The Learning Experience

Regulation: 3270.161(d)

Description: Potentially hazardous food refrigerated

Noncompliance Area: During the time of the inspection, in the Preschool 2B classroom, two lunch boxes containing yogurt and cheese were observed hanging in the children's cubbies. These items are required to be refrigerated.

Correction Required: Potentially hazardous food brought from the child's home or provided by the facility shall be refrigerated.

Regulation: 3270.31(e)

Description: Age and Training

Noncompliance Area: At the time of the inspection, staff person #1 only had 6.5 hours of childcare training during their 10/2024-10/2025 training period.

Correction Required: A staff person shall obtain an annual minimum of 12 clock hours of childcare training. Staff person #1 must take 9 hours of professional development to fulfill requirement for training year 10/2024-10/2025. Hours used to fulfill training year 10/2024-10/2025 may not be used to fulfill current training year.

Regulation: 3270.75(c)

Description: Has all items

Noncompliance Area: At the time of the inspection, in the Make-Believe Boulevard class, tweezers and scissors were missing from the red bag's first aid kit.

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

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

Noncompliance Area: At the time of the inspection on 3/23/26, staff person #1 acknowledged that child #1 was removed from the classroom by a member of an outside agency. Child #1 was then observed in the staff lounge with the member of the outside agency. No staff of the facility were observed with child #1. Staff person #19 acknowledged that there was no written parent consent for the children to be removed from the classroom.

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. TIERED LIS: 1.) Children must be supervised at all times. This portion of the plan requires an immediate correction date. 2.) The legal entity must develop or update their written supervision policies and procedures to be implemented in the facility. The written policy must ensure that each child is seen, heard, assessed and able to be directed at all times. The policy must also include a plan for each staff to be assigned the responsibility for supervision of specific children, including the requirement that the staff person know the names and whereabouts of the children in his/her assigned group and be physically present with the children in his/her group on the facility premises and on facility excursions off the facility premises. The written policy will address the procedure for not leaving children under the supervision of anybody who is not a staff person of the facility. The updated policies must also reflect the need for parental consent for any child to leave the classroom to receive outside services. It will be sent to DHS for review prior to training any staff. Both the updated supervision policies and new supervision procedures must be submitted to the Northeast Regional Office for approval prior to implementation. Once approved by the Department, the director will ensure that all current employees and any new hires are trained on the policies and procedures, and it must be documented in their files. This date of correction will be when the policies and procedures have been approved, and all staff will be trained.

Regulation: 3270.133(3)

Description: Name on bottle

Noncompliance Area: At the time of the inspection, the Avi-Q present for child #2 and the Valtoco present for child #3 did not contain a label with the name of the child for whom the medication is 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: 3270.151(c)(2)

Description: Mantoux TB

Noncompliance Area: At the time of the inspection, the health assessment on file for staff person #29 did not include a date as to when tuberculosis screening was conducted (see LIS code sheet for date of hire).

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: 3270.192(5)

Description: Two written references

Noncompliance Area: At the time of the inspection, staff persons #7, #14 and #21 did not have two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person on file.

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

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

Description: Age and Training

Noncompliance Area: At the time of the inspection, staff person #3 did not update Pediatric First Aid/CPR training every 24 months, as required. This is evidenced by the current Pediatric First Aid/CPR training date of 12/27/25 and the previous training date of 10/3/23.

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

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: At the time of the inspection, staff person #7 did not complete Pediatric First Aid/CPR training within 90 days of hire. This is evidenced by the Pediatric First Aid/CPR training date of 3/9/26 (see LIS code sheet for date of hire).

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

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: At the time of the inspection, staff person #17 did not have completed clearances on file for the state of Florida and they acknowledged they resided there within the last 5 years. Staff person #17 was observed having direct contact and routine interaction with children. Staff person #30 did not update the Child Abuse clearance every 60 months, as required. This is evidenced by the current child abuse clearance on file dated 11/10/25 and the previous child abuse clearance dated 11/05/2020. Staff person #19 acknowledged that staff person #30 had direct contact and routine interaction with children during the timeframe of the clearance update lapse. Previously, on 04/28/25, the requirement for using the newest disclosure statement going forward was provided as technical assistance with Staff #19. On 03/23/26, during a review of staff files, it was observed that an old version of the disclosure statement was signed for new hires, staff person#16, #21 and staff person #28, and did not contain a date of signature. Staff person #7, a new hire, had an old version of the disclosure statement that was signed on 12/3/25.

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. The OCDEL Announcement C-25-01, effective 2/1/25, states that an individual may be employed on a provisional basis in a certified child care facility when the following conditions are met, and documentation is maintained on file: Have results of the following, no older than 60 months: 1. PA Child Abuse History Clearance; 2. NSOR verification; 3. Out-of-state clearances (if applicable); 4. Signed Disclosure Statement for Child Care Employment; and 5. Either FBI Criminal History Clearance; or PSP Criminal History Clearance In addition to those obtained, the following clearances must be applied for prior to starting provisional employment: 1. FBI Criminal History Clearance; or 2. PSP Criminal History Clearance Staff Person #17 may not work in a childcare position at the facility until all completed out-of-state clearances are on file at the facility.

Regulation: 3270.35(b)

Description: Group sup qualifications

Noncompliance Area: At the time of the inspection, staff person #17 did not have a transcript to determine what major the Associate of Art degree that was on file was in, and therefore, cannot qualify as a group supervisor.

Correction Required: A group supervisor shall have attained one of the qualification levels specified at §3270.35(b)(1)-(4).

Regulation: 3270.31(e)

Description: Age and Training

Noncompliance Area: CONTINUED NON-COMPLIANCE: At the time of the inspection on 7/18/25, staff person #2 only had 5.5 hours of childcare training during the 12/23-12/24 training period. Staff person #15 only had 11 hours of childcare training during the 4/24-4/25 training period. Staff person #24 only had 5.5 hours of childcare training during the 2/24-2/25 training period. Staff person #28 only had 5.5 clock hours of childcare training during the 8/23-8/24 training period. Staff person #30 did not have any clock hours of child care training on file during the 6/24-6/25 training period. An acceptable plan of correction was received stating the correction would be implemented by 8/29/25. An inspection occurred on 9/9/25. Staff person #30 still did not have any clock hours of child care training on file during the 6/24-6/25 training period.

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

Regulation: 3270.33(a)

Description: Each staff person meets quals

Noncompliance Area: CONTINUED NON-COMPLIANCE: At the time of the inspection on 7/18/25, staff person #30 did not have a transcript on file to accompany the bachelor's degree on file to determine what the degree is in. Staff person #35 did not have her education from Colombia evaluated to determine the US education equivalency. An acceptable plan of correction was received stating the correction would be implemented by 8/8/25. An inspection occurred on 9/9/25, staff person #30 still did not have a transcript on file to accompany the bachelor's degree on file to determine what the degree is in.

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.

Regulation: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: At the time of the inspection, there were torn rest mats with the inside foam exposed observed in the Preschool 1A classroom.

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: At the time of the inspection, the refrigerator in the Toddler B classroom did not contain a thermometer.

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

Regulation: 3270.133(7)(iv)

Description: Amount to administer

Noncompliance Area: At the time of the inspection, the medication log for the medications present for child #11 and child #12 did not include the amount to be administered.

Correction Required: A medication log shall include the amount of medication administered.

Regulation: 3270.182(3)/3270.182(5)

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

Noncompliance Area: At the time of the inspection, on the emergency contact form for child #2, there was no signed consent for emergency medical care and no signed parental consent for administration of minor first-aid procedures by facility staff for the child.

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

Regulation: 3270.192(4)

Description: CPSL information

Noncompliance Area: Previously, on 04/28/25, the requirement for using the newest disclosure statement going forward was provided as technical assistance with Staff #1. On 7/18/25, during a review of staff files, it was observed that an old version of the disclosure statement was signed for a new hire, Staff #6, #17, #18, #27 on 5/7/25, 5/12/25, 5/20/25, 5/28/25

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

Regulation: 3270.31(e)

Description: Age and Training

Noncompliance Area: At the time of the inspection, staff person #2 only had 5.5 hours of childcare training during the 12/23-12/24 training period. Staff person #15 only had 11 hours of childcare training during the 4/24-4/25 training period. Staff person #24 only had 5.5 hours of childcare training during the 2/24-2/25 training period. Staff person #28 only had 5.5 clock hours of childcare training during the 8/23-8/24 training period. Staff person #30 did not have any clock hours of child care training on file during the 6/24-6/25 training period.

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

Regulation: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: At the time of the inspection, staff person #4 did not complete mandated reporter training every 60 months prior to the current certificate's expiration. This is evidenced by the previously documented mandated reporter training on file being dated 1/21/20 and the current documented mandated reporter training on file being dated 4/14/25.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Mandated Reporter Training must be renewed every 60 months (5 years), prior to the previous certification turning 60 months.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: At the time of the inspection, staff person #42 had a child abuse clearance dated 2/8/23 which was of volunteer status and not employment. Staff person #42 had routine interaction and direct contact with children.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Staff Person #42 may not work in a child care position with routine interaction and direct contact with children at the facility.

Regulation: 3270.33(a)

Description: Each staff person meets quals

Noncompliance Area: At the time of the inspection, staff person #30 did not have a transcript on file to accompany the bachelor's degree on file to determine what the degree is in. Staff person #35 did not have her education from Colombia evaluated to determine the US education equivalency.

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.

Regulation: 3270.95(a)/3270.95(b)

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

Noncompliance Area: At the time of the inspection, the Director could not locate the documentation for the installation of the interconnected fire detection system.

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

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

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

Noncompliance Area: The facility self-reported that on 6/13/25, child #1 was found in the hallway running towards the playground door by staff #3. Child #1 told staff person #3 that she was left alone in the bathroom and the rest of her class was outside with staff person #1 and staff person #2. As per the Director, child #1 was left alone for approximately 30 seconds. Staff person #1 and staff person #2 have resigned effective 6/16/25.

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. TIERED LIS: 1. Children must be supervised at all times. This portion of the plan shall have an immediate correction date. 2. The legal entity must submit documentation in a format approved by DHS proving that the facility procedure for counting children is followed at all times e.g., a checklist. The legal entity will confirm continuing compliance by sending copies of the documentation to the Regional Office of Child Development and Early Learning on a weekly basis for a period of three months after DHS approves the documentation format. The documentation must be received by close of business on Monday for the week prior. This date of correction must extend out to a period of 3 months after an acceptable counting checklist has been submitted.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: At the time of the inspection, staff person #4 did not have a current NSOR on file. This is evidenced by the NSOR on file dated 2/7/20.

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

Regulation: 3270.102(c)

Description: Outdoor equip.- protective surfacing

Noncompliance Area: At the time of the inspection on 4/28/25, the operator could not provide documentation of the ASTM poured-in-place rubber surfacing showing that it meets the fall height requirement for the embedded equipment that was present on site.

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: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: Staff person #27 has completed pediatric first-aid and CPR training, however the trainer has not provided documentation that they are PQAS-certified in that training curriculum.

Correction Required: Staff persons shall complete professional development within 90 days of hire as listed in subsection (f)10. Until such time as the required training has been completed, staff person #27 must be supervised when interacting with children at a minimum by an AGS who has completed all preservice trainings and has all qualifications to care for children unsupervised. If there are no staff person(s) available to supervise staff person #27, staff person #27 may not work in a child-care position at the facility.

Regulation: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: At the time of the inspection, staff person #26 did not complete mandated reporter training every 60 months prior to the current certificate's expiration. This is evidenced by the previously documented mandated reporter training on file being dated 11/20/19 and the current documented mandated reporter training on file being dated 1/13/25.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Mandated Reporter Training must be renewed every 60 months (5 years), prior to the previous certification turning 60 months.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: At the time of the inspection on 4/28/25, staff person #19 did not update the NSOR certificate every 60 months prior to the current certificate's expiration. This is evidenced by the previously documented NSOR certificate on file being dated 8/2/19 and the current documented NSOR certificate on file being dated 9/27/24. Staff person #26 did not update the Child Abuse and FBI clearances every 60 months prior to the current certificate's expiration. This is evidenced by the previously documented Child Abuse and FBI clearances on file being dated 11/18/19 and 11/13/19, respectively. The current documented Child Abuse and FBI clearances on file being dated 1/16/25 and 2/12/25, respectively. Staff person #19 and #26 have direct contact and routine interaction with children.

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. All required clearances need to be renewed prior to expiration of each certificate, every 60 months.

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

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

Noncompliance Area: The facility self-reported that on 7/17/24, child #20 was left alone in the Preschool B2 classroom for a period of 5 minutes at 8:30am while staff person #20 took the other children to the outdoor play space. Child #20 was found in the classroom by a parent of the facility.

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. The legal entity must arrange for all facility staff employed as of the date of the training to receive a minimum of three hours of training regarding Ratios and Supervision of children. The legal entity must receive DHS approval of the training content prior to scheduling the training.

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

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

Noncompliance Area: The facility self-reported that on 7/17/24, child #20 was left alone in the Preschool B2 classroom for a period of 5 minutes at 8:30am while staff person #20 took the other children to the outdoor play space. Child #20 was found in the classroom by a parent of the facility.

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. Children must be supervised at all times.

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

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

Noncompliance Area: The facility self-reported that on 7/17/24, child #20 was left alone in the Preschool B2 classroom for a period of 5 minutes at 8:30am while staff person #20 took the other children to the outdoor play space. Child #20 was found in the classroom by a parent of the facility.

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. The legal entity must develop or update their written supervision policies and procedures to be implemented in the facility. The written policy must ensure that each child is seen, heard, assessed and able to be directed at all times. The policy must include how the facility will ensure appropriate supervision during transition times and while in the outdoor play area. The policy must also include a plan for each staff to be assigned the responsibility for supervision of specific children, including the requirement that the staff person know the names and whereabouts of the children in his/her assigned group and be physically present with the children in his/her group on the facility premises and on facility excursions off the facility premises. The policy must also address how these groups will be transitioned from one staff person to another during staffing changes. The facility must create and implement specific procedures using a tangible supervision system, e.g. supervision cards, supervision lists, or another approved method, to ensure appropriate supervision at all times. Both the updated supervision policies and new supervision procedures must be submitted to the Northeast Regional Office for approval prior to implementation. Once approved by the Department, the director will ensure that all current employees and any new hires are trained on the policies and procedures and it must be documented in their files.

Regulation: 3270.106(f)

Description: 2 feet apart

Noncompliance Area: In the Make Believe Blvd classroom during rest time, children were laying on mats which were not at least 2 feet of space on three sides.

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

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

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

Noncompliance Area: The agreements being used for all children does not specify the persons designated by a parent to whom the child may be released. The emergency contact form for child #1 did not include the address of the individual designated by the 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. 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(b)(3)/3270.124(b)(6)

Description: Parent home/work address, phone/Insurance coverage information

Noncompliance Area: The emergency contact form for child #1 through child #4 and child #7, child #8 and child #9 did not include the enrolling parent's work address. The emergency contact form for child #1, child #3, child #7, child #8 and child #10 did not contain the health insurance coverage and/or policy number for the child.

Correction Required: Emergency contact information must include the home and work addresses and telephone numbers of the enrolling parent. 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: 3270.124(c)/3270.181(e)

Description: Each child care space/Emergency master file updated

Noncompliance Area: Emergency contact forms throughout the classrooms in the facility were not updated according to emergency contact in the child's 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.

Regulation: 3270.131(a)

Description: Health information

Noncompliance Area: Child #9 did not have a health report on file and has been enrolled at the facility for more than 60 days (see LIS code sheet for date of admission).

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

Regulation: 3270.134(a)/3270.152

Description: Child's hands washed/Adult Hygiene

Noncompliance Area: In the Infant B classroom, the staff person did not wash a child's hands after diapering. She also did not wash her hands after she changed the child's diaper. In the Toddler A classroom, the staff person did not wash the child's hands after diapering.

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

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: At the time of the inspection, the emergency plan on file did not contain continuity of operations during and after an emergency that includes continuing daily operations, backing up or retrieving health and other key records/files and managing financial issues such as paying employees and bills during the aftermath of the disaster.

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. The OCDEL ANNOUNCEMENT C-22-04 requires facility emergency plans to include continuity of operations during and after an emergency that includes continuing daily operations, backing up or retrieving health and other key records/files and managing financial issues such as paying employees and bills during the aftermath of the disaster.

Regulation: 3270.151(a)

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

Noncompliance Area: Staff person #22 did not obtain a health assessment every 24 months as required. This is evidenced by the current health assessment dated 7/2/24 and the previous health assessment dated 4/15/22.

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

Regulation: 3270.171(b)/3270.171(c)

Description: Safe pick-up and drop-off in writing/Safe routes posted

Noncompliance Area: Written notification of safe routes were not posted by the operator in the childcare facility.

Correction Required: Safe pedestrian crossways, pick-up and drop-off points and bike routes shall be appropriately determined in the vicinity of the facility and communicated to the children and parents in writing. Written notification of safe routes shall be posted by the operator at a conspicuous location in the child care facility.

Regulation: 3270.182(3)/3270.182(5)

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

Noncompliance Area: The emergency contact forms for child #1, child #3, child 8 and child #9 did not include signed parental consent for emergency medical care for the child or signed parental consent for administration of minor first-aid procedures by facility staff.

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

Regulation: 3270.27(a)(3)/3270.27(a)(4)

Description: Contact when arises/Contact when ended

Noncompliance Area: The emergency plan did not include a method for facility persons to contact parents as soon as reasonably possible when an emergency situation arises or a method for facility persons to inform parents that the emergency has ended and to provide instruction as to how parents can safely be reunited with their children.

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

Regulation: 3270.27(a)(5)

Description: Emergency plan

Noncompliance Area: The emergency plan did not include accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions.

Correction Required: The facility shall have an emergency plan that provides for accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions.

Regulation: 3270.27(c)

Description: Training regarding plan

Noncompliance Area: Staff person #3 did not have emergency plan training on file at time of hire (see LIS code sheet for date of hire). Staff person #6, staff person #7, staff person #8, staff person #9, staff person #14, staff person #18, staff person #19, staff person #20, staff person #21, staff person #24, staff person #29, staff person #33 did not have documentation of emergency plan training being conducted annually. This is evidenced by the current training dated 3/4/24 and the and no documented training in 2023. The operator had admitted to discarding the documentation of the training that occurred in 2023.

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: 3270.27(f)

Description: Emergency plan

Noncompliance Area: There was no documentation proving that the emergency plan was sent to both local and county emergency management agencies for review.

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

Regulation: 3270.31(e)

Description: Age and Training

Noncompliance Area: Staff person #6 only had 5 clock hours of child care training during the 2/23-2/24 training period. Staff person #8 and staff person #15 only had 1 clock hour and 4 clock hours of child care training during the 11/22-11/23 training period, respectively. Staff person #9 and staff person #14 only had 2 and 6 clock hours of child care training during the 12/22-12/23 training period, respectively. Staff person #19 only had 8 clock hours of child care training during the 1/23-1/24 training period. Staff person #21 only had 4 clock hours of child care training during the 7/22-7/23 training period. Staff person #29 only had 1 clock hours of child care training during the 5/23-5/24 training period.

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

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

Description: Age and Training

Noncompliance Area: Staff person #22 has not completed Pediatric First Aid/CPR training within the last 24 months. This is evidenced by the previously documented Pediatric First Aid/CPR training on file being dated 5/20/22.

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. Staff person #22 will have until 7/26/24 to complete the required training. Until such time as the required training has been completed, staff person #22 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 #22, staff person #22 may not work in a child-care position at the facility.

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

Description: Fire safety - 1 yr.

Noncompliance Area: Staff person #19 did not taken fire safety training annually. This is evidenced by the current training dated 6/25/24 and the previous training dated 1/12/23.

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

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: Staff person #2 and staff person #33 have a PA State Police clearance that stated, "Request Pending" and no dissemination date, making these incomplete clearances. Staff person #4 did not have a completed NSOR certificate on file. Staff person #12 has an FBI clearance dated 5/31/23 stating the staff person had a record, but the Rap sheet was not attached. This makes this an incomplete clearance. Staff person #18 and staff person #39 did not have proof of contact to the state of New York to obtain the Sex Offender registry results. These staff have been employed for more than 45 days. (see LIS code sheet for date of hire). Staff person #16 did not have a receipt of fingerprinting submission for the FBI clearance and did not receive FBI fingerprinting until 5/30/24. Staff person #17 did not submit the request for the NSOR certificate until 10/2/23. Staff person #34 did not obtain the Child Abuse clearance until 8/18/23, did not submit for the FBI clearance until 8/21/23 and the NSOR certificate until 8/29/23. Staff person #38 did not obtain fingerprinting for the DHS clearance until 3/7/24. These dates of clearance submission are after the initial employment dates for staff #16, staff #17, staff person #34 and staff person #38. Staff person #17 also does not have a witness signature on the disclosure statement (see LIS code sheet for date of hire).

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. The CPSL was updated to include a 45-day provisional hiring period. Staff person #2, staff person #4, staff person #12, staff person #18, staff person #33 and staff person #39 may not work in a child care position at the facility until all clearances are obtained.

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

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

Noncompliance Area: Staff person #13 and staff person #22 did not have a transcript to accompany the degrees on file to determine the major of the degree, therefore, staff person #13 and staff person #22 does not qualify for the position they were performing. Staff person #33 did not have 2 years (2,500 hours) of prior childcare experience on file and did not qualify for the position they were 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: 3270.51

Description: Similar Age Level

Noncompliance Area: In the Toddler A room, 5 young toddlers were sleeping on mats and 4 young toddlers were eating at a table. There was one staff person present in the room. This number and age of children requires there to be two staff present. In the Toddler B room, there were ten young toddlers present with one staff person. Seven children were laying on mats and three children were sitting with the staff person off of their mats. This number and age of children requires there to be two staff present.

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. The Legal Entity / Director must establish a ratio policy. The policy must address how the facility will maintain proper staff:child ratios at all times. The policy must also address situations that might affect staff:child ratios, such as rest time ratio requirements and children who are no longer on their mats during rest time. As part of the policy, the legal entity must print and post the required ratios in each measured child care space. This policy must be sent to the Northeast Regional Office for review and approval. Once approved, all existing staff and new hires must be trained on the approved procedures, and their signatures will indicate their understanding and ability to implement the policy. This documentation must be maintained at the facility.

Regulation: 3270.51

Description: Similar Age Level

Noncompliance Area: In the Toddler A room, 5 young toddlers were sleeping on mats and 4 young toddlers were eating at a table. There was one staff person present in the room. This number and age of children requires there to be two staff present. In the Toddler B room, there were ten young toddlers present with one staff person. Seven children were laying on mats and three children were sitting with the staff person off of their mats. This number and age of children requires there to be two staff present.

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 Preschool 1A, in an unlocked cabinet which was accessible to children, there was a bottle of Allergy Relief, a can of Gillette shaving cream and Speed Stick deodorant.

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: 3270.69(b)

Description: 110º F or less

Noncompliance Area: In the Toddler A room, the sink used for handwashing measured 117° F.

Correction Required: Hot water temperature, in areas accessible to children, may not exceed 110° F.

Regulation: 3270.95(a)/3270.95(b)

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

Noncompliance Area: During unannounced inspection conducted 1/10/2024, facility's fire detection testing log indicated that smoke alarms were tested past 30 days on the following occasions: 6/7/2023-7/13/2023; 7/13/2023-8/14/2023; 8/14/2023-9/22/2023; 9/22/203-10/31/2023; 11/22/2023-12/26/2023.

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

Regulation: 3270.113(b)

Description: No physical punishment

Noncompliance Area: Two employees observed STAFF #1 pick children up in an aggressive manner from behind and put them firmly on their mats for nap time. Both employees spoke to administrative staff. Administrative staff notified ChildLine and spoke to STAFF #1 who denied the allegation. STAFF #1 was suspended pending an internal investigation. STAFF #1 voluntarily resigned within 5 minutes of suspension.

Correction Required: A facility person may not use any form of physical punishment, including spanking a child. Director will review the facility's policy for child guidance, discipline and classroom management at the next staff meeting on 6/21/23. All staff will sign off that they reviewed the policy. Director will review the policy individually with any staff who are not in attendance at the staff meeting. Director will send cert rep a copy of the meeting agenda and policy and the sign-off sheet.

Regulation: 3270.113(b)

Description: No physical punishment

Noncompliance Area: Two employees observed STAFF #1 pick children up in an aggressive manner from behind and put them firmly on their mats for nap time. Both employees spoke to administrative staff. Administrative staff notified ChildLine and spoke to STAFF #1 who denied the allegation. STAFF #1 was suspended pending an internal investigation. STAFF #1 voluntarily resigned within 5 minutes of suspension.

Correction Required: A facility person may not use any form of physical punishment, including spanking a child. STAFF #1 voluntarily resigned on 5/5/23.

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: On 3/1/23 an unannounced monitoring was conducted at the facility. STAFF #2 has 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 within 90 days of hire as listed in subsections (f)1-10. STAFF #2 must receive pediatric first aid /CPR training in an approved curriculum by a PQAS-certified trainer. Until such time as the correction is implemented, STAFF #2 must be supervised, when interacting with children, by a GS or AGS who has completed the required training related to this citation. If there are no staff available to supervise STAFF #2, STAFF # 2 may not work in a childcare position at the facility.

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: On 3/1/23 an unannounced monitoring was conducted at the facility. STAFF #1 has not completed the following required pre-service training within 90 days of their date of hire (see code sheet): pediatric first aid/CPR training in an approved curriculum by a PQAS-certified trainer.

Correction Required: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10. STAFF #1 will have until 3/17/23 to complete the required training. Until such time as the correction is implemented, STAFF #1 must be supervised, when interacting with children, by a GS or AGS who has completed the required training related to this citation. If there are no staff available to supervise STAFF #1, STAFF #1 may not work in a childcare position at the facility.

Regulation: 3270.76/3270.77(a)

Description: Building Surfaces/No peeling paint or plaster

Noncompliance Area: During unannounced monitoring on 3/1/23 Cert Rep observed damaged paint below the first window to the right of each emergency exit in the following rooms: Toddler B, PS 2A, PS 1.

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

Regulation: 3270.131(b)(2)

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

Noncompliance Area: During renewal inspection on 7/18/22 cert rep reviewed several children's files. CHILD # 1, a preschooler, health assessment was dated 7/9/21. CHILD # 1 does not have an updated health assessment within 12 months. CHILD # 2, an older toddler, health assessment was dated 6/29/21. CHILD # 2 does not have an updated health assessment within 12 months.

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

Regulation: 3270.192(2)(ii)

Description: Exp, educ., training prior to facility

Noncompliance Area: During renewal inspection on 7/25/22 cert rep reviewed all staff files. STAFF # 1, 2, 3, 4, 6, 8, 9, 14, all AGS's possessing a high school diplomas, do not have verification of 2,500 hours of child care experience prior to service at the facility. STAFF # 5, an AGS possessing an associate's degree in a non-human services field , does not have verification of 2,500 hours of child care experience prior to service at the facility. See code sheet for start dates. STAFF # 7, an AGS, does not have verification of education and child care experience prior to service at the facility.

Correction Required: A facility person's record shall include verification of child care experience, education and training prior to service at the facility.

Regulation: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: During renewal inspection on 7/25/22 cert rep reviewed all staff files. STAFF # 2, 6, 13, 15 have not resided in PA for at least 5 years and do not have the required out-of-state clearances in files.

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

Regulation: 3270.34(a)(6)

Description: Staff evaluations

Noncompliance Area: During renewal inspection on 7/25/22 cert rep reviewed all staff files. STAFF # 10 (see code sheet for start date) evaluation was dated 7/9/21. STAFF # 10 does not have an updated evaluation in file.

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: 3270.77(a)

Description: No peeling paint or plaster

Noncompliance Area: During renewal inspection on 7/25/22 cert rep observed damaged paint on the green wall by the window with plants in the PS2 room.

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

Regulation: 3270.77(a)

Description: No peeling paint or plaster

Noncompliance Area: During unannounced monitoring inspection on 4/11/22 cert rep observed damaged paint by the trash can in the diaper area of Infant B room.

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