Titusville Ymca After School Program

Regulation: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: Broken magnatiles were observed in the Green room. In the Orange room, wood blocks were observed with broken and splintered edges, which could cause injury to children.

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: 3270.111(b)

Description: Posted in group space

Noncompliance Area: At the time of inspection, the facility lacked a posting of the written plan of daily activities in the Green and Pink classrooms.

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

Regulation: 3270.123(a)

Description: Signed

Noncompliance Area: The file for Child #5 lacked a financial agreement signed by the operator and the parent.

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

Regulation: 3270.123(a)(3)

Description: Services proceeded

Noncompliance Area: The file for Child #8 lacked a child service report and is beyond 6 months from date of enrollment (SEE IS CODE SHEET).

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

Regulation: 3270.123(a)(4)

Description: Arrival/departure times

Noncompliance Area: The financial agreement form on file for Child #8 lacked arrival and departure times.

Correction Required: An agreement shall specify the child's arrival and departure times.

Regulation: 3270.123(b)/3270.182(8)

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

Noncompliance Area: The file for Child #7 contained the original financial agreement when the parent is to receive the original agreement.

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

Regulation: 3270.124(b)(6)

Description: Insurance coverage information

Noncompliance Area: The emergency contact forms for Child #1 lacked the child's health insurance/MA coverage name and policy number for the child's health care benefits.

Correction Required: 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(f)/3270.181(c)

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

Noncompliance Area: The two most recent parent reviews and signatures for the emergency contact forms on file for Child #4 (5/26/25 & 1/12/26) and Child #7 (4/28/25 & 12/2/25) are dated more than 6 months apart.

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

Regulation: 3270.131(a)/3270.182(1)

Description: Health information/Initial and subsequent health reports

Noncompliance Area: The file for Child #2, enrolled more than 60 days, lacked an initial health report. (See LIS Code Sheet). The file for Child #8 contained an initial health assessment dated 2/12/26, more than 60 days beyond enrollment (SEE IS CODE SHEET).

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

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

Description: Immunization record/Dismissal policy

Noncompliance Area: The immunization record for Child #6 (PSA) lacked the following immunizations: 4 doses of DTAP, 4 doses of HiB, 3 doses of Polio, 1 dose of MMR, 1 dose of Varicella, and 2 doses of Hepatitis A without a Letter of Exemption in the file.

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). Child #6 must be dismissed from care by close of business on 5/12/26 and may only return to care when the immunization record is updated or when a parent provides a written, signed exemption letter.

Regulation: 3270.131(d)(7)

Description: Free from contagious/communicable disease

Noncompliance Area: The health assessment on file for Child #3, dated 10/1/25, does not indicate if the child is free from contagious disease and may participate in child care.

Correction Required: A health report shall include a statement that the child is able to participate in child care and appears to be free from contagious or communicable disease.

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: The facility's Continuity of Operations policy in the emergency plan lacked procedures on 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.

Regulation: 3270.151(a)

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

Noncompliance Area: The two most recent health assessments on file for Staff #2 (3/8/24 & 4/24/26) and Staff #7 (6/14/23 & 5/4/26) are dated more than 24 months apart.

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

Regulation: 3270.181(c)

Description: Emergency info/agreement updated 6 mos

Noncompliance Area: The two most recent parent reviews and signatures for the financial agreement forms on file for Child #4 (1/10/25 & 1/12/26) and Child #7 (4/28/25 & 12/2/25) are dated more than 6 months apart.

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

Regulation: 3270.192(5)

Description: Two written references

Noncompliance Area: The file for Staff #3 contained 1 of 2 written nonfamily reference letters attesting to the staff person's suitability to work in child care.

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

Regulation: 3270.27(a)(5)

Description: Emergency plan

Noncompliance Area: The facility's emergency plan lacked accommodations for 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: The most recent emergency plan trainings on file for Facility Person #8 and Facility Person #9 are dated 3/24/25, more than 12 months prior.

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

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

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

Noncompliance Area: The two most recent Pediatric First Aid/CPR trainings on file for Staff #4 are dated 11/18/23 & 2/18/26, more than 24 months apart.

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: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The two most recent Pennsylvania State Police clearances (2/4/21 & 4/30/26) and Child Abuse clearances (6/2/20 & 5/7/26) on file for Staff #5 are dated more than 60 months apart. The two most recent mandated reporter trainings on file for Staff #1 are dated 4/20/21 and 5/1/26, more than 60 months apart. The file for Staff #3 lacked a disclosure statement. The file for Staff #6 contained a disclosure statement dated 1/9/25, lacking a witness signature, making it invalid.

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

Regulation: 3270.66(a)

Description: Locked or inaccessible

Noncompliance Area: In the Orange classroom, multiple cans of sunscreen in a bag next to the door and cans of shaving cream in an unlocked cabinet labeled "Keep out of reach of children" were observed to be accessible. In the Purple Room, multiple cans of shaving cream labeled "Keep out of reach of children" were observed to be accessible in a fabric bin behind the teacher's desk.

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: 3270.67(d)

Description: Contaminated trash in closed plastic-lined receptacle

Noncompliance Area: Unlidded trash cans containing used tissues were observed in the Blue and Green classrooms.

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

Regulation: 3270.76

Description: Building Surfaces

Noncompliance Area: A protruding screw, which could be harmful to children, was observed to be accessible to children under the white board in the Blue room. In the Gross Motor space, exposed bolts were observed on the fence and were accessible to children.

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

Regulation: 3270.77(a)

Description: No peeling paint or plaster

Noncompliance Area: Peeling paint and plaster was observed near the AC unit in the Brown room, next to the couch in the Pink room, to the right of the closet in the Pink room, on the door frame entrance area of the Pink room, on the window sill in the Orange room, and under the sink in the Boys Bathroom. Damaged plaster resulting in a small hole in the wall was observed under the white board in the Blue room.

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

Regulation: 3270.82(h)

Description: Handwashing signs

Noncompliance Area: The Girls Bathroom lacked handwashing signs in six bathroom stalls.

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

Regulation: 3270.95(a)/3270.95(b)

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

Noncompliance Area: The fire alarm 30-day test log includes test dates 1/9/26-2/9/26, more than 30 days apart.

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: In the Orange Room, Blue Room, and Pink Room, foam blocks were observed with teeth mark 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: 3270.123(a)(3)

Description: Services proceeded

Noncompliance Area: The most recent child service report on file for Child #3 is dated 4/21/25, more than 6 months beyond the child's date of enrollment (SEE IS CODE SHEET).

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

Regulation: 3270.123(b)/3270.182(8)

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

Noncompliance Area: The file for Child #1 contained the original financial agreement when the parent is to receive the original agreement.

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

Regulation: 3270.124(b)(2)

Description: Physician name, address, phone

Noncompliance Area: The emergency contact form on file for Child #2 and Child #3 lacked a complete address and telephone number for the child's physician or source of medical care.

Correction Required: Emergency contact information must include the name, address and telephone number of the child's physician or source of medical care.

Regulation: 3270.124(b)(3)

Description: Parent home/work address, phone

Noncompliance Area: The emergency contact form on file for Child #2 and Child #4 lacked a complete address and telephone number for the enrolling parent.

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

Regulation: 3270.124(b)(7)

Description: Name/address/phone release person

Noncompliance Area: The emergency contact form on file for Child #4 lacked complete addresses for all listed 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(f)/3270.181(c)

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

Noncompliance Area: The most recent 6 month review signature for the emergency contact form on file for Child #1 is dated 1/16/25, more than 6 months beyond the child's date of enrollment (SEE IS CODE SHEET).

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

Regulation: 3270.131(a)(4)/3270.182(1)

Description: Initial health report for school age; accordance with school attendance/Initial and subsequent health reports

Noncompliance Area: The initial health assessment and immunization record on file for Child #5 are dated 4/11/25, more than 60 days beyond the child's date of enrollment (SEE IS CODE SHEET).

Correction Required: The initial health report for a school-age child must be dated in accordance with the requirements for medical examinations for school attendance in 28 Pa. Code § 23.2 (relating to medical examinations). A child's record shall contain initial and subsequent health reports.

Regulation: 3270.131(d)(5)/3270.131(e)(1)

Description: Immunization record/Exemption documentation from parent/guardian

Noncompliance Area: The immunization record for Child #2 (Preschool Age) lacked the following immunizations: 1 dose of Pneumococcal without a Letter of Exemption in the file. Child #2 must be dismissed from care by close of business on 5/22/25 and may only return to care when the immunization record is updated or when a parent provides a written, signed exemption letter.

Correction Required: A health report shall include a review of the child's immunized status according to recommendations of the ACIP. The facility shall require the parent to provide updated written verification from a physician, physician's assistant, CRNP, the Department of Health or a local health department of ongoing vaccines administered to an infant, toddler or preschool child in accordance with the schedule recommended by the ACIP.

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 initial tuberculosis test on file for Staff #1 (dated 1/14/25) and Staff #2 (dated 11/31/24) are dated after the staff person's date of hire. The initial health assessment on file for Staff #4 (dated 11/18/24) and Staff #5 (dated 10/14/24) are dated beyond the staff person's date of hire (SEE IS CODE SHEET). The initial health assessment and tuberculosis test on file for Staff #6 are dated 8/6/23, which is more than 1 year prior to the staff person's date of hire (SEE IS CODE SHEET).

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 tuberculosis test on file for Staff #6 dated 8/6/23 lacked results of the screening which is due at time of hire (SEE IS 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: 3270.151(c)(3)

Description: Exam communicable disease

Noncompliance Area: The health assessment on file for Staff #2 does not indicate that the staff person was examined for communicable diseases.

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

Regulation: 3270.151(c)(5)

Description: Physician/CRNP assessment

Noncompliance Area: The health assessment on file for Staff #2 and Staff #3 does not include the physician or health care professional's assessment of the person's suitability to provide child care.

Correction Required: An adult health assessment must include the physician's or CRNP's assessment of the person's suitability to provide child care.

Regulation: 3270.192(5)

Description: Two written references

Noncompliance Area: The file for Staff #7 contained 2 written letters of reference, but one letter was written by a family member making it unacceptable. The file for Facility Person #14 lacked 2 nonfamily written reference letters.

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

Regulation: 3270.27(a)(5)

Description: Emergency plan

Noncompliance Area: The facility's emergency plan lacked 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: The file for Staff #6 contained initial emergency plan training dated 3/24/25, more than 90 days from the staff person's date of hire (SEE IS CODE SHEET). The file for Facility Person #13 lacked emergency plan training.

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(e)

Description: Letter to parents

Noncompliance Area: The facility's emergency plan parent letter lacked accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions.

Correction Required: The operator shall provide to the parent of each enrolled child a letter explaining the emergency procedures. The operator shall also provide to the parent of each enrolled child a letter explaining any subsequent update to the plan.

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

Description: Fire safety - 1 yr.

Noncompliance Area: The two most recent fire safety trainings on file for Staff #8, Staff #9, Staff #10, Staff #11, Staff #12 are dated 6/20/23 and 4/30/25, more than 12 months apart.

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)

Description: Health and Safety Training

Noncompliance Area: Staff #2 did not complete the following required pre-service training within 90 days of their hire date (SEE IS CODE SHEET): Mandated Reporter Training. The training was completed on 2/12/25. Staff #6 did not complete the following required pre-service training within 90 days of their hire date (SEE IS CODE SHEET): Get Started with Center-Based Care Revised-2022. The training was completed on 12/13/24.

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

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The FBI clearances on file for Staff #4 (dated 8/21/23) and Staff #5 (dated 11/11/22) were issued by the Department of Education and are unacceptable for child care. Staff #4 (dated 4/25/25) and Staff #5 (dated 4/23/25) have updated and acceptable FBI clearances on file at the time of the renewal inspection.

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

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The mandated reporter trainings on file for Staff #4 (dated 1/8/25) and Staff #5 (dated 8/18/21) are not approved trainings, making them invalid.

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

Regulation: 3270.36(b)(5)/3270.192(2)(iii)

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

Noncompliance Area: The file for Staff #9, classified as an assistant group supervisor, lacked documentation of 2 years of experience with children.

Correction Required: An assistant group supervisor shall have a high school diploma or a general educational development certificate and 2 years experience with children. 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: In the Purple Room, a power strip lacked protective outlet coverings in every outlet.

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: Multiple canisters containing small amounts of Joico Lightening Powder, labeled "Keep out of the reach of children", were observed on shelves in the Orange Room and were accessible to children. Toxic cleaners and cans of paint were observed in the Boiler Room, which was unlocked and accessible to children. Toxic cleaners were observed in an unlocked closet next to the cafeteria 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: 3270.72(d)

Description: Above ground window opening restricted to 6"

Noncompliance Area: Windows in the Green Room and Brown Room, located on the second floor of the building, lacked any form of window restrictions limiting the window opening to six inches or less.

Correction Required: Windows or doors above the ground floor that open directly to the outdoors and are accessible to children shall be constructed, modified or adapted to limit the opening to 6 or fewer inches.

Regulation: 3270.76

Description: Building Surfaces

Noncompliance Area: In the Blue Room, a metal piece of the heater was detached from the heating system and could be hazardous to children. A clean out pipe was observed protruding from a wall in a bathroom stall on the basement level with exposure to the interior wall, was not clean and in good repair, and was accessible to children.

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: 3270.76

Description: Building Surfaces

Noncompliance Area: Peeling paint and plaster was observed on the window sills in the Pink Room and Green 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: 3270.82(h)

Description: Handwashing signs

Noncompliance Area: In the bathroom located in the Blue Room lacked a handwashing sign at every sink and toilet.

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

Regulation: 3270.95(a)/3270.95(b)

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

Noncompliance Area: Based on a conversation with the director, the facility is not testing the fire alarm system every 30 days and maintaining a log of the test dates, as required with the 12/19/20 Chapter 3270 regulation updates. The facility schedules annual fire system inspections, even though they are able and required to manually test the alarm every 30 days.

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: 3270.124(f)/3270.181(c)

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

Noncompliance Area: There was more than six months between reviews/updates of the emergency contact and financial agreement information on file for child #2. This is evidenced by the dates of 3/1/23 and then 2/20/24.

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

Regulation: 3270.131(a)/3270.182(1)

Description: Health information/Initial and subsequent health reports

Noncompliance Area: The file for child #1 lacked an initial health report within 60 days following the first day of attendance at the facility. SEE IS CODE SHEET. There is now a health report on file and dated 12/11/23.

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

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: The emergency plan lacked a plan addressing continuity of operations for the aftermath of a 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.

Regulation: 3270.151(a)/3270.192(3)

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

Noncompliance Area: There was more than 24 months between the previous and most current and updated health reports on file for staff #1 and 2. There are now current health reports on file. The files for facility persons #4 and 5 lack a health report which has been completed within the past 24 months.

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: 3270.192(5)

Description: Two written references

Noncompliance Area: The files for facility persons #4 and 5 lack two written nonfamily references from individuals attesting to the persons 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: 3270.21

Description: General Health and Safety

Noncompliance Area: In the PS 3 room, observed 3 pairs of adult scissors in an accessible drawer in the teacher's desk.

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

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

Description: Contact when arises/Contact when ended

Noncompliance Area: The facilities emergency plan lacked a plan that provides for a method for facility persons to contact parents as soon as reasonably possible when an emergency situation arises and a 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.

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(c)/3270.192(2)(iii)

Description: Training regarding plan/Exp, educ., training at facility

Noncompliance Area: The files for facility persons #4 and 5 lack verification of any emergency plan training.

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

Regulation: 3270.27(e)

Description: Letter to parents

Noncompliance Area: The parent letter explaining the emergency plan procedures and updates lacked an explanation of lockdown, a method to contact parents to notify them that there is an emergency and a method to inform parents that the emergency has ended and how they can be safely reunited with their children and accommodations for children with disabilities and children with chronic medical conditions.

Correction Required: The operator shall provide to the parent of each enrolled child a letter explaining the emergency procedures. The operator shall also provide to the parent of each enrolled child a letter explaining any subsequent update to the plan.

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: Staff person #1 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.

Correction Required: Staff person(s) shall complete professional development in the topics of 3270.31(f) within 90 days of hire. Staff person #1- will have 15 days from POC requested date to complete the required training. Until such time as the required training has been completed, staff person 31 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 #1, staff person #1 may not work in a child-care position at the facility.

Regulation: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: Facility persons #4 and 5 have not completed the mandated reporter training within 90 days of their date of hire (see IS code sheet).

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to Child Protective Services). Staff person/facility person/volunteer #4 and 5 will have 15 days from POC requested date to complete the mandated reporter training. Until such time as the required training has been completed, staff person/facility person/volunteer # 4 and 5 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 person(s) available to supervise staff person/facility person/volunteer #4 and 5-, staff person/facility person/volunteer #4 and 5 may not work in a child-care position at the facility.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: There was more than 60 months between the PSP, Child Abuse and DHS FBI clearances on file for staff #1. There are now current clearances on file. Dates are as follows: PSP - 1/22/19 and 4/30/24, Child Abuse- 1/26/19 and 5/6/24 and FBI- 8/27/18 and 5/1/24. The file for staff #3 lacked an NSOR on or before initial start date in a child care position. SEE IS CODE SHEET. There is now an NSOR on file and dated 2/12/24. The file for facility person #4 lacks a disclosure statement. The file for facility person #5 lacks an NSOR and a disclosure statement.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Facility Person # 5-- may not work in a child care position at the facility. 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: 3270.65

Description: Protective Outlet Covers 5 yrs. or less

Noncompliance Area: In the PS 1 room, observed an electrical outlet under a picture of a sunflower which lacked a protective receptacle cover.

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

Regulation: 3270.75(b)

Description: Inaccessible to children

Noncompliance Area: In the PS 2 room, observed that the first-aid kit was sitting on the chalk board and was accessible to the children in care.

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

Regulation: 3270.75(c)

Description: Has all items

Noncompliance Area: The first aid kit in the PS 1 room lacked soap.

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: 3270.77(a)

Description: No peeling paint or plaster

Noncompliance Area: The wall outside of the boy's bathroom which was blue and yellow, under the sinks in the boy's bathroom and outside of the stalls in the boy's bathroom had peeling paint.

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

Regulation: 3270.82(g)

Description: Clean and good repair

Noncompliance Area: The base of the faucet at the sink and wall beside the sink in the bathroom in the PS 3 Room were dirty.

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

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: The files for Staff #1, #2, #3 and #4 lacked completion of the UPDATED 1 Hour Health and Safety Training on or before 12/30/2022.

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: 3270.21

Description: General Health and Safety

Noncompliance Area: In Room #1, four (4) pair of adult scissors, Room #2, four (4) pair of adult scissors and Room #3, three (3) pair of adult scissors were observed on the teacher's desks which were accessible to children.

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

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

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

Noncompliance Area: Mandated Reporter Training for staff #3 was dated more than 60 months ago.

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

Regulation: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: Two approximately 12"x8"x8" plastic storage bins in areas accessible to children in care in the Tiny Footsteps 1 Room were observed to have cracked edges that could cause laceration and/or pinch point injuries. A dry erase board in an area accessible to children in care in the K4 Room was observed to have a sharply edged metal mounting brace that could cause laceration injuries.

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: 3270.102(c)

Description: Outdoor equip.- protective surfacing

Noncompliance Area: The facility's outdoor equipment located in the outdoor play space was observed to be embedded, but lacked sufficient substrate as recommended by the United States Consumer Product Safety Commission.

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: 3270.131(d)(7)

Description: Free from contagious/communicable disease

Noncompliance Area: The file for Child #1 contained a health assessment that did not include a physician's attestation that the child is able to participate in child care.

Correction Required: A health report shall include a statement that the child is able to participate in child care and appears to be free from contagious or communicable disease.

Regulation: 3270.131(d)(8)

Description: Age appropriate screenings complete

Noncompliance Area: The file for Child #1 did not include a physician's statement that all age appropriate screenings were completed as recommended by the American Academy of Pediatrics.

Correction Required: A health report shall include a statement that age-appropriate screenings recommended by the American Academy of Pediatrics were conducted since the time of the previous health report required by this section.

Regulation: 3270.27(c)/3270.192(2)(iii)

Description: Training regarding plan/Exp, educ., training at facility

Noncompliance Area: Although the files for Staff #3 and #4 contained documentation of the completion of emergency plan training completed in the past 12 months, each staff member previously completed emergency plan training more than 12 months prior to the most recent training.

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. 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(e)(4)(ii)/3270.192(2)(iii)

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

Noncompliance Area: Although the files for Staff #1, #3, #4, and #5 contained documentation of the completion of fire safety training that was completed over the past 12 months, the previously completed fire safety trainings for each staff were dated more that 12 months prior.

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

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

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

Noncompliance Area: Although the file for Staff #3 contained documentation of the completion of mandated reporter training completed in the past 60 months, the previously completed mandated reporter training on file was dated more than 60 months prior to the most recent training.

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

Regulation: 3270.34(a)(6)

Description: Staff evaluations

Noncompliance Area: The files for Staff #2, #4, and #5 contained performance evaluations completed in the past year; however, the previous evaluations for each noted staff member were completed more than 12 months prior to the most recent evaluations.

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: 3270.75(a)

Description: In child care spaces

Noncompliance Area: A first-aid kit was not present in the Tiny Footsteps room.

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