UPMC Passavant Childrens House

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The staff file for Staff person #1 was observed to contain a current National Sex Offender Registry (NSOR) check dated 7/10/26 which was not obtained prior to first day working with children (See IS CODE SHEET) as required under the Child Protective Service Law (CPSL.)

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: 3270.123(a)

Description: Signed

Noncompliance Area: The child file for Child #1 contained a current financial agreement for that lacked the operator's signature.

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

Regulation: 3270.131(b)(2)/3270.182(1)

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

Noncompliance Area: The child file for Child #2, who is a preschool age child, was observed to contain an updated health report dated 1/6/25 which was conducted more than 12 months from the previously dated 10/31/24 health report on file.

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

Regulation: 3270.181(c)

Description: Emergency info/agreement updated 6 mos

Noncompliance Area: The child file for Child #2 contained a current emergency contact form that was not reviewed and signed by the parent at least once every 6 months; the two most recent reviews of the emergency contact form were signed on 1/5/26 and 6/5/25. The child file for Child #3 contained a current emergency contact form that was not reviewed and signed by the parent at least once every 6 months; the two most recent reviews of the emergency contact form were signed on 12/15/25 and 5/12/25. The child file for Child #4 contained a current emergency contact form that was not reviewed and signed by the parent at least once every 6 months; the two most recent reviews of the emergency contact form were signed on 12/19/25 and 5/4/25. The child file for Child #5 contained a current emergency contact form that was not reviewed and signed by the parent at least once every 6 months; the two most recent reviews of the emergency contact form were signed on 12/16/25 and 1/2/25.

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

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

Description: Fire safety - 1 yr.

Noncompliance Area: The staff file for Staff person #4 was observed to contain fire safety trainings that were conducted more than 12 months apart; those fire safety trainings are dated 12/24/25 and 10/9/24.

Correction Required: Staff persons shall participate, at least annually, in fire safety 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: 3270.34(a)(6)

Description: Staff evaluations

Noncompliance Area: The staff file for Staff person #1 and Staff person #2 contained a current staff evaluation dated Dec. 2025 which was not completed at least once every 12 months from the previous staff evaluation on file dated Nov. 2024.

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: 3270.36(b)(5)/3270.192(2)(ii)

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

Noncompliance Area: The staff file for Staff person #3 who is functioning as an Assistant Group Supervisor, lacked proof of education.

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 prior to service at the facility.

Regulation: 3270.66(a)

Description: Locked or inaccessible

Noncompliance Area: In the PreK Room, a travel sized hand sanitizer was observed attached to a child's jacket that was hanging approximately a foot and a half from the floor in a cubby allowing it to be accessible to the preschool age children in care.

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: 3270.33(a)/3270.192(2)(iv)

Description: Each staff person meets quals/Transcript, diploma and letters

Noncompliance Area: The staff file for Staff person #1, who is functioning as an assistant group supervisor, contained a foreign diploma that lacked additional documentation to show that the diploma had been evaluated to determine its validity and whether or not it meets qualifications for the position.

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 acceptable verification of experience, education or training is a transcript or a diploma or a letter signed by a representative of the experiential, educational or training entity.

Regulation: 3270.76

Description: Building Surfaces

Noncompliance Area: In the Gym, one ceiling tile located on the left side of the room nearest the built in shelving unit was observed to not be kept clean as evidence by having a water spot from a previous leak. In the hallway outside of the Toddler 2 Room one ceiling tile was observed to not be kept clean as evidence by having a water spot from a previous leak.

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: 3270.131(b)(2)

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

Noncompliance Area: The child file for Child #1, who is a preschool age child, was observed to contain an updated health report dated 1/8/25 which was conducted more than 12 months from the previously dated 12/27/23 health report on file. The child file for Child #2, who is a preschool age child, was observed to contain an updated health report dated 11/1/24 which was conducted more than 12 months from the previously dated 10/30/23 health report on file.

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: 3270.27(a)(6)

Description: Emergency plan

Noncompliance Area: The most recent emergency drill documented at the facility dated 8/7/24 was observed to lack mention of special accommodation used for any category of children and problems/observations encountered during the drill.

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

Regulation: 3270.27(b)

Description: Plan reviewed/updated annually

Noncompliance Area: The last two reviews of the facility emergency plan were not completed annually; those reviews were dated 8/21/23 and 11/16/24.

Correction Required: The operator shall review the emergency plan at least annually and update the plan as needed. The operator shall document in writing each review and update of the emergency plan and kept on file at the facility.

Regulation: 3270.113(a)(1)

Description: Staff assigned to specific children

Noncompliance Area: *In the Preschool Room, at approximately 10:30am, two staff and 16 preschool age children were observed. During the onset of supervision and ratio, Staff person #1 identified and named 8 preschool aged children and Staff person #2 identified and named 7 preschool aged children thus leaving 1 child unaccounted for. Staff were again asked to identify and name the children whom they were responsible for; Staff person #1 identified and named 8 preschool aged children and Staff person #2 identified and named 7 preschool aged children thus still leaving 1 child unaccounted for.

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

Regulation: 3270.113(a)(1)

Description: Staff assigned to specific children

Noncompliance Area: ***In the Preschool Room, at approximately 10:30am, two staff and 16 preschool age children were observed. During the onset of supervision and ratio, Staff person #1 identified and named 8 preschool aged children and Staff person #2 identified and named 7 preschool aged children thus leaving 1 child unaccounted for. Staff were again asked to identify and name the children whom they were responsible for; Staff person #1 identified and named 8 preschool aged children and Staff person #2 identified and named 7 preschool aged children thus still leaving 1 child unaccounted for.

Correction Required: ***Director and all current employees will be required to schedule, attend, and participate in an in-person training with ELRC regarding the importance of supervision grouping and tools (i.e. tag system, face to name, etc.). Proof of participation will be submitted to the OCDEL Western Region Certification Rep upon completion. The training will count towards the mandatory 12 training hours required by the Department.

Regulation: 3270.113(a)(1)

Description: Staff assigned to specific children

Noncompliance Area: **In the Preschool Room, at approximately 10:30am, two staff and 16 preschool age children were observed. During the onset of supervision and ratio, Staff person #1 identified and named 8 preschool aged children and Staff person #2 identified and named 7 preschool aged children thus leaving 1 child unaccounted for. Staff were again asked to identify and name the children whom they were responsible for; Staff person #1 identified and named 8 preschool aged children and Staff person #2 identified and named 7 preschool aged children thus still leaving 1 child unaccounted for.

Correction Required: **The director will conduct random supervision/ratio assessments of each classroom at least 3 times per week, at various times of the day, for the next 3 months. During the assessment, the director will ask each staff person in each classroom to identify the children that are in their assigned supervision group by naming each child and pointing to each child. The director will document all assessments in a log, including the date, time, name of staff person and the number and ages of children each staff are responsible for. The log will be submitted to the DHS representative prior to use. The completed logs will be made available to DHS representatives upon request. Assessments will begin immediately upon acceptance of the plan of correction.

Regulation: 3270.21

Description: General Health and Safety

Noncompliance Area: In Kindergarten Prep Room a stapler was observed on a table and accessible to children in care. In the School Age Room a stapler was observed stored on an arts and crafts wood shelving unit and accessible to children in care.

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

Regulation: 3270.123(a)(3)

Description: Services proceeded

Noncompliance Area: The child file for Child #1 contained a current child service report dated 12/1/23 that was not completed every 6 months from the previous report dated 5/15/23. The child file for Child #2 contained a current child service report dated 12/4/23 that was not completed every 6 months from the previous report dated 5/30/23.

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: 3270.131(b)(2)

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

Noncompliance Area: The child file for Child #2, who is a preschool age child, was observed to contain an updated health report dated 6/5/23 which was conducted more than 12 months from the previously dated 5/24/22 health report on file.

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: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: Staff person #1, Staff person #2, and Staff person #4 have not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Revised 10hr Health and Safety Training 2022. Staff person #1, Staff person #2, and Staff person #4 contained the old ten-hour Health and Safety Training and the 1hr updated training were on file which are not acceptable for new staff hired after 10/4/22.

Correction Required: Staff person(s) shall complete professional development in the topics of 3270.31(f)(1 -- 10) within 90 days of hire. Staff person #1, Staff person #2, and Staff person #4--- will have until 2/10/24 to complete the required training.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The staff file for Staff person #3 contained a current National Sex Offender Registry check dated 7/20/23 which was applied for timely though not received within 45 days of hire [See IS CODE SHEET] as required for provisional hiring under the Child Protective Service Law (CPSL).

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: 3270.113(a)(1)

Description: Staff assigned to specific children

Noncompliance Area: During a swimming inspection, at approximately 10:15am, Staff person #1 and eleven young school aged children were observed. During the onset of supervision and ratio, Staff person #1 identified and named 6 young school aged children thus leaving 5 children unaccounted for. Staff person #2 was observed coming out of the restroom and claimed responsibility for the 5 young school aged children allowing all children to be accounted for. Staff person #2 was observed to not be physically present with their assigned group of children.

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

Regulation: 3270.115(a)(5)

Description: Staff:child ratios while swimming

Noncompliance Area: During a swimming inspection, at approximately 10:15am, Staff person #1 and eleven young school aged children were observed resulting in the staff:child swim ratio being 1:11. Staff person #2 was observed coming out of the restroom and claimed responsibility for the 5 other young school aged children resuming compliance with staff-child ratios.

Correction Required: The staff-child ratios while children are swimming are Infant 1:1; Young or older toddler 1:2; Preschool 1:5; Young school-age 1:6; Older school-age1:8.

Regulation: 3270.124(c)

Description: Each child care space

Noncompliance Area: At approximately 11:15am, outside in the toddler play space, 3 staff and 29 preschool age children were observed outside playing and the emergency contact forms for all of the children were not present.

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

Regulation: 3270.75(a)

Description: In child care spaces

Noncompliance Area: At approximately 11:15am, outside in the toddler play space, 3 staff and 29 preschool age children were observed outside playing and a first-aid kit was not present.

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

Regulation: 3270.113(a)

Description: Supervised at all times

Noncompliance Area: Based on staff interviews it was determined that a young toddler was left alone in the gym for approximately nine minutes with no adult supervision.

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

Regulation: 3270.113(a)(1)

Description: Staff assigned to specific children

Noncompliance Area: **Based on staff interviews it was determined that a young toddler was left alone in the gym for approximately nine minutes with no adult supervision.

Correction Required: **Director must arrange for all staff to complete the following one-hour training from Better Kid Care titled Supervision: Moving Children. Proof of training will be submitted upon completion and may be counted towards annual training hours. Compliance will be verified through an unannounced inspection.

Regulation: 3270.113(a)(1)

Description: Staff assigned to specific children

Noncompliance Area: *Based on staff interviews it was determined that a young toddler was left alone in the gym for approximately nine minutes with no adult supervision.

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

Regulation: 3270.113(a)(1)

Description: Staff assigned to specific children

Noncompliance Area: ***Based on staff interviews it was determined that a young toddler was left alone in the gym for approximately nine minutes with no adult supervision.

Correction Required: The director shall hold monthly staff meetings for a period of two months from the acceptance of the plan of correction, which shall include all staff persons to discuss supervision and grouping requirements and any current and previous violations under this regulation. Provider must keep documentation of a dated agenda along with a signed attendance sheet for each monthly meeting. Documentation of each monthly meeting will be made available to OCDEL-DHS representatives upon request.

Regulation: 3270.151(a)

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

Noncompliance Area: The staff file for Staff person #4, contained a current health assessment dated 11/1/21 which was conducted more than 24 months from the previously dated 10/28/19 health assessment on file.

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

Regulation: 3270.151(c)(2)

Description: Mantoux TB

Noncompliance Area: The staff file for Staff person #2, was observed to contain a tuberculosis screening test results dated 11/16/20 which was conducted more than 12 months prior to providing initial service in a childcare setting (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: 3270.31(e)(4)(i)

Description: Age and Training

Noncompliance Area: The staff file for Staff person #3 contained current first-aid/CPR training dated 11/5/22 which was not renewed on or before the expiration of the previous training certificate on file dated 1012/20.

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: Staff person #4 had not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Health and Safety Training; the health and safety training on file was completed prior to 9/30/16 and is not considered an acceptable training. Staff person #4 now has health and safety training on file dated 11/23/22.

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 file for Staff person #1 was observed to lack documentation of having applied for and received a State sex offender check and State criminal background check from the State in which they resided in within the previous five years as required by the Child Protective Service Law (CPSL).

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: 3270.51

Description: Similar Age Level

Noncompliance Area: *Based on staff interviews it was determined that a young toddler was left alone in the gym for approximately nine minutes with no adult supervision. During this time, staff: child ratio was 0:1.

Correction Required: The director shall hold monthly staff meetings for a period of two months from the acceptance of the plan of correction, which shall include all staff persons to discuss staff: child ratio requirements and any current and previous violations under this regulation. Provider must keep documentation of a dated agenda along with a signed attendance sheet for each monthly meeting. Documentation of each monthly meeting will be made available to OCDEL-DHS representatives upon request.

Regulation: 3270.51

Description: Similar Age Level

Noncompliance Area: Based on staff interviews it was determined that a young toddler was left alone in the gym for approximately nine minutes with no adult supervision. During this time, staff: child ratio was 0:1.

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: 3270.95(a)/3270.95(b)

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

Noncompliance Area: The facility had verification of annual testing on 8-30-21 of the fire detection system by a fire safety professional that lacked the required documentation showing that the deficiencies listed on the report were corrected and the fire detection system was in full compliance with 62 P.S. 1016(c)(3). A new report was submitted on 5-5-22 showing that the fire detection system was re-inspected on 5-3-22 and was in full compliance with 62 P.S. 1016(c)(3). The fire detection system was not in compliance between 8-30-21 to 5-3-22.

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

Regulation: 3270.133(7)(i)

Description: Name of medication

Noncompliance Area: In the pre-k room, there was Children's Advil for child #1, and the medication log lacked the name of the medication.

Correction Required: A medication log shall include the name of the medication.

Regulation: 3270.64

Description: Outside Walkways

Noncompliance Area: At approximately 10:25 a.m., the patio and sidewalk outside the back exit doors from the preschool room were observed to be covered with snow.

Correction Required: Outside walkways shall be free from ice, snow, leaves, equipment and other hazards.

Regulation: 3270.75(b)

Description: Inaccessible to children

Noncompliance Area: In the gym, the first-aid kit was in a cabinet with the lock not functioning and was unlocked resulting in the first-aid kit being accessible to children. The pre-k group was observed in the gym, and the backpack with the first-aid kit inside was on the floor and accessible to children.

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

Regulation: 3270.77(a)

Description: No peeling paint or plaster

Noncompliance Area: In the pre-k room, there was peeling paint in one area on the back right wall near the cots.

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

Regulation: 3270.95(a)/3270.95(b)

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

Noncompliance Area: The facility lacked proof of purchase of the interconnected fire detection system in accordance with 62 P.S. 1016(c)(3).

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.

Noncompliance Area: In the indoor gym, there were several fabric blocks with tears in multiple places that had small pieces coming apart that could be placed in a child's mouth.

Correction Required: Toys and objects with a diameter of less than 1 inch, objects with removable parts that have a diameter of less than 1 inch, plastic bags and styrofoam objects may not be accessible to children who are still placing objects in their mouths.

Noncompliance Area: In the Kindergarten room, the back of the black cabinet near the refrigerator was coming apart with nails sticking out from the back piece of the cabinet that was a visible hazard and unsafe.

Correction Required: Furniture must be durable, safe, easily cleaned and appropriate for the child's size, age and special needs.

Noncompliance Area: On the outdoor play space near the building, there were multiple areas on the fence with bolts protruding out from the fence that were a visible hazard.

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

Noncompliance Area: In the gym, there was a multicolored mat that had tears in multiple places with small pieces coming apart that could be placed in a child's mouth. In the 2 year old room, there were pieces of cellophane paper in the discovery table with many of the pieces that were less than 1 inch in diameter that could be placed in a child's mouth.

Correction Required: Toys and objects with a diameter of less than 1 inch, objects with removable parts that have a diameter of less than 1 inch, plastic bags and styrofoam objects may not be accessible to children who are still placing objects in their mouths.

Noncompliance Area: The file for child #1 had a child service report that exceeded 6 months between reports.

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).

Noncompliance Area: The file for staff person #1 had a staff evaluation that exceeded 12 months between 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.

Noncompliance Area: In the preschool room, the water temperature at the sink in the room was 118 degrees, and the water temperature at the sink on the right in the bathroom was 120 degrees.

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

Noncompliance Area: In the preschool room in the bathroom, a handwashing sign was not posted at the first 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.

Noncompliance Area: In the Kindergarten Prep room with 18 total children, staff person #2 named 9 preschoolers in her group and staff person #3 named 8 preschoolers in her group, resulting in 17 out of 18 children being named in a group and 1 child not being named in a group.

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

Noncompliance Area: The file for facility person #1 had a health assessment that had a TB test read date that was after his start date.

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.

Noncompliance Area: The file for facility person #1 had emergency plan training that was completed after his start date.

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.

Noncompliance Area: The file for facility person #1 had a volunteer Child Abuse clearance and requires a Child Abuse clearance for employment.

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

Noncompliance Area: In the preschool room, the closet door was open with a bin that had many sunscreens that 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.

Noncompliance Area: In the Kindergarten Prep room, there were 6 cots that were stacked on the table by the door to the hallway that were obstructing the exit to the room.

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

Noncompliance Area: In the infant room, there were several large foam blocks with many teeth marks and small pieces coming apart that could be placed in a child's mouth. In the older toddler room, there were 3 foam flat shapes with many teeth marks and small pieces coming apart that could be placed in a child's mouth. In the older toddler room, the discovery table had dirt and many small sticks that were less than 1 inch in diameter that could be placed in a child's mouth.

Correction Required: Toys and objects with a diameter of less than 1 inch, objects with removable parts that have a diameter of less than 1 inch, plastic bags and styrofoam objects may not be accessible to children who are still placing objects in their mouths.

Noncompliance Area: In a locked storage room in the gym, there was an expired EpiPen for child #1.

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

Noncompliance Area: The file for staff person #1 had an initial health assessment with a chest X-ray, and lacked a tuberculosis screening by the Mantoux method or a positive tuberculin skin test with the chest X-ray.

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.

Noncompliance Area: In the school-age room, there was a medication for a parent of a child that is in the school-age room. The medication was not intended for a child in the facility.

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.

Noncompliance Area: The file for staff person #1 had a health assessment that lacked the physician`s or CRNP`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.

Noncompliance Area: The file for staff person #2 had invalid mandated reporter training that was dated prior to 12/2014.

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.

Noncompliance Area: In the preschool room, there was a garbage can next to the sink that did not have a lid.

Correction Required: A toilet area, training chair area, diapering area and sink area shall be equipped with a clean, lidded waste receptacle.

Noncompliance Area: There were googly eyes, which are smaller then 1 inch, in the Toddler 1 room.

Correction Required: Toys and objects with a diameter of less than 1 inch, objects with removable parts that have a diameter of less than 1 inch, plastic bags and styrofoam objects may not be accessible to children who are still placing objects in their mouths.

Noncompliance Area: The file for Child #2 includes a child service report which is dated more than 6 months after the child's enrollment date.

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).

Noncompliance Area: The emergency contact form on file for Child #1, Child #3, and Child #4 did not include 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.

Noncompliance Area: The initial health assessment and tuberculosis test for Sraff person #3 are dated after the employee's first date working with children.

Correction Required: A facility person providing direct care who comes into contact with the children or who works with food preparation shall have a health assessment conducted within 12 months prior to providing initial service in a child care setting and every 24 months thereafter. A health assessment is valid for 24 months following the date of signature, if the person does not contract a communicable disease or develop a medical problem.An adult health assessment must include tuberculosis screening by the Mantoux method at initial employment. Subsequent tuberculosis screening is not required unless directed by a physician, physician's assistant, CRNP, the Department of Health or a local health department.

Noncompliance Area: The file for Staff person #4 did not include 2 written references attesting to the person's suitability to work in a child care posituin.

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

Noncompliance Area: The files for Staff person #1 and Staff person #2, who are volunteers, have clearances dated after their first day working with children.

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

Noncompliance Area: There were toxics stored on top of the refrigerator in the pre-school room which were not stored in a bin or basin which allows for toxics to spill or drip into the refrigerator

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