Rainbows End Child Academy

Regulation: 3270.113(a)

Description: Supervised at all times

Noncompliance Area: Based on the facility's self-reported noncompliance and staff statements, it was determined that on April 6, 2026, Staff Persons #1, #2, and #3 conducted an excursion with 12 children (3 young toddlers and 9 older toddlers) to the Garden room located at the Carnegie Library of Pittsburgh - Squirrel Hill. At approximately 11:40 a.m., the group departed the Garden room and returned to the facility at 12:00 p.m. Upon arrival at the facility, Staff Persons #1, #2, and #3 then realized Child #1 was not present and was left behind at the library alone and unsupervised.

Correction Required: Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. Outdoor play space used by the facility is considered part of the facility premises. Tiered LIS: 1. Children on the facility premises and on facility excursions off the premises shall be supervised by a staff person at all times. 2. The Operator will collaborate with ELRC 5 to develop and implement a tangible identification system for each staff to identify the specific children in their respective supervisory groups, and for tracking children during transition periods. The selected identification system must be submitted to the Western Regional Office for review. All staff will utilize the identification method appropriately at all times while supervising children for a minimum of 3 months from the date the system is submitted for review. The correction date for this portion of the plan shall be at minimum 3 months from the date the selected system is submitted to the Western Regional Office. 3. The operator will require all staff persons at the facility to complete a training regarding Ratio, Active Supervision, and the implementation of the selected identification system. The training must be offered by ELRC 5, in-person and a minimum of 2 hours. The training must be completed within 4 months of the approval of this plan of correction. The training must be approved by the Department prior to implementation. Upon completion of the training, staff training documentation will be provided to the OCDEL-DHS representative by email. The training may count towards the mandatory 12 training hours required by the Department. The operator shall provide a date for when this training will be complete.

Regulation: 3270.113(a)(1)

Description: Staff assigned to specific children

Noncompliance Area: Based on the facility's self-reported noncompliance and staff statements, it was determined that on April 6, 2026, Staff Persons #1, #2, and #3 conducted an excursion with 12 children (3 young toddlers and 9 older toddlers) to the Garden room located at the Carnegie Library of Pittsburgh - Squirrel Hill. At approximately 11:40 a.m., the group departed the Garden room and returned to the facility at 12:00 p.m. Upon arrival at the facility, Staff Persons #1, #2, and #3 then realized Child #1 was not present and was left behind at the library alone and unsupervised without a staff person physically present.

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

Regulation: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: In the Gym, a children's soft climbing block was observed to be torn and not in good repair. In the OT/PS room, a plastic lid was observed to be cracked with sharp corners and not in good repair.

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

Regulation: 3270.107

Description: Refrigerator

Noncompliance Area: The refrigerator in the Infant room lacked an operable thermometer.

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

Regulation: 3270.124(b)(3)

Description: Parent home/work address, phone

Noncompliance Area: The emergency contact form in the file for child #1 lacked the enrolling parent's work telephone number.

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

Regulation: 3270.124(c)

Description: Each child care space

Noncompliance Area: Emergency contact information for child #2 was not present in the Gym where the child was observed to be receiving care. Emergency contact information for child #3 was not present in the Infant room where the child was observed to be 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.

Regulation: 3270.151(a)/3270.192(3)

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

Noncompliance Area: The two most recent health assessments in the file for Staff Person #1 are dated more than 24 months apart: 1/18/23 and 3/19/25.

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

Regulation: 3270.151(c)(2)

Description: Mantoux TB

Noncompliance Area: The file for Staff Person #3 contained documentation of TB screening results dated 10/20/25 but was not at initial employment (See LIS Code Sheet).

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: 3270.27(c)

Description: Training regarding plan

Noncompliance Area: The file for Staff Person #4 contained documentation of emergency plan training on 5/3/24 and 6/20/25, which is more than 12 months apart.

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

Regulation: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: The file for Staff Person #2 contained documentation of FBI clearance results dated 10/14/19 and 12/11/24, which is more than 60 months apart.

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

Regulation: 3270.34(a)(6)

Description: Staff evaluations

Noncompliance Area: The files for Staff Persons #1, #2, #5, #6 contained documentation of written evaluations dated more than 12 months apart. The file for Staff Person #4 did not contain documentation at the time of inspection of a written evaluation within the last 12 months.

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

Regulation: 3270.91(a)

Description: Stairs, exits, etc. unobstructed

Noncompliance Area: A children's wooden bench was obstructing an exit door from the Infant room to the YT room.

Correction Required: Stairways, hallways, exits from rooms, exits from the facility and other means of egress serving as an exit shall be unobstructed.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The file for Staff Person #1 contained documentation of PA State Police clearance results with a Record for Control but lacked the corresponding Rap Sheet within 45 days of hire (See IS Code Sheet) as required for provisional hiring under the CPSL.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Facility Person #1 may not work in a child care position at the facility.

Regulation: 3270.192(5)

Description: Two written references

Noncompliance Area: The file for Staff Person #3 lacked one written, nonfamily reference from individuals attesting to the person's suitability to serve as a facility person.

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

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

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

Noncompliance Area: The files for Staff Persons #1, #2 and #3, identified as assistant group supervisors, lacked qualification documents for the position in which the staff persons are performing.

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

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: Staff person #2 was observed to be caring for children unsupervised. Staff person #2 has not completed the following pre-service trainings required prior to caring for children unsupervised: Health and Safety training and Pediatric First Aid/CPR.

Correction Required: A facility shall be operated in conformity with applicable Federal and State laws and regulations. State agencies whose regulations may relate to the operation of a facility include the Department of Environmental Resources, the Department of Labor and Industry, the Department of Health, the Department of Education and the Department of Transportation. Conditions at the facility may not pose a threat to the health or safety of the children. Until such time as the required pre-service trainings are completed, staff person #-2 must be supervised by a AGS who has completed the required trainings related to this citation. If there are no staff persons available to supervise staff person #2, staff person #2 may not work in a child-care position at the facility.

Regulation: 3270.192(4)

Description: CPSL information

Noncompliance Area: The files for staff persons #1 and #2 did not contain documentation of NSOR clearance results prior to date of hire (See IS Code Sheet) as required under the CPSL.

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. Facility Person #1 and #2 may not work in a child care position at the facility.

Regulation: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: The files for staff persons #1 and #2 did not contain documentation of NSOR clearance results prior to date of hire (See IS Code Sheet) as required under the CPSL.

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

Regulation: 3270.51

Description: Similar Age Level

Noncompliance Area: On 5/21/25 at approximately 9:40am in the Older Toddler room, staff person #1 identified 9 older toddlers in their assigned group of children. At approximately 9:45am in the Preschool room, staff person #3 identified 18 preschool-aged children in their assigned group of children.

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. Tiered LIS: 1. The required staff:child ratios must be maintained at all times. 2. Within 60 days of the approval of this plan of correction, the Legal Entity will ensure the director arrange all staff persons, including the Legal Entity to attend a minimum of two hours of in-person training conducted by the ELRC on ratio and supervision. The training is titled Creating a Safe Environment Through Active Supervision. The two hours of training will be counted towards staff person's annual clock hours. 3. The Legal Entity will ensure the director partner with the ELRC to develop a Staff Coverage Schedule that includes designated lunch and restroom times based on staff shifts and ratio needs. Breaks will be scheduled to maintain required staff-to-child ratios, with floaters or designated staff providing coverage. Staff must remain in childcare spaces until properly relieved. The schedule must be posted in all childcare spaces, and all breaks will be documented in a log. The director will review the schedule and log weekly for 3 months to adjust for any staffing or enrollment changes. Documentation will be made available to OCDEL upon request. 4. The Legal Entity will ensure the director develops and implements a hands-free child tracking system to support classroom coverage and maintain appropriate staff-to-child ratios. The director will conduct walk-throughs twice daily to ensure staff are using the system appropriately and remaining in designated childcare spaces. 5. The Legal Entity will ensure the director holds 2 monthly staff meetings following the meeting with the ELRC. Topics will include the structured break schedule, restroom procedures, maintaining staff-child ratios, use of the break log, roles of temporary staff, floaters, and permanent staff, and proper use of the child tracking system. Inspection summaries issued within the last six months will also be reviewed. Each meeting will include a dated agenda and a signed attendance sheet. All documentation will be made available to OCDEL upon request.

Regulation: 3270.113(b)

Description: No physical punishment

Noncompliance Area: According to staff statements, on 3-17-25, staff person #1 was observed hitting an infant child on the back of the head.

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

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: Based on staff interviews, on 9/25/24 at approximately 12:00pm, staff person #2 was observed to be caring for children unsupervised. Staff person #2 has not completed the following pre-service trainings required prior to caring for children unsupervised: Pediatric first aid/CPR and Health and Safety.

Correction Required: A facility shall be operated in conformity with applicable Federal and State laws and regulations. State agencies whose regulations may relate to the operation of a facility include the Department of Environmental Resources, the Department of Labor and Industry, the Department of Health, the Department of Education and the Department of Transportation. Conditions at the facility may not pose a threat to the health or safety of the children. Until such time as the required pre-service trainings are completed, staff person #2 must be supervised, when interacting with children, by an AGS who has completed the required trainings related to this citation. If there are no staff person(s) available to supervise staff person #2, staff person #2 may not work in a child-care position at the facility.

Regulation: 3270.151(a)/3270.192(3)

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

Noncompliance Area: The file for staff person #2 did not include documentation of a health assessment conducted at initial employment.

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

Regulation: 3270.151(c)(2)

Description: Mantoux TB

Noncompliance Area: The file for staff person #2 did not include documentation of a TB screening at initial employment.

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: 3270.52

Description: Mixed Age Level

Noncompliance Area: On 10/4/24 at approximately 8:45am, staff person #1 and 10 children were observed in the OT Room. Staff person #1 named 7 older toddlers, 2 young toddlers, and 1 preschool age child that was in their assigned group of children.

Correction Required: *When children are grouped in mixed age levels, the age of the youngest child in the group determines the staff:child ratio and maximum group size in accordance with the requirements in § 3270.51 (relating to similar age level). The required staff:child ratios must be maintained at all times.

Regulation: 3270.52

Description: Mixed Age Level

Noncompliance Area: On 10/4/24 at approximately 8:45am, staff person #1 and 10 children were observed in the OT Room. Staff person #1 named 7 older toddlers, 2 young toddlers, and 1 preschool age child that was in their assigned group of children.

Correction Required: **Within two months of the approval of this plan of correction, the Legal Entity and all staff must participate in training regarding ratio of children provided by the ELRC. The Legal Entity shall send proof of completion to the assigned certification representative within 7 days of completion. Proof of completion shall include a staff attendance sign-in sheet, as well as trainer acknowledgement.

Regulation: 3270.76

Description: Building Surfaces

Noncompliance Area: The front doors to the entrance of the facility do not work properly as the electronic buzzer does not unlock the door granting immediate access.

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

Regulation: 3270.106(f)

Description: 2 feet apart

Noncompliance Area: On 9/13/24 at approximately 9:50am, child #4 was observed sleeping in a crib that lacked at least 2 feet of space on each side.

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

Regulation: 3270.113(a)

Description: Supervised at all times

Noncompliance Area: Based on interviews with staff, staff person #2 was in the YT Room with a group of 7 young toddlers at approximately 8:30am. Staff person #2 was standing at the diaper changing table looking down while changing a child's diaper. Staff person #2 heard a noise and looked up around the room. Child #1 was in the play area near the ledge by the windows and was bleeding from their forehead. Staff person #2 stated they did not observe the child fall or what occurred. Based on interviews with staff, staff person #5 was in the Indoor Gym with a group of older toddler and preschool age children. Staff person #5 noticed a red ring around the eye of child #2. Staff person #5 did not see when the mark occurred or what caused the mark on the child. On 9/13/24, staff person #2 was observed caring for children in the YT Room while wearing ear pods in both ears. Staff person #2 stated they were on the telephone. On 9/13/24, staff person #6 was observed positioned with their back towards 3 infants laying on the floor and 1 infant sleeping in a crib in the corner of the room. The crib was located behind furniture where the staff person was unable to properly see and supervise the child.

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

Regulation: 3270.119

Description: Infant sleep position

Noncompliance Area: Three infants were observed sleeping on a boppy pillow on the floor, not in the position recommended by the AAP.

Correction Required: Infants shall be placed in the sleeping position recommended by the American Academy of Pediatrics unless there is a medical reason an infant should not sleep in this position. The medical reason shall be documented in a statement signed by a physician, physician's assistant or CRNP and placed in the child's record at the facility.

Regulation: 3270.124(c)

Description: Each child care space

Noncompliance Area: Emergency contact forms were not present for several children that were observed receiving care in the Infant, Older Toddler and Preschool Rooms.

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

Regulation: 3270.151(a)/3270.192(3)

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

Noncompliance Area: The file for staff person #1 lacked a health assessment at initial employment.

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

Regulation: 3270.151(c)(2)

Description: Mantoux TB

Noncompliance Area: The file for staff person #1 lacked a TB screening and the results of the screening at initial employment.

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: 3270.166(5)

Description: Six-months-old held

Noncompliance Area: On 9/13/24 at approximately 9:50am, child #3 who is under 6 months of age, was not held while being bottle fed. Child #3 was observed with a bottle in their mouth while laying on a boppy pillow on the floor.

Correction Required: An infant 6 months of age or younger shall be held while being bottle fed.

Regulation: 3270.182(7)

Description: Reports of accidents, injuries and illnesses. Original report - parent same day Copy - facility accident file. Copy - child's file

Noncompliance Area: The facility did not have documentation of an incident report on file for child #1 who bumped their head and was bleeding.

Correction Required: A child's record shall contain reports of accidents, injuries and illnesses involving a child in care at the facility. The original report shall be given to the parent on the day of the incident. The second copy of the report shall be retained at the facility in an accident file. The third copy of the report shall be retained at the facility in the child's file.

Regulation: 3270.21

Description: General Health and Safety

Noncompliance Area: On 9/13/24, loose crib sheets were observed in a crib that was in use by child #4.

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

Regulation: 3270.51

Description: Similar Age Level

Noncompliance Area: Based on interviews with staff, the facility is not in compliance with ratio in the mornings until approximately 8:30/9:00am in the YT Room. On 9/13/24 at approximately 9:30am, staff person #1 was observed in the bathroom area with 8 children. Staff person #1 identified 8 older toddlers in their assigned group of children. At approximately 9:35am, staff person #2 was observed in the YT Room and identified 6 young toddlers in their assigned group of children. At approximately 9:45am, staff person #4 was observed in the Indoor Gym and identified 8 older toddlers in their assigned group.

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

Regulation: 3270.52

Description: Mixed Age Level

Noncompliance Area: On 9/13/24 at approximately 9:35am, staff person #3 and a group of children were observed in the YT Room. Staff person #3 identified 5 young toddlers and 2 older toddlers in their assigned group.

Correction Required: When children are grouped in mixed age levels, the age of the youngest child in the group determines the staff:child ratio and maximum group size in accordance with the requirements in § 3270.51 (relating to similar age level).

Regulation: 3270.62(b)

Description: Play space - 65 square feet/child

Noncompliance Area: On 9/13/24 at approximately 9:45am, staff person #4 and 8 children were observed in the Indoor Gym that has a capacity of 6.

Correction Required: Outdoor or indoor play space shall be measured at 65 square feet per child.

Regulation: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: Several resting mats in the PS room were observed to be ripping and not in good repair.

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

Regulation: 3270.124(f)/3270.181(c)

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

Noncompliance Area: The emergency contact form in the file for child #1 has not been reviewed and updated by the parent working the last six months. The most recent review was on 7/11/2023.

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

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: Staff person #4 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Pediatric first aid/CPR.

Correction Required: Staff person shall complete professional development in the topics of 3270.31(f)(1 -- 10) within 90 days of hire. Staff person #4 will have until 9/5/24 to complete the required training. Until such time as the required training has been completed, staff person #4 must be supervised, when interacting with children, by an AGS who has completed the required training related to this citation. If there are no staff available to supervise staff person #4, staff person #4 may not work in a child-care position at the facility.

Regulation: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: The two most recent Mandated Reporter trainings in the file for staff person #2 are dated more than 60 months apart.

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

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The file for staff persons #1 and #3 were observed to have documentation of FBI Clearance results that were not renewed before the expiration date of the most current certification. Staff person #1: 4/29/19 and 6/3/24. Staff person #3: 2/12/19 and 4/12/24.

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

Regulation: 3270.34(a)(6)

Description: Staff evaluations

Noncompliance Area: The two most recent staff evaluations in the files for staff persons #1, #2 and #3 are dated more than one year apart: 9/2022 and 12/2023.

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

Regulation: 3270.82(h)

Description: Handwashing signs

Noncompliance Area: Handwashing signs were not posted near the sink and the diapering area in the YT room.

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

Regulation: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: Observed tears, which exposed the inner foam, in several of the rest mats in the PS/SA Area of the large room.

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

Regulation: 3270.106(f)

Description: 2 feet apart

Noncompliance Area: Observed in the Infant Room, less than two feet of space on three sides of the Pack 'n' Play, where Child #4 was sleeping.

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

Regulation: 3270.113(a)(1)

Description: Staff assigned to specific children

Noncompliance Area: On 8/24/23, in the PS/SA Area of the large room, Staff Person #7 was supervising a mixed group of 10 children (8 Preschool and 2 Younger School Age and Staff Person #9 was supervising a group of 5 Preschool children. At 9:22 am, Staff Person #7 left her group with Staff Person #9 to answer the door for OCDEL Certification Persons. This resulted in Staff Person #9 supervising a mixed group of 15 Preschool and Younger School Age Children (13 PS 2 YSA). This group was out of ratio for approximately five minutes.

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

Regulation: 3270.124(b)(7)

Description: Name/address/phone release person

Noncompliance Area: The emergency contact form in the file for Child #3 lacked the address of one of the release persons.

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

Regulation: 3270.124(d)

Description: Excursions

Noncompliance Area: On 8/24/2023, at approximately 10:30, Staff Person #7 and #9 were leaving for an excursion to the library with 19 Preschool/Younger School Age Children. When Certification Reps asked to view the Emergency Contact Binder, emergency contact forms were available for only 8 of the 19 children leaving for the excursion. Staff went back to PS/SA Area to retrieve the appropriate binder. After this, emergency contact forms were available for 18 of the 19 children leaving for the excursion. Neither binder contained an emergency contact form for Child #3. This form was retrieved from the office.

Correction Required: When children leave the facility on walking and riding excursions, emergency contact information specific to each child on the excursion shall accompany a staff person on the excursion.

Regulation: 3270.131(d)(5)/3270.131(e)(3)

Description: Immunization record/Dismissal policy

Noncompliance Area: The most recent immunization record in the file for Child #1 did not include documentation of a flu shot administered within the past year. The most recent health report in the file for Child #2 contained no immunizations.

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 #1 and #2 must be dismissed from care by close of business 8/24/23 and may only return to care when the immunization record is updated or when a parent provides a written, signed exemption letter.

Regulation: 3270.133(3)

Description: Name on bottle

Noncompliance Area: The first aid kits in all rooms contained cleansing wipes, which contained alcohol, which were not labeled with the name of the child for whom the medication was intended. The first aid kit in the Older Toddler Area of the large room, also contained Benadryl cream, which was not labeled with the name of the child for whom the medication was intended.

Correction Required: The label of a medication container shall identify the name of the medication and the name of the child for whom the medication is intended. Medication shall be administered to only the child whose name appears on the container.

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: The one hour health and safety training update in the file for Staff Person #3 was conducted after the prescribed timeframe of 12/30/22.

Correction Required: A facility shall be operated in conformity with applicable Federal and State laws and regulations.State agencies whose regulations may relate to the operation of a facility include the Department of Environmental Resources, the Department of Labor and Industry, the Department of Health, the Department of Education and the Department of Transportation. Conditions at the facility may not pose a threat to the health or safety of the children.

Regulation: 3270.151(a)/3270.192(3)

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

Noncompliance Area: The most recent health assessments in the files for Staff Person #5 and #6 exceeded 24 months between health assessments. The initial health assessment in the file for Staff Person #7 was conducted after the staff person's first day working in child care.

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

Regulation: 3270.171(c)

Description: Safe routes posted

Noncompliance Area: Pick-up and Drop-off procedures were not posted at the facility.

Correction Required: Written notification of safe routes shall be posted by the operator at a conspicuous location in the child care facility.

Regulation: 3270.25(a)

Description: Availability of certificate of compliance and applicable regulations

Noncompliance Area: The parent board did not include information on how to access the regulations for PA Chapter 3270 electronically.

Correction Required: The facility's current certificate of compliance shall be posted in a conspicuous location used by parents. The operator shall provide the parent of each child enrolled with information on how to access the regulations in this chapter electronically and with instructions for contacting the appropriate regional child care office.

Regulation: 3270.27(a)(6)

Description: Emergency plan

Noncompliance Area: An emergency drill had not been conducted in the past 12 months. The most recent documented emergency drill was conducted on 1/27/22.

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

Regulation: 3270.27(f)

Description: Emergency plan

Noncompliance Area: The operator did not have documentation that a copy of the emergency plan had been sent to the local municipality.

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

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: Staff person #8 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): 10 hour Health and Safety Training. ((Previous 6 hour Health and Safety Training conducted on 12/5/18 is not valid).

Correction Required: Staff person(s) shall complete professional development in the topics of 3270.31(f)(1 -- 10), within 90 days of hire. Staff person #8 will have until 9/12/23 to complete the required training. Until such time as the required training has been completed, staff person #8 must be supervised, when interacting with children, by an AGS or higher who has completed the required training related to this citation. If there are no staff available to supervise staff person #8, staff person #8 may not work in a child-care position at the facility.

Regulation: 3270.31(f)(1)

Description: Health and Safety Training - Prevention and control of infectious diseases

Noncompliance Area: The Pediatric First Aid/CPR and Health and Safety Training in the file for Staff Person #4 were conducted more than 90 days after the staff person's first day working at the facility (See LIS Code Sheet).

Correction Required: Staff persons shall complete professional development in the 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 within 90 days of hire.

Regulation: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: The most recent Mandated Reporter Trainings in the file for Staff Person #1 exceeded 60 months between trainings.

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

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The disclosure statements in the files for Staff Person# 4, #8 and #10 were on outdated forms. The FBI Clearance in the file for Staff Person #7 was a DOE Clearance and not the approved DHS Clearance required for childcare.

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 #7 may not work at the facility.

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

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

Noncompliance Area: The file for Staff Person #4, an AGS, lacked verification of a High School Diploma and two years child care experience.

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

Regulation: 3270.52

Description: Mixed Age Level

Noncompliance Area: On 8/24/23, in the PS/SA Area of the large room, Staff Person #7 was supervising a mixed group of 10 children (8 Preschool and 2 Younger School Age and Staff Person #9 was supervising a group of 5 Preschool children. At 9:22 am, Staff Person #7 left her group with Staff Person #9 to answer the door for OCDEL Certification Persons. This resulted in Staff Person #9 supervising a mixed group of 15 Preschool and Younger School Age Children (13 PS 2 YSA). This group was out of ratio for approximately five minutes. Also on 8/24/23, at 9:25 am, Staff Person #2 was supervising a mixed group of 13 younger and older toddlers (2 YT and 11 OT) in the OT Area of the large room. This was the result of a staff person who was late. Group remained over ratio until approximately 10:00 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 in § 3270.51 (relating to similar age level).

Regulation: 3270.65

Description: Protective Outlet Covers 5 yrs. or less

Noncompliance Area: Observed an surge strip, which lacked receptacle covers for five of the outlets, in the PS/SA Area of the large room.

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

Regulation: 3270.66(a)

Description: Locked or inaccessible

Noncompliance Area: Observed bleach and Lysol cleaning products, which were accessible to children, in the single toilet stall restroom. Observed a bottle of Swiffer solution attached to a mop, which was accessible to children, in the double toilet stall restroom.

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

Regulation: 3270.66(c)

Description: Toxic use- no contamination

Noncompliance Area: Observed four bottles of sunblock, which had expired, in the sunblock/sunscreen bin of the large room.

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: 3270.75(c)

Description: Has all items

Noncompliance Area: The first aid kit in the Older Toddler Area of the large room lacked gloves.

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

Regulation: 3270.76

Description: Building Surfaces

Noncompliance Area: Observed dangling wires, which create a potential tangling hazard, in the following areas: Fisher Price rocker in the left corner of the Infant Room. Flat screen TVs in the Older Toddler Area and PS/SA Area of the large room. Light-up desk in the PS/SA Area of the large room. Observed a broken stereo in the corner near the exit of the PS/SA Area of the large room. Observed brown stains from possible water damage on five of the ceiling tiles in the Gym/Nap Room.

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: Observed peeling paint on the left window sill 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.

Regulation: 3270.78

Description: Lighting

Noncompliance Area: The Gym/Nap Room did not have sufficient lighting for staff to see their children during naptime.

Correction Required: Rooms, hallways, stairways, outside steps, porches and ramps shall be lighted by artificial or natural light.

Regulation: 3270.81

Description: Glass

Noncompliance Area: A visual strip or other visual identification was not placed on glass door, which separates the large child care space from the staff office.

Correction Required: A visual strip or other visual identification shall be placed on glass located in a traffic area, a child care space or a play space.

Regulation: 3270.94(a)(1)

Description: Every 60 days

Noncompliance Area: The fire drill/fire system check log documented one occurrence when fire drills exceeded 60 days between drills: 6/8/23-8/9/23.

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)/3270.95(b)

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

Noncompliance Area: The fire drill/fire system check log documented one occurrence when fire system checks exceeded 30 days between drills: 1/13/23-2/13/23.

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

Regulation: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: A child's plastic VTech Tote and Go Laptop was observed to be cracked exposing the children to sharp corners and rough edges.

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

Regulation: 3270.135(a)(3)

Description: Disposable diapers

Noncompliance Area: In the bathroom, a soiled diaper was observed in a garbage can that lacked a plastic-lined, hands-free covered can. The diapering area in the YT room lacked plastic-lined, hands free covered can.

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

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

Description: Mantoux TB/Health assessment, TB test

Noncompliance Area: The file for staff #2 lacked documentation of a tuberculosis screening at initial employment (See LIS CODE SHEET). The tuberculosis screening documentation on file is dated 9/20/22.

Correction Required: An adult health assessment must include tuberculosis screening by the Mantoux method at initial employment. Subsequent tuberculosis screening is not required unless directed by a physician, physician's assistant, CRNP, the Department of Health or a local health department. A facility person's record shall include a written report of initial and subsequent health assessments, including the results of initial and subsequent tuberculin skin tests, x-rays or other medical documentation necessary to confirm freedom from communicable tuberculosis.

Regulation: 3270.21

Description: General Health and Safety

Noncompliance Area: One pair of adult scissors and one bottle of White Out labeled "Keep out of reach of children" were observed on children's storage shelves behind the children's table in the YT room, and one pair of adult scissors were observed on a staff's persons desk in the OT/PS room accessible to children in care.

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

Regulation: 3270.31(e)

Description: Age and Training

Noncompliance Area: The file for staff person #1 lacked an annual minimum of 12 clock hours of child care training for the year December 19, 2020 - December 19, 2021.

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

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

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

Noncompliance Area: The file for staff person #1 was observed to have documentation pediatric first aid/CPR that was not renewed before the expiration date of the most current certification: 9/12/19 and 9/27/22.

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. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

Regulation: 3270.65

Description: Protective Outlet Covers 5 yrs. or less

Noncompliance Area: One outlet cover was observed to be missing next to the sink in the OT/PS bathroom which was accessible to children under the age of 5.

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

Regulation: 3270.66(a)

Description: Locked or inaccessible

Noncompliance Area: A bottle of bleach water, hand sanitizer and a bottle of Lysol disinfectant spray were observed to be placed on the diapering table in the YT room, and a container of antibacterial hand wipes were observed on a staff person's desk in the OT/PS room which was accessible to children.

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

Regulation: 3270.66(b)

Description: Original container

Noncompliance Area: One bottle of bleach water was observed in the yellow storage cubes placed next to cereal, crackers and a child's bottle in the Infant room.

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

Regulation: 3270.94(a)(1)

Description: Every 60 days

Noncompliance Area: The facility had documentation of fire drills being conducted that exceeded 60 days from 10/1/21-12/1/21 and 5/13/22-7/12/22.

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)/3270.95(b)

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

Noncompliance Area: The facility had documentation of testing the fire alarm system that exceeded 30 days from 1/10/22-2/26/22, 7/25/22-8/25/22, and 8/25/22-9/25/22.

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

Regulation: 3270.52

Description: Mixed Age Level

Noncompliance Area: Staff #1 identified her supervisory group to include 6 total children. Five children were two years old and one child was one years old. The youngest determines the staff ratio which is 1:5.

Correction Required: When children are grouped in mixed age levels, the age of the youngest child in the group determines the staff:child ratio and maximum group size in accordance with the requirements in § 3270.51 (relating to similar age level).

Regulation: 3270.111(b)

Description: Posted in group space

Noncompliance Area: In the infant room, the daily activities schedule was not posted.

Correction Required: The written plan of daily activities shall be posted in the group space.

Regulation: 3270.113(a)

Description: Supervised at all times

Noncompliance Area: During naptime in the preschool room, child #2 was sleeping behind a desk and therefore staff #4 could not see, hear, direct, and assess child #2..

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

Regulation: 3270.133(3)

Description: Name on bottle

Noncompliance Area: In the two year old room, 20 Top Care alcohol pads were observed in a first aid kit and none of them were labeled with a specific child's name,

Correction Required: The label of a medication container shall identify the name of the medication and the name of the child for whom the medication is intended. Medication shall be administered to only the child whose name appears on the container.

Regulation: 3270.133(5)

Description: Original label

Noncompliance Area: The Epinephrine Pen which belonged to child #1 had an expiration date of April 2021 and therefore was expired and unusable.

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

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

Description: Fire safety - 1 yr.

Noncompliance Area: The file for staff #1 contained a fire safety training date of 9-19-2020 and 9-30-2021 which exceeded the annual renewal requirement.

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

Regulation: 3270.31(f)(7)/3270.192(2)(iii)

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

Noncompliance Area: The file for staff #5 did not contain emergency plan training.

Correction Required: 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)).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)/3270.192(2)(iii)

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

Noncompliance Area: Staff #2 with a hire date of 11/11/2020 had a health and safety training date of 10-1-2021 exceeding the allowable 90 day training for a new employee.

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

Regulation: 3270.51

Description: Similar Age Level

Noncompliance Area: Staff #1 escorted one child out of the two year old room to allow that child to finish a craft. Staff #3 remained in the two year old room and was responsible for six children. Two children were one and a half years old and four children were two years old.

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

Regulation: 3270.66(a)

Description: Locked or inaccessible

Noncompliance Area: In the front of the two year old room, located in an open bin, 11 Dab-O-Ink Daubers had "Keep out of reach of children" on the label and were accessible to children.

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

Regulation: 3270.77(a)

Description: No peeling paint or plaster

Noncompliance Area: In the girls restroom, peeling paint was observed above both sinks and plaster was exposed underneath both sinks.

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