Ymca Early Learning Center

Regulation: 3270.182(7)

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

Noncompliance Area: Child #1 pulled up the dress of child #2 and kicked and punched child #2 in the private area on two separate occasions, once on 6/24/26 and then again on 7/8/26. An incident report was not written and provided to the family until at least 7/6/26 for the first incident. The family did not receive a report for the second incident.

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

Regulation: 3270.51

Description: Similar Age Level

Noncompliance Area: Continued Non-Compliance: During a complaint investigation, it was confirmed through multiple staff interviews that the Preschool and PreK classrooms are out of ratio most mornings. An acceptable plan of corrections was received that stated "Staff:Child ratios will be maintained at all times. The YMCA Early Learning Center will implement a Staffing and Ratio Compliance Policy to ensure required staff-to-child ratios are maintained at all times. The policy will include procedures for morning arrivals, nap time, and end-of-day transitions to prevent classrooms from exceeding ratio limits. Administrative staff will monitor attendance and staffing throughout the day, conduct routine ratio checks, and address concerns immediately. Attendance and staffing patterns will be reviewed regularly to support compliance. All staff will be trained on ratio requirements, supervision expectations, and procedures for reporting ratio concerns. Documentation of training will be maintained in personnel files. The YMCA Richmond Early Learning Center will maintain compliance with staffing ratio requirements by reviewing attendance and staffing throughout the day, including opening, transitions, breaks, and closing. Administrative staff will conduct routine ratio checks and ensure adequate classroom coverage. Children will only be combined when DHS ratios and maximum group sizes are maintained. Staff will receive ongoing training on supervision and ratio requirements, conduct regular child counts, and maintain active supervision at all times. The Program Director or designee will monitor compliance daily and address any concerns immediately through coaching, scheduling adjustments, and corrective action as needed." The final correction date provided was 7/20/26. During an unannounced inspection on 7/23/26, staff #1 was alone with 7 older toddlers, and stated that she was alone with 8 older toddlers on the previous day. Staff #2 was alone with 9 older toddlers.

Correction Required: When children are grouped in similar age levels, the following maximum child group sizes and ratios of staff persons apply: Infants 1:4 with a maximum group size of 8; Young toddlers 1:5 with a maximum group size of 10; Older toddlers 1:6 with a maximum group size of 12; Preschool children 1:10 with a maximum group size of 20; Young school-age children 1:12 with a maximum group size of 24; Older school-age children 1:15 with a maximum group size of 30. TIERED LIS: 1) The required staff:child ratios must be maintained at all times. This portion of the plan must have an immediate correction date. 2) For a period of 3 months, the facility shall have no occurrences of non-compliance related to staff:child ratios. The operator shall demonstrate compliance on unannounced visits over the next 3 months. The correction date for this portion of the plan shall be at minimum 3 months from the date the Regional Office approves the plan of corrections.

Regulation: 3270.192(5)

Description: Two written references

Noncompliance Area: There were no written references on file for staff #3.

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: Staff persons #1 and #2 have not completed Pediatric first aid and CPR training on or before expiration of the most current certification. This is evidenced by the previously documented Pediatric first aid and CPR training on file expiring 4/17/24. Documentation of updated Pediatric first aid and CPR training is not on file.

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. Until such time as the required training has been completed, staff persons #1 and #2 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 persons #1 and #2, staff persons #1 and #2 may not work in a child-care position at the facility

Regulation: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: The disclosure statement for staff #3 and #4 were not signed by a witness.

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

Regulation: 3270.36(b)(5)

Description: HS/GED + 2 yrs

Noncompliance Area: There was insufficient documentation to qualify staff #3, #4, and #5 for the identified assistant group supervisor position. Staff #3 had an Associates in Arts degree with no information on what the course of study was and no documentation of experience. Staff #4 had a high school diploma and .96 hours of experience documented. Staff #5 had a high school diploma and no experience documented.

Correction Required: An assistant group supervisor shall have a high school diploma or a general educational development certificate and 2 years experience with children.

Regulation: 3270.51

Description: Similar Age Level

Noncompliance Area: During a complaint investigation, it was confirmed through multiple staff interviews that the Preschool and PreK classrooms are out of ratio most mornings.

Correction Required: When children are grouped in similar age levels, the following maximum child group sizes and ratios of staff persons apply: Infants 1:4 with a maximum group size of 8; Young toddlers 1:5 with a maximum group size of 10; Older toddlers 1:6 with a maximum group size of 12; Preschool children 1:10 with a maximum group size of 20; Young school-age children 1:12 with a maximum group size of 24; Older school-age children 1:15 with a maximum group size of 30. TIERED LIS: 1. The required staff:child ratios must be maintained at all times. This portion of the plan must have an immediate correction date. 2. The legal entity shall create a policy to ensure proper staffing to cover ratios in all classrooms at all times throughout the day. The policy must address the steps staff are to take to avoid being over ratio at drop off, at nap time, and at the end of the day. The policy must be approved by the Northeast Regional Office prior to dissemination. Staff shall be trained on the policy and documentation of the training shall be filed in the staff files. The operator shall provide a date for when this portion of the plan will be fully completed.

Regulation: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: There was a mat being used in room #7 that was torn and had the interior foam exposed.

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: 3270.131(a)

Description: Health information

Noncompliance Area: There was no health assessment on file within 60 days of the start date of child #1.

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: 3270.133(6)

Description: Written consent

Noncompliance Area: Child #1 had been administered Fluticasone Propionate and the medication was in the classroom, however, there was no parental consent for the administration of the medication.

Correction Required: A parent shall provide written consent for administration of medication or a special diet.

Regulation: 3270.34(a)(6)

Description: Staff evaluations

Noncompliance Area: There was a gap of greater than 12 months in the written evaluation for staff #1. The most recent evaluation was on 3/28/25. The previous evaluation was in 2023.

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

Regulation: 3270.124(f)/3270.181(c)

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

Noncompliance Area: There were gaps of greater than 6 months in the updates of emergency contact and fee agreements for several children. The following were observed: the emergency contact and fee agreement for child #1 were dated 7/29/24 then again on 3/24/25. The emergency contact and fee agreement for child #2 were dated 7/10/24 then again on 2/18/25. The emergency contact information for child #3 was dated 7/29/24 and then again on 2/14/25.

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(b)(1)

Description: Infant: updated health report every 6 months

Noncompliance Area: As of the renewal inspection on 4/2/25, the most recent health assessment for child #1, a young toddler, was dated 7/8/24.

Correction Required: The operator shall require the parent to provide an updated health report at least every 6 months for an infant or young toddler.

Regulation: 3270.131(d)(7)

Description: Free from contagious/communicable disease

Noncompliance Area: The health assessment of child #4 did not include a statement that the child is able to participate in child care and appears to be free from contagious or communicable disease.

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: 3270.133(5)

Description: Original label

Noncompliance Area: There was Tylenol for child #5 in Room 14 that expired on 1/2025.

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

Regulation: 3270.27(f)

Description: Emergency plan

Noncompliance Area: As of the renewal inspection on 4/2/25, the updated emergency plan had not been sent to the local municipality.

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

Regulation: 3270.66(d)

Description: Toxic plants not permitted

Noncompliance Area: There were aloe plants in the infant room, which have been determined to be toxic to children.

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

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

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

Noncompliance Area: On 10/23/24 child #1 ran unattended through an open door from the playground into the building, through the building, out the front door and onto a heavily travelled road, Route 222, in front of the facility. Staff were unaware that child #1 had left the playground.

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. 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)/3270.113(a)(1)

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

Noncompliance Area: On 10/23/24 child #1 ran unattended through an open door from the playground into the building, through the building, out the front door and onto a heavily travelled road, Route 222, in front of the facility. Staff were unaware that child #1 had left the playground.

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. 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 current facility staff to receive a minimum of two hours of PQAS-approved in-person training, including technical assistance, regarding supervision of children and developmentally appropriate practices. This training must be completed as a live training or in-person. The legal entity must receive DHS approval of the training content prior to scheduling the training. Training may not be conducted while children are in care.

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

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

Noncompliance Area: On 10/23/24 child #1 ran unattended through an open door from the playground into the building, through the building, out the front door and onto a heavily travelled road, Route 222, in front of the facility. Staff were unaware that child #1 had left the playground.

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 / Director will review and update existing supervision policies and procedures. The policy must focus on ensuring that each child is seen, heard, assessed and able to be directed at all times. The policy must include the required staff:child ratios for each age group. The policy must include how the facility will ensure appropriate supervision and ratios during transition times and while in the outdoor play area. The policy must include how the facility will ensure appropriate supervision and ratios during nap time. 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 assigned group and be physically present with the children in his 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 policy must be approved by the Northeast Regional Office. Once approved, the policy must be reviewed with all existing staff and with staff hired over the next three (3) months. This policy must be reviewed with all new staff prior to them working in childcare. Documentation of the review must be submitted to the Northeast Regional Office and retained in all staff's file.

Regulation: 3270.124(b)(6)

Description: Insurance coverage information

Noncompliance Area: During the renewal inspection on 10/29/24, the emergency contact information for child #1 did not contain health insurance information.

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(c)

Description: Each child care space

Noncompliance Area: During the renewal inspection on 10/29/24, the emergency contact information for child #2 was not in the classroom where the child was receiving care.

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

Regulation: 3270.133(3)/3270.133(5)

Description: Name on bottle/Original label

Noncompliance Area: During the renewal inspection on 10/29/24, there was Polysporin in the first aid kit in Room 7. The Polysporin expired 6/2022 and was not labeled for an individual child.

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

Regulation: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: It was observed in Room 8 that the sand located in the manipulative table was unclean and contained surface mold and sprouting plants. The manipulative table was freely accessible to children in care. It was observed in Rooms 5 and 6 that rest mats used by the children in care were ripped 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: 3270.106(a)

Description: Clean, age appropriate

Noncompliance Area: It was observed in Rooms 5, 7, and 8 that the children's rest equipment was left unlabeled.

Correction Required: Individual, clean, age-appropriate rest equipment shall be provided for preschool, toddler and infant children as agreed between the child's parent and the operator. The rest equipment shall be labeled for the use of a specific child and used only by the specified child.

Regulation: 3270.106(f)

Description: 2 feet apart

Noncompliance Area: It was observed in Room 14 and 18 that the sleeping equipment in use at the time of inspection did not contain at least 2 feet of space on at least 3 sides of that rest equipment.

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: 3270.107

Description: Refrigerator

Noncompliance Area: It was observed that the thermometer located in the classroom refrigerator in Room 8 was broken.

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: 3270.111(b)

Description: Posted in group space

Noncompliance Area: It was observed and stated by staff that the classroom schedule in Room 5 was not posted.

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

Regulation: 3270.124(b)(7)

Description: Name/address/phone release person

Noncompliance Area: Emergency contact form for child #1 did not contain the release person's address.

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(c)

Description: Each child care space

Noncompliance Area: It was observed in Room 5 that the emergency contact form for child #4 was not present in that space where the child was receiving care. It was observed in Room 7 that the emergency contact form for child #5 was not present in that space where the child was receiving care.

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

Regulation: 3270.131(b)(2)

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

Noncompliance Area: File for child #3, see code sheet for date of birth, contained a health report dated 3/17/21, but no subsequent health report was observed on file dated within the last 12 months as required.

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

Description: Immunization record/Dismissal policy

Noncompliance Area: File for child #3, see code sheet for date of birth, contained a health report dated 3/17/21, but no subsequent health report was observed on file dated within the last 12 months. Due to the outdated documentation on file, the immunization record observed did not contain the status of all age-appropriate vaccines as recommended by the ACIP.

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).

Regulation: 3270.133(1)

Description: Original container

Noncompliance Area: It was observed in Room 14 that the Albuterol medication present for child #6 was not being stored in its original container.

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

Regulation: 3270.133(7)(vii)

Description: Staff initials

Noncompliance Area: It was observed in Room 13 that a medication log was present showing that Tylenol was administered to a child on 8/16/23, but the staff that administered this medication did not initial the medication log on that date as required.

Correction Required: A medication log shall include the initials of the staff person who administered the medication.

Regulation: 3270.151(c)(3)

Description: Exam communicable disease

Noncompliance Area: Health assessment form on file for staff person #4 was incomplete. The health assessment did not contain documentation showing an examination for communicable diseases was completed or the results of that examination.

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

Regulation: 3270.151(c)(4)/3270.151(c)(5)

Description: Information re: medical problems/Physician/CRNP assessment

Noncompliance Area: Heath assessment form on file for staff person #2 was incomplete. The health assessment contained a written statement explaining that the person conducting the physical was "unable to answer" the question regarding the staff person's suitability to provide adequate care to children. Health assessment form on file for staff person #4 was incomplete. The health assessment did not contain a written assessment of the staff person's suitability to provide adequate care to children.

Correction Required: An adult health assessment must include information on medical problems that might threaten the health of the children or prohibit a staff person from providing adequate care to children. An adult health assessment must include the physician's or CRNP's assessment of the person's suitability to provide child care.

Regulation: 3270.161(d)/3270.161(e)

Description: Potentially hazardous food refrigerated/Fresh fruit/vegetables refrigerated

Noncompliance Area: It was observed that pre-packaged apple slices, requiring refrigeration, were left stored in the outdoor first aid kit backpack.

Correction Required: Potentially hazardous food brought from the child's home or provided by the facility shall be refrigerated. Fresh fruits and vegetables that are not used on the day of purchase shall be refrigerated.

Regulation: 3270.181(c)

Description: Emergency info/agreement updated 6 mos

Noncompliance Area: File for child #2 contained both an agreement form and emergency contact form that were signed and dated by parents on 1/11/23 and 8/1/23. These dates and reviews are more than 6-month 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: 3270.182(4)

Description: Consent for administration of medications or special dietary needs

Noncompliance Area: It was observed in Room 5 that two medications were present the day of inspection for child #7, Benadryl and an EpiPen, but no parental consent for the administration of those medication was observed on file at the facility.

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

Regulation: 3270.21/3270.133(3)

Description: General Health and Safety/Name on bottle

Noncompliance Area: It was stated by staff person #8 in Room 8 that an Albuterol haler present along with a medication log was to be used for child #8. Medication was labeled and prescribed to someone other than child #8. Written medication log showed that the medication was administered to child #8 on 6/14/2023 by staff person #8. Medication log indicated that 90 mcg of Albuterol was given twice on 6/14/2023, while written instructions from the parent stated 110 mcg of Albuterol should have been administered twice as needed.

Correction Required: Conditions at the facility may not pose a threat to the health or safety of the children. 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: 3270.21/3270.133(3)

Description: General Health and Safety/Name on bottle

Noncompliance Area: It was stated by staff person #8 in Room 8 that an Albuterol haler present along with a medication log was to be used for child #8. Medication was labeled and prescribed to someone other than child #8. Written medication log showed that the medication was administered to child #8 on 6/14/2023 by staff person #8. Medication log indicated that 90 mcg of Albuterol was given twice on 6/14/2023, while written instructions from the parent stated 110 mcg of Albuterol should have been administered twice as needed.

Correction Required: Conditions at the facility may not pose a threat to the health or safety of the children. 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. Staff #8 is required to receive a minimum of 3 hours of PQAS-approved training regarding medication administration in child care. The legal entity must receive DHS approval of the training content prior to scheduling the training.

Regulation: 3270.21/3270.133(3)

Description: General Health and Safety/Name on bottle

Noncompliance Area: It was stated by staff person #8 in Room 8 that an Albuterol haler present along with a medication log was to be used for child #8. Medication was labeled and prescribed to someone other than child #8. Written medication log showed that the medication was administered to child #8 on 6/14/2023 by staff person #8. Medication log indicated that 90 mcg of Albuterol was given twice on 6/14/2023, while written instructions from the parent stated 110 mcg of Albuterol should have been administered twice as needed.

Correction Required: Conditions at the facility may not pose a threat to the health or safety of the children. 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. The Legal Entity/Director will establish health and safety guidance that defines the facility's medication policies and procedures. The policies and procedures must at minimum include: A description of how life sustaining and non-life sustaining medications are accepted into the facility, how the facility will store any accepted medications to ensure regulatory compliance, the expectations and requirements for completing medication logs and obtaining parental consent for administration of medications, a description of staff responsibilities and how management will monitor ongoing implementation of this policy and procedures. This health and safety guidance must be submitted to the Department prior to implementation for approval. Once approved by the Department, the director will ensure that all current employees and any new hires are trained on the facility's medication policies and procedures.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: File for staff person #1, see code sheet for hire date, did not contain a fully completed state police clearance. This full clearance was printed and placed on file during the time of inspection. Files for staff person #3, #5, and #6, see code sheet for hire dates, did not contain a NSOR verification certificate. File for staff person #7, see code sheet for hire date, contained a NSOR verification certificate dated 6/1/23; this certificate was dated more than 45 days from the their start date.

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 #3, #5, and #6 may not be present at the facility until all required completed clearances are obtained and placed on file.

Regulation: 3270.66(a)

Description: Locked or inaccessible

Noncompliance Area: It was observed in Room 7 that a bottle used for a fish tank stated "keep out of reach of children" was stored in a lower level cabinet accessible to 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: 3270.66(b)

Description: Original container

Noncompliance Area: It was observed in Room 17 that a spray bottle of cleaner, used by facility staff, was not labeled.

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

Regulation: 3270.75(c)

Description: Has all items

Noncompliance Area: It was observed in Room 5 that tweezers were not present in the first aid kit used in that space.

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: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: Although staff person #1 completed their original 6 hour health and safety training topics on 8/21/17, and the the 1 hour Pennsylvania Health and Safety Update on 6/2/23, staff person #1 had not completed that required 1 hour updated pre-service training within 90 days of their date of hire (see LIS code sheet).

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

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

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

Noncompliance Area: On 5/2/23, staff person #1 stated that they took a group of preschool children down to use the bathroom. Child #1 ran out of the bathroom and down the hallway. Staff person #1 left the bathroom in pursuit of child #1 leaving the remaining children in the bathroom unsupervised for approximately 45 seconds. Staff person #2 stated that child #2 has run out of the bathroom several times causing staff person #2 to chase the child down the hallway leaving the remaining children in the bathroom for up to 2 minutes unsupervised. Several other staff, including staff person #2, #3, and #4, stated that over the course of the last month or two they have had several issues with children eloping from classrooms and the preschool bathroom area which had caused multiple cases of either a lapse in direct supervision or that child to no longer be in the same physical space as their primary care staff person.

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 / Director will establish a supervision policy. The policy will include how the facility will demonstrate their knowledge and ability to adequately supervise children at all times. The policy must focus on ensuring that each child is seen, heard, assessed and able to be directed at all times. The policy must include the required staff:child ratios for each age group. The policy must include how the facility will ensure appropriate supervision and ratios during transition times and while in the outdoor play area. The policy must include how the facility will ensure appropriate supervision and ratios during nap time. 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 assigned group and be physically present with the children in his 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. This supervision and ratio policy must be submitted to the Department prior to implementation for approval. Once approved by the Department, the director will ensure that all current employees and any new hires are trained on this policy.

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

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

Noncompliance Area: On 5/2/23, staff person #1 stated that they took a group of preschool children down to use the bathroom. Child #1 ran out of the bathroom and down the hallway. Staff person #1 left the bathroom in pursuit of child #1 leaving the remaining children in the bathroom unsupervised for approximately 45 seconds. Staff person #2 stated that child #2 has run out of the bathroom several times causing staff person #2 to chase the child down the hallway leaving the remaining children in the bathroom for up to 2 minutes unsupervised. Several other staff, including staff person #2, #3, and #4, stated that over the course of the last month or two they have had several issues with children eloping from classrooms and the preschool bathroom area which had caused multiple cases of either a lapse in direct supervision or that child to no longer be in the same physical space as their primary care staff person.

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 will develop and implement a written staff observation plan when staff persons are present with a group of children on the facility's premises. Northeast Regional Office will approve the observation plan before it is implemented. The legal entity will confirm continued compliance by maintaining records of the documentation at the facility for a period of 90 days after the form has been approved. The completed observation forms will be made available for certification representative to review during unannounced visits and submitted to the Northeast Regional Office on a weekly basis.

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

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

Noncompliance Area: On 5/2/23, staff person #1 stated that they took a group of preschool children down to use the bathroom. Child #1 ran out of the bathroom and down the hallway. Staff person #1 left the bathroom in pursuit of child #1 leaving the remaining children in the bathroom unsupervised for approximately 45 seconds. Staff person #2 stated that child #2 has run out of the bathroom several times causing staff person #2 to chase the child down the hallway leaving the remaining children in the bathroom for up to 2 minutes unsupervised. Several other staff, including staff person #2, #3, and #4, stated that over the course of the last month or two they have had several issues with children eloping from classrooms and the preschool bathroom area which had caused multiple cases of either a lapse in direct supervision or that child to no longer be in the same physical space as their primary care staff person.

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 to receive a minimum of three hours of PQAS-approved in-person training, including technical assistance, regarding supervision of children and developmentally appropriate practices. This training must be completed as a live training or in-person. The legal entity must receive DHS approval of the training content prior to scheduling the training. Training may not be conducted while children are in care.

Regulation: 3270.21/3270.113(a)

Description: General Health and Safety/Supervised at all times

Noncompliance Area: On 5/2/23, staff person #1 stated that they took a group of preschool children down to use the bathroom. Child #1 ran out of the bathroom and down the hallway. Staff person #1 left the bathroom in pursuit of child #1 leaving the remaining children in the bathroom unsupervised for approximately 45 seconds. Staff person #2 stated that child #2 has run out of the bathroom several times causing staff person #2 to chase the child down the hallway leaving the remaining children in the bathroom for up to 2 minutes unsupervised. Several other staff, including staff person #2, #3, and #4, stated that over the course of the last month or two they have had several issues with children eloping from classrooms and the preschool bathroom area which had caused multiple cases of either a lapse in direct supervision or that child to no longer be in the same physical space as their primary care staff person.

Correction Required: Conditions at the facility may not pose a threat to the health or safety of the children. 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. Children must be supervised at all times.

Regulation: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: It was observed in Room 7 that three toy bins used by children were cracked and broken.

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: 3270.131(d)(5)/3270.131(e)(2)(i)

Description: Immunization record/Exemption documentation from parent/guardian

Noncompliance Area: File for child #1, did not contain a written review of the status of all immunizations recommended by the ACIP, and an exemption note was not found on file.

Correction Required: A health report shall include a review of the child's immunized status according to recommendations of the ACIP. Exemption from immunization for religious belief or strong personal objection equated to a religious belief shall be documented by a written, signed and dated statement from the child's parent or guardian. The statement shall be kept in the child's record.

Regulation: 3270.151(c)(5)

Description: Physician/CRNP assessment

Noncompliance Area: File for staff person #1 did not contain verification on their health assessment form that an assessment of the person's suitability to provide child care was conducted.

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: 3270.76/3270.102(a)

Description: Building Surfaces/Clean and good repair

Noncompliance Area: On 10/08/21, during a renewal inspection, it was observed that a mold-like substance was found scattered around the entire facility specifically noted on the following surfaces: in Room 18 this was observed on a child-sized chair, in Room 9 this was observed on the toy shelf and a ceiling tile, in Room 7 this was observed on the ceiling tiles and areas of the cabinet doors, and in Room 8 this was observed on the ceiling tiles and all along the water pipes in the ceiling of that room. On 11/23/21, continue noncompliance observed. The documentation obtained by the facility confirmed the presence of mold, but the air quality test documentation was incomplete. The facility did not obtain mold testing as described in the plan of correction obtained on 10/26/21; no documentation was provided showing that the mold present was at an acceptable level or was not hazardous. The facility did complete a visual clean up of all previously noted surfaces, but facility did not complete a follow up test which was required for a finalized report to determine if mold is controlled and not hazardous.

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

Regulation: 3270.106(a)

Description: Clean, age appropriate

Noncompliance Area: It was observed in Room 18 that a crib contained a mold-like substance leaving it unclean, and in Room 5 cots were stacked together with a mold-like substance present on those pieces of rest equipment leaving them unclean.

Correction Required: Individual, clean, age-appropriate rest equipment shall be provided for preschool, toddler and infant children as agreed between the child's parent and the operator. The rest equipment shall be labeled for the use of a specific child and used only by the specified child.

Regulation: 3270.107

Description: Refrigerator

Noncompliance Area: It was observed in Room 16 that the thermometer placed in the classroom refrigerator was no longer operable.

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: 3270.123(a)/3270.123(a)(1)

Description: Signed /Amount of fee

Noncompliance Area: Agreement on file for child #2 did not specify the fee amount and was not signed by the operator.

Correction Required: An agreement shall be signed by the operator and the parent. An agreement shall specify the amount of the fee to be charged per day or per week.

Regulation: 3270.124(b)(3)

Description: Parent home/work address, phone

Noncompliance Area: Emergency contact form for child #3 did not contain the enrolling parent's work address.

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

Regulation: 3270.131(d)(5)

Description: Immunization record

Noncompliance Area: File for child #1 did not contain the status of all age-related immunizations recommended by the ACIP.

Correction Required: A health report shall include a review of the child's immunized status according to recommendations of the ACIP.

Regulation: 3270.151(a)

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

Noncompliance Area: File for staff person #2 did not contain a completed health assessment.

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: 3270.166(4)

Description: Bottles labeled

Noncompliance Area: It was observed in Room 17 that a bottle was not labeled.

Correction Required: Disposable nursers and bottles shall be labeled with the child's name.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: File for staff person #1, hired 9/1/21, did not contain a signed disclosure statement.

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.

Regulation: 3270.75(c)

Description: Has all items

Noncompliance Area: It was observed in Room 18 that the first aid kit was missing gloves.

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

Regulation: 3270.76/3270.102(a)

Description: Building Surfaces/Clean and good repair

Noncompliance Area: It was observed that a mold-like substance was found scattered around the entire facility specifically noted on the following surfaces: in Room 18 this was observed on a child-sized chair, in Room 9 this was observed on the toy shelf and a ceiling tile, in Room 7 this was observed on the ceiling tiles and areas of the cabinet doors, and in Room 8 this was observed on the ceiling tiles and all along the water pipes in the ceiling of that room. It was observed in Room 7 that the shelves and floor in that room contained dirt and small debris making it visibly dirty. It was observed in Room 4, Room 5, Room 8, Room 9, Room 13, and Room 15 that the floors in those rooms contained dirt and small debris making them visibly dirty. It was observed in Room 15 that the vent along the floor of the AC unit was excessively dusty and in the bathroom in Room 13 the vent above the toilet was excessively dusty. The ceiling tiles were missing from areas in Room 8 and the bathroom in Room 13 causing a visible hazard. On 11/23/21, the following items were implemented: Room 4, Room 5, Room 7, Room 8, Room 9, Room 13, and Room 15 all areas cited for being unclean or dusty in these rooms were now cleaned. The ceiling tiles that were missing from areas in Room 8 and the bathroom in Room 13 were replaced. On 11/23/21, the following items were not implemented: the mold-like substance was confirmed to be mold after professional testing completed, and the correction for the mold portion of this violation was not implemented due to a lack of adequate documentation showing that the mold is controlled and not hazardous. Violation recited on SIN-00196666.

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. 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: 3270.77(a)

Description: No peeling paint or plaster

Noncompliance Area: It was observed in Room 6 that a line of chipped and damaged paint was located under the calendar in the classroom.

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