date and valid.

Noncompliance Area: At the time of inspection, mulch (less than an inch in diameter) was observed to be accessible from the toddler playground, as the mulch from the preschool / school age playground was able to easily be reached from the toddler side (through the fence), and mulch was coming underneath the gate that connected the two playgrounds.

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.

Noncompliance Area: At the time of inspection, the following was observed: School age children left the child care space and went down hall to the bathroom. The children alerted the staff persons each time, but staff did not move to the doorway to supervise the child. This happened multiple times in a 15-20 minute time period. Staff persons 1-3 were present in the child care space with 29 children. When staff were asked which specific children they were responsible for, only 21 of the 29 children in the room were accounted for in primary care groups. Staff person 3 reported that she was responsible for child 3, but when she attempted to locate the child in the room, she was unable to do so. A short time period later, staff person 2 told Staff person 3 that the child went to the bathroom.

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.

Noncompliance Area: At the time of inspection, the emergency contact information on file for child 2 did not include addresses of two of the listed release persons (incomplete), nor the enrolling parent's work address.

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

Noncompliance Area: At the time of inspection, emergency contact information was not present in all of the child care spaces in which children were receiving care. Of the emergency contact information that was available in the child care space, it had not all been updated last time the information was updated in the master file.

Correction Required: When children are in the facility, emergency contact information shall be present in a child care space for children receiving care in the space. If emergency information is updated in a master file, it shall be updated accordingly in other facility records.

Noncompliance Area: At the time of inspeciton, the written plan identifying the means of transporting a child to emergency care and staffing provisions in the event of an emergency was not displayed conspicuously in the yellow school age child care space.

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

Noncompliance Area: At the time of inspection, the record child 3 did not contain signed parental consent for emergency medical care. The file also did not include signed written consent for administration of minor first-aid procedures by facility staff.

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

Noncompliance Area: At the time of inspection, 29 school age children were observed in a child care space with 2 staff persons (staff 1 and 3). Staff person 3 had left the room for a short period of time.

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.

Noncompliance Area: At the time of inspection, receptacle covers were not in place in multiple electrical outlets throughout the CLASP space. Kindergarten children (5 year olds) receive care in the space.

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

Noncompliance Area: At the time of inspection, a container of hand sanitizer was observed in the eating room in the child care building in an area accessible to the children (CORRECTED ON SITE). Another container of hand sanitizer was observed in an area accessible to toddlers in the front toddler child care space. (CORRECTED ON SITE)

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

Noncompliance Area: At the time of inspection of the classrooms in the CLASP space, it was observed that each space does not have it's own first-aid kit. The facility has one backpack and it travels space to space.

Correction Required: A first-aid kit shall be in a child care space.

Noncompliance Area: The following was observed at the time of inspection. Floor tiles were completely loose from the floor in the basement childcare space in the child care building. Cables were hanging loose from the ceiling to the desk in the Catacombs / School age child care space.

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.

Noncompliance Area: Diaper changing surface in the bathroom and infant rooms were ripped which prevented cleaning and sanitizing.

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. Diaper changing surfaces shall be cleaned after each use by wiping the surface with a sanitizing solution or by changing a pad or other surface covering.

Noncompliance Area: Emergency information for child 1 did not contain address for release persons.

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

Noncompliance Area: No written feeding schedules have been obtained for the infants in care.

Correction Required: A written statement giving the formula and feeding schedule for an infant shall be obtained from the parent.

Noncompliance Area: Record for child 1 did not contain written permission to administer minor first aid.

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

Noncompliance Area: There is a sunken area beside the plastic playhouse creating a trip hazzard in the outdoor play space on the toddler playground.

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.

Noncompliance Area: Peeling paint was observed in the large main area / activity space in the CLASP building.

Correction Required: Peeled or damaged paint or damaged plaster is not permitted on indoor or outdoor surfaces in the child care facility.

Noncompliance Area: Fire drill logs indicate that drills have not been conducted a minimum of one time per 60 days.

Correction Required: A fire drill shall be held at least every 60 days. Facility persons and children in attendance shall participate in the fire drill. Facility persons and children shall exit the building, weather permitting.

Noncompliance Area: Evacuation routes were not posed in the childcare building. They are posted in the schoolage spaces in the CLASP building.

Correction Required: Evacuation routes shall be posted.