Ymca Of Brookville

Regulation: 3270.27(a)(2)

Description: Emergency plan

Noncompliance Area: The facility's emergency plan submitted on 11/7/25 lacked information regarding the evacuation of children from the facility building and evacuation of children to a location away from the facility premises.

Correction Required: The facility shall have an emergency plan that provides for accommodations for evacuation of children from the facility building and evacuation of children to a location away from the facility premises.

Regulation: 3270.27(e)

Description: Letter to parents

Noncompliance Area: 2ND CITATION: The parent letter lacked information regarding accommodations for infants, and toddlers. PREVIOUSLY CITED ON 9/16/25

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

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

Noncompliance Area: 2ND CITATION: The file for Staff #2, identified as an Assistant Group Supervisor (AGS) lacked verification of their staff qualifications. PREVIOUSLY CITED ON 9/16/25

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

Regulation: 3270.106(f)

Description: 2 feet apart

Noncompliance Area: At 11:55 am in the toddler room, a child was in a port-a-crib that lacked at least 2 feet of space on three sides.

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

Regulation: 3270.115(a)(8)

Description: Included in ratio/annual training

Noncompliance Area: The water safety training on file for Staff #1 was dated 9/11/25 which is more than 12 months from the previous training dated 2/16/24.

Correction Required: A facility person who is counted in the staff-child swimming ratio shall annually complete water safety instruction.

Regulation: 3270.123(a)(2)

Description: Date fee to be paid

Noncompliance Area: The agreement form for Child #2 lacked the date on which the fee is to be paid.

Correction Required: An agreement shall specify the date on which the fee is to be paid.

Regulation: 3270.123(a)(3)

Description: Services proceeded

Noncompliance Area: The files for Child #2, #5 and #8 lacked current Child Service Reports, the Department's approved form to provide information to the family about the child's growth and development.

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 agreement form for Child #5 lacked the child's departure time. The agreement forms for Child #6 and Child #7 lacked the child's arrival and departure times.

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

Regulation: 3270.123(a)(6)/3270.182(2)

Description: Admission date/Application, admission, withdrawal dates

Noncompliance Area: The file for Child #1 lacked the date of admission.

Correction Required: An agreement shall specify the date of the child's admission. A child's record shall contain the dates of application, admission and withdrawal of the child.

Regulation: 3270.123(b)/3270.182(8)

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

Noncompliance Area: The files for Child #3 and #5 contained the original fee agreement forms signed by the parent.

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 for Child #1 lacked the address of the child's physician or source of medical care. The emergency contact form for Child #8 lacked the telephone number of 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 for Child # 8 lacked the enrolling parent's home telephone number and work address.

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

Regulation: 3270.124(b)(6)

Description: Insurance coverage information

Noncompliance Area: The emergency contact form for Child #2 lacked the policy number of the child's health insurance coverage. The emergency contact form for Child #5 lacked the health insurance coverage and policy number for the child.

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(b)(7)

Description: Name/address/phone release person

Noncompliance Area: The emergency contact forms for Child #2, #7, and #9 lacked the address of the individual designated by the parent to whom the child may be released.

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 file for Child #2 lacked a current emergency contact form and fee agreement. The previous update documented is 1/7/25. The files for Child #5, #6, #8 & #9 contained current emergency contact forms and fee agreements that were not obtained within 6 months of the previous updates.

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: 3270.133(4)

Description: Locked

Noncompliance Area: In the main room along the far wall the cabinet that contained children's medicine was unlocked making the medicine accessible to children

Correction Required: Medication shall be stored in a locked area of the facility or in an area that is out of the reach of children.

Regulation: 3270.151(a)/3270.192(3)

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

Noncompliance Area: The file for Staff #3 lacked a 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. 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)(1)

Description: Physical examination

Noncompliance Area: The health assessments on file for Staff #8 and #12 lacked documentation of a physical examination.

Correction Required: An adult health assessment must include a physical examination.

Regulation: 3270.151(c)(3)/3270.151(c)(5)

Description: Exam communicable disease/Physician/CRNP assessment

Noncompliance Area: The health assessment on file for Staff #8 lacked documentation of examination for communicable diseases and the physician's assessment of the person's suitability to provide child care.

Correction Required: An adult health assessment must include an examination for communicable diseases and the results of that examination. An adult health assessment must include the physician's or CRNP's assessment of the person's suitability to provide child care.

Regulation: 3270.18(a)

Description: On file at facility

Noncompliance Area: The liability insurance policy on file for the facility expired 5/22/25.

Correction Required: The legal entity shall have comprehensive general liability insurance to cover the persons who are on the premises. A current copy of the insurance policy shall be on file at the facility.

Regulation: 3270.25(a)/3270.25(b)

Description: Availability of certificate of compliance and applicable regulations/Post the inspection summary

Noncompliance Area: The certificate of compliance that was posted was not the current certificate.

Correction Required: The facility's current certificate of compliance shall be posted in a conspicuous location used by parents. The operator shall provide the parent of each child enrolled with information on how to access the regulations in this chapter electronically and with instructions for contacting the appropriate regional child care office. The operator shall post a copy of each inspection summary issued by the Department in a conspicuous location used by parents. The inspection summary shall remain posted until an agent of the Department verifies that each regulatory noncompliance item cited on the inspection summary has been corrected.

Regulation: 3270.27(a)(1)/3270.27(a)(4)

Description: Emergency plan/Contact when ended

Noncompliance Area: The facility's emergency plan lacked lockdown information and 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 accommodations for shelter of children during an emergency including lock-down, shelter in place at the facility and shelter at locations away from the facility premises. 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)

Description: Training regarding plan

Noncompliance Area: The most recent emergency plan training on file for Staff #1 was dated 2/16/24 over a year ago. The files for Staff #2 and Staff #4 lacked documentation of initial 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 parent letter lacked information explaining the emergency procedures for lockdown situation, a method to contact parents when an emergency arises and for facility persons to inform parents that the emergency has ended and instructions as to how parents can safely be reunited with their children, and 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)

Description: Age and Training

Noncompliance Area: The file for Staff #5 lacked 9 hours of the 12 annual child care training hours required for the most recent review window December 2023-December 2024. The file for Staff #6 lacked 9 hours of the 12 annual child care training hours required for the most recent review window December 2023-December 2024.

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

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

Description: Fire safety - 1 yr.

Noncompliance Area: The fire safety training documentation on file for Staff #1 was dated 2/21/24, more than 12 months ago. The fire safety training documentation on file for Staff #9 was dated 3/19/25, which was obtained more than 12 months from the previous training dated 2/27/24.

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: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: Staff person #7 & #11 have not completed the following required pre- service training within 90 days of their date of hire (see LIS code sheet): Health and Safety Training 3270.31(f)(1-9).

Correction Required: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10. Until such time as the required training has been completed, staff person #7 & #11 must be supervised, when interacting with children at a minimum by, an AGS who has completed all preservice trainings and has all qualifications to care for children unsupervised. If there are no staff person(s) available to supervise staff person #7 & 11, staff person #7 & 11 may not work in a child-care position at the facility.

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

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

Noncompliance Area: The file for Staff #9 contained documentation of Pediatric FA/CPR training dated 10/30/24 which was obtained after the previous Pediatric FA/CPR training dated 4/12/22 expired.

Correction Required: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10. 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 file for Staff #6 contained an FBI clearance dated 3/18/24 which was obtained more than 60 months after the previous clearance dated 1/10/19. The file for Staff #6 contained an NSOR certificate dated 3/19/24 which was obtained more than 60 months after the previous certificate dated 1/15/20. The file for Staff #7 lacked a current PA State Criminal Clearance; the one on file dated 8/21/20 was obtained 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 a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Staff #7 may not work in a child care position at the facility.

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

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

Noncompliance Area: The file for Staff #2, identified as an Assistant Group Supervisor (AGS); Staff #8, identified as a Group Supervisor (GS); and Staff #12, identified as a GS, lacked verification of their staff qualifications.

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

Regulation: 3270.34(a)(6)

Description: Staff evaluations

Noncompliance Area: The most recent staff evaluation on file for Staff #1, #3, and #9 were completed more than 12months from the previous staff evaluation. The most recent staff evaluation on file for Staff #1 was dated 10/3/23. The most recent staff evaluation on file for Staff #3 was dated 8/9/24. The most recent staff evaluation on file for Staff #9 was dated 9/15/23. The most recent staff evaluation on file for Staff #12 was dated 9/2/25, which is more than 12 months from initial hire date. The file for Staff #4, employed more than 12 months, lacked an annual staff evaluation.

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 file for Staff #1 and #10, identified as an Assistant Group Supervisors (AGS), lacked verification of the staff's experience with children.

Correction Required: An assistant group supervisor shall have attained one of the following qualification levels: A high school diploma or a general educational development certificate and 2 years experience with children. A record shall include a copy of the Verification of child care experience, education and training prior to service at the facility.

Regulation: 3270.65

Description: Protective Outlet Covers 5 yrs. or less

Noncompliance Area: In the PAL 2 room, an outlet accessible to children 5 years of age or younger, lacked a receptacle cover.

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

Regulation: 3270.66(b)

Description: Original container

Noncompliance Area: A plastic bag containing food for a child was observed next to Clorox disinfectant spray and Restroom disinfectant cleaner in the white storage cabinet located in the preschool area of the Main Child Care Room.

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

Regulation: 3270.77(a)

Description: No peeling paint or plaster

Noncompliance Area: Peeling paint was observed in the PAL 2 room on the window ledges and door frames, in the main room on the window ledges, and on the handrails in the stairwells.

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

Regulation: 3270.133(4)

Description: Locked

Noncompliance Area: In the main room along the far wall the cabinet that contained children's medicine was unlocked making the medicine accessible to children.

Correction Required: Medication shall be stored in a locked area of the facility or in an area that is out of the reach of children.

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: Staff person #1, #3 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Pediatric First Aid/CPR. Based on staff statements, the document in the file of Staff person #3, Get Started with Center-Based Care: Building Blocks for Quality, dated 11.20.24, was not obtained through the staff person completing the training.

Correction Required: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)1-10 or (g)1-10. Until such time as the required training has been completed, staff person #1, #3 must be supervised, when interacting with children at a minimum by, an AGS who has completed all preservice trainings and has all qualifications to care for children unsupervised. If there are no staff person(s) available to supervise staff person #1, #3, staff person #1, #3 may not work in a child-care position at the facility

Regulation: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: Staff person #1 has not completed mandated reporter training within the last 60 months. This is evidenced by the previously documented mandated reporter training on file being dated 3/19/20.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to Child Protective Services). Until such time as the required training has been completed, staff person#1 must be supervised, when interacting with children at a minimum by, an AGS who has completed all preservice trainings and has all qualifications to care for children unsupervised. If there are no staff person(s) available to supervise staff person/facility person/volunteer #1, staff person/facility person/volunteer #1 may not work in a child-care position at the facility.

Regulation: 3270.66(a)

Description: Locked or inaccessible

Noncompliance Area: In the main room on the table near the teacher's desk was a staff book bag that was unzipped and contained sunscreen which stated keep out of reach of children 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: 3270.76

Description: Building Surfaces

Noncompliance Area: In the main room there was ceiling tiles that were stained with a brow substance. In the main room near the portable wall was a large piece of the wood floor worn away causing a tripping 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.

Regulation: 3270.65

Description: Protective Outlet Covers 5 yrs. or less

Noncompliance Area: In the Upstairs Gym (Dance Studio) there was an electrical outlet to the left of the mirrored wall that lacked a protective receptacle cover. The outlet was accessible to children 5 years of age and younger.

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: There was a bottle labeled "disinfectant" on a low shelf in the Upstairs Gym (Dance Studio) that was accessible to the 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: 3270.72(d)

Description: Above ground window opening restricted to 6"

Noncompliance Area: Observed three windows in the Upstairs Gym (Dance Studio) on the third floor that were open and accessible to children and were not modified to limit the opening to 6 inches or fewer.

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: 3270.192(5)

Description: Two written references

Noncompliance Area: The file for staff person #1 was missing a second letter of reference.

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(f)

Description: Health and Safety Training

Noncompliance Area: Staff person #1 does not have a completed health and safety training on file within 90 days of hire (SEE LIS CODE SHEET) Staff person #1 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Get Started with Center-based Care: Building Blocks for Quality and must not complete Health and Safety Training Part 1 and Part 2 per the Announcement C-24-03 Updates to Health and Safety Pre-Service Training and professional Development Requirements.

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

Regulation: 3270.82(h)

Description: Handwashing signs

Noncompliance Area: The bathroom in the pre-k room on the top floor did not have a handwashing sign above the sink.

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

Regulation: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: Observed a chair in the second floor preschool room had a damaged seat cover and exposed foam.

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: 3270.133(4)

Description: Locked

Noncompliance Area: Observed in the second-floor preschool room, Tylenol accessible to children in an unlocked filing cabinet and liquid prescription medication accessible to children in the refrigerator.

Correction Required: Medication shall be stored in a locked area of the facility or in an area that is out of the reach of children.

Regulation: 3270.133(7)

Description: Medication log

Noncompliance Area: Observed the facility did not have an established medication log for a bottle of Tylenol which had been opened and stored at the facility.

Correction Required: An operator is responsible to establish and maintain a medication log if prescription or nonprescription medication is administered.

Regulation: 3270.25(b)

Description: Post the inspection summary

Noncompliance Area: Observed the facility had the first page of the negative sanction letter posted but the inspection summary attachments were not posted with the letter.

Correction Required: The operator shall post a copy of each inspection summary issued by the Department in a conspicuous location used by parents. The inspection summary shall remain posted until an agent of the Department verifies that each regulatory noncompliance item cited on the inspection summary has been corrected.

Regulation: 3270.27(a)(6)

Description: Emergency plan

Noncompliance Area: Observed the documented annual emergency drills revealed that the facility has conducted the same emergency drill for the previous three years.

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

Regulation: 3270.36(b)(5)

Description: HS/GED + 2 yrs

Noncompliance Area: Observed staff file #1 did not contain documentation of 2 years 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.

Regulation: 3270.65

Description: Protective Outlet Covers 5 yrs. or less

Noncompliance Area: Observed an electrical outlet by the cots in the preschool room did not have 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: 3270.72(d)

Description: Above ground window opening restricted to 6"

Noncompliance Area: Observed a window in the bathroom attached to the second floor preschool/school age room was not adapted to limit the opening to 6 or fewer inches. Observed a window on the third floor in the PAL 1 room which was not restricted to prevent the window from opening to 6 or fewer inches.

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: 3270.95(a)/3270.95(b)

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

Noncompliance Area: Observed 2 times (7/24/24-9/11/24 and 10/1/24-11/4/24) in the previous 12 months the documented fire alarm testing was conducted 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: 3270.133(5)

Description: Original label

Noncompliance Area: An Epi-Pen for Child #1 was observed to be expired, with an expiration date of 8/2024.

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

Regulation: 3270.151(a)/3270.192(3)

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

Noncompliance Area: The file for Staff #3 contained a health assessment dated 4/23/24, after the date of hire. (SEE LIS 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: 3270.192(5)

Description: Two written references

Noncompliance Area: The file for Staff #2 lacked two written, nonfamily references.

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 did not contain a plan that provides for 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: 3270.31(e)(4)(i)

Description: Age and Training

Noncompliance Area: The most recent Pediatric First Aid/CPR training on file for Staff #6 is dated 1/31/23, exceeding the expiration date.

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: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: The file for Staff #1 contained a disclosure statement that was not dated, making it invalid. The file for Staff #3 contained an NSOR clearance dated 9/24/24, after the 45-day provisional hire period. The most recent NSOR clearance on file for Staff #4 is dated 1/16/20, more than 60 months prior. The most recent NSOR clearance on file for Staff #5 is dated 1/14/20, more than 60 months prior. The two most recent PA State Police clearances on file for Staff #6 are dated 8/20/19 and 8/29/24, more than 60 months apart. (SEE LIS CODE SHEET)

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services) LACKING REQUIRED HIRING DOCUMENTS: Staff #4 and Staff #5 -- may not work in a childcare 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: 3270.66(b)

Description: Original container

Noncompliance Area: In the second floor Child Care Room, a spray bottle containing sanitizer was not labeled to specify the contents.

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: 3270.106(a)

Description: Clean, age appropriate

Noncompliance Area: Per observation and staff statements, the rest equipment provided for the preschool, toddler and infant children are not labeled for the use of a specific child and are used by multiple children.

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: 3270.182(7)

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

Noncompliance Area: Based on staff statements, reports of accidents, injuries and illnesses involving children in care at the facility are not consistently documented. When a report is documented copies are not placed in the child's file and the facility's accident file.

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: 20.71(a)(7)

Description: Fraud or deceit in obtaining or attempting to obtain a certificate of compliance

Noncompliance Area: It was determined that the Pediatric CPR/FIRST AID cards for staff person #1 and staff person #3 dated 9-14-24 were fraudulent because staff person #1 and staff person #3 were not present for the trainings. Staff person #2, the Pediatric CPR/First aid trainer, admitted to putting staff person #1's name on the training roster knowing that staff person #1 was not present for the training on 9/14/24. On 11/27/24, Staff person #3 reported that they had not taken Pediatric CPR/First aid within the past 6 months.

Correction Required: The Department may deny, refuse to renew or revoke a certificate of compliance for fraud or deceit in obtaining or attempting to obtain a certificate of compliance.

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

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

Noncompliance Area: Staff person #3's Pediatric CPR/First aid expired 7/2024. The Pediatric CPR/FIRST AID card on file for staff person #3 and dated 9/14/24 is fraudulent and therefore, is not an acceptable training. On 11/27/24, Staff person #3 reported that they had not taken Pediatric CPR/First aid within the past 6 months. Staff person #2 was the trainer documented on the Pediatric CPS/First Aid card dated 9/14/24.

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: 3270.31(f)(10)

Description: Health and Safety Training - Pediatric First Aid and CPR

Noncompliance Area: * The Pediatric CPR/First aid card on file for staff person #1 and dated 9/14/24 is fraudulent and therefore, is not an acceptable training. Staff person #1 reported that they never took the Pediatric CPR/first aid training on 9/14/24. Staff person #2, the Pediatric CPR/First aid trainer, admitted to putting Staff person #1's name to the training roster knowing that Staff person #1 was not present for the training on 9/14/24.

Correction Required: * Staff persons shall complete professional development in pediatric first aid and pediatric cardiopulmonary resuscitation within 90 days of hire.

Regulation: 3270.31(f)(10)

Description: Health and Safety Training - Pediatric First Aid and CPR

Noncompliance Area: ** The Pediatric CPR/First aid card on file for staff person #1 and dated 9/14/24 is fraudulent and therefore, is not an acceptable training. Staff person #1 reported that they never took the Pediatric CPR/first aid training on 9/14/24. Staff person #2, the Pediatric CPR/First aid trainer, admitted to putting Staff person #1's name to the training roster knowing that Staff person #1 was not present for the training on 9/14/24.

Correction Required: ** The legal entity will not accept Pediatric CPR/FA trainings from PQAS approved trainer, staff #2, for a period of 5 months.

Regulation: 3270.91(a)

Description: Stairs, exits, etc. unobstructed

Noncompliance Area: On 10/25/24, in the upstairs toddler room, observed a book rack which was blocking the exit to the hallway which leads to the bathroom.

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

Regulation: 3270.113(a)

Description: Supervised at all times

Noncompliance Area: On 8/27/24, facility person #5, was alone with two infants in the Baby Room from 5:15 - 5:30 PM. Facility person #5 is 17 years of age and is not qualified as a 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.

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: Facility person #5, who was acting in the capacity of a staff person, was caring for children unsupervised. Facility person #5, has not completed the following pre-service training required prior to caring for children unsupervised: Health and Safety and Pediatric CPR/FA.

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: 3270.31(b)

Description: Staff person - 18 yrs.

Noncompliance Area: Facility person #5, who was acting in the capacity of a staff person, was 17 years of age.

Correction Required: A staff person shall be 18 years of age or older.

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: Staff person # 2 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Health and safety training.

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 #2 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 #2 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 #, staff person # 2 may not work in a child-care position at the facility.

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: Staff person # 1 did not complete Health and Safety training within 90 days of their date of hire. There is now health and safety training on file and dated 7/8/24. SEE IS CODE SHEET.

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 director reported that facility person #5, who was acting in the capacity of a staff person, had a file which lacked an NSOR and DHS FBI clearance. The file for staff #1 lacks a disclosure statement on or before initial start date in a child care position. The file for staff #2 lacks a disclosure statement on or before initial start date in a child care position and 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 6/10/24. The file for staff #3 lacked an FBI clearance on or before initial start date in a child care position. There is now an FBI clearance on file and dated 9/23/24. The disclosure statement on file for staff 4 lacks a date. The file for staff #6 lacks a current FBI clearance. This is evidenced by the FBI clearance on file with date of 9/27/2019.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Facility Person # -- 5 and 6 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: 3270.51

Description: Similar Age Level

Noncompliance Area: On 8/27/24, facility person #5, was alone with two infants in the Baby Room from 5:15 - 5:30 PM. Facility person #5 is 17 years of age and is not qualified as a staff person. Ratio 0:2.

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's fire detections system panel is indicating a Trouble Zone 2. The director reported that there is an issue with the system regarding communication and the alarms randomly go off without smoke or fire in the building. On 10/1/24, the fire system was let off and was heard throughout the child care areas of the building.

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: 3270.95(a)/3270.95(b)

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

Noncompliance Area: There was no record of 30 day manual checks of the fire detection system on file at the facility.

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 infant room, observed a bouncy seat with images of foxes and used for the infants in care, which was soiled. In the PAL 2 room, observed a white cracked toy bin.

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: On 3/15/24, observed two infants, both who were present at the facility, use the same pack -n- play for their separate naps.

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: 3270.123(a)(2)/3270.123(a)(5)

Description: Date fee to be paid/Designated release persons

Noncompliance Area: The fee agreements on file for children #1 and 2 lack a date on which the fee is to be paid. The fee agreement on file for child #2 lacks the release persons to whom the child may be released.

Correction Required: An agreement shall specify the date on which the fee is to be paid. An agreement shall specify the persons designated by a parent to whom the child may be released.

Regulation: 3270.123(a)(3)

Description: Services proceeded

Noncompliance Area: The file for child #2, lacks a child service report within the past six months.

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: 3270.124(f)/3270.181(c)

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

Noncompliance Area: The emergency contact and fee agreements on file for child #2, lack a review/update within the past six months.

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)/3270.182(1)

Description: Infant: updated health report every 6 months/Initial and subsequent health reports

Noncompliance Area: The file for child #1, who is a young toddler, lacks a health assessment which has been completed within the past six months. There was more than six months between the previous and most current and updated health assessments on file for child #2.

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. A child's record shall contain initial and subsequent health reports.

Regulation: 3270.133(3)

Description: Name on bottle

Noncompliance Area: In the Downstairs PS room First Aid kit, observed burn cream, eye wash solutions, aspirin and antacid which lacked a label with a child's name.

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

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

Description: Mantoux TB/Health assessment, TB test

Noncompliance Area: The file for staff #10, lacks a TB screening within 12 months of providing initial service in a child care position.

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

Regulation: 3270.27(a)(6)

Description: Emergency plan

Noncompliance Area: There was an emergency drill which was conducted on 2/8/24. However, only one class participated in the drill and not all children who were present at the time of the drill.

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

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

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

Noncompliance Area: The file for staff #8, lacks two of the required twelve hours of annual child care training. The file for staff #9, lacks three of the required 12 hours of annual child care training.

Correction Required: A staff person shall obtain an annual minimum of 12 clock hours of child care training. A facility person's record shall include verification of child care experience, education and training following the outset of service at the facility.

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: Staff person #15 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Pediatric CPR/FA.

Correction Required: Staff person(s) shall complete professional development in the topics of 3270.31(f)(1 -- 10), Staff person #15 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 #15 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 #15, staff person #15 may not work in a child-care position at the facility.

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: The file for staff #8, lacked health and safety training within 90 days of hire. SEE IS CODE SHEET. There is now health and safety training on file and dated 3/15/24.

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 file for staff #2, lacked a DHS FBI clearance on or before initial start date in a child care position. SEE IS CODE SHEET. There is now an FBI clearance on file and dated 8/7/23. The file for staff #3, lacked a DHS FBI clearance on or before initial start date in a child care position. SEE IS CODE SHEET. There is now an FBI clearance on file and dated 11/9/23. The file for staff #4, lacked a DHS FBI clearance on or before initial start date in a child care position. SEE IS CODE SHEET. There is now an FBI clearance on file and dated 2/26/24. The file for staff #5, lacks a DHS FBI clearance on or before initial start date in a child care position. The file for staff #7, lacks a DHS FBI clearance on or before initial start date in a child care position and the disclosure statement on file was dated after start date. SEE IS CODE SHEET. There is now an FBI clearance on file and dated 8/7/23 and a disclosure statement dated 8/7/23. The file for staff #11 lacks the most current disclosure statement on or before initial start date in a child care position. The file for staff #12, lacks a DHS FBI clearance which was completed within the past 60 months and lacks the most current disclosure statement on or before initial start date in a child care position. This is evidenced by the current FBI clearance on file which is dated 7/24/18. The file for staff #14 lacks the most current disclosure statement on or before initial start date in a child care position. The file for staff #16, lacks a DHS FBI clearance within the past 60 months. This is evidenced by the current FBI clearance on file which is dated 1/19/19.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Facility Person # 5, 12 and 16 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: 3270.33(a)/3270.192(2)(ii)

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

Noncompliance Area: The file for staff #2, who holds the title of aide, lacks 2500 hours of child care experience. The file for staff #3, who holds the title of aide, lacks verification of an 8th grade education and 2500 hours of child care experience. The file for staff #4, who holds the title of assistant group supervisor, lacks 2500 hours of child care experience. The file for staff #5, who holds the title of aide, lacks verification of an 8th grade education and 2500 hours of child care experience. The file for staff # 6, who holds the title of aide, lacks verification of an 8th grade education and 2500 hours of child care experience. The file for staff #7, who holds the title of assistant group supervisor, lacks verification of 2500 hours of child care experience. The file for staff #8, who holds the title of assistant group supervisor, lacks verification of 2500 hours of child care experience. The file for staff #11, who holds the title of assistant group supervisor, lacks 1250 hours of child care experience . The file for staff #12, who holds the title of assistant group supervisor, lacks verification of 2500 hours of child care experience. The file for staff #13, who holds the title of assistant group supervisor, lacks verification of a high school diploma and 2500 hours of child care experience. The file for staff #17, who holds the title of assistant group supervisor, lacks 2500 hours of child care experience.

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

Regulation: 3270.34(a)(6)

Description: Staff evaluations

Noncompliance Area: The file for staff #1, lacked a staff evaluation within 12 months of start date in a child care position. SEE IS CODE SHEET. There is now a staff evaluation on file and dated 9/15/23.

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: 3270.66(a)

Description: Locked or inaccessible

Noncompliance Area: In the Downstairs PS Room, observed toxic glass cleaner, brillo pads and various cleaning products underneath the kitchen sink in an unlocked cabinet. The kitchen, which can be entered directly from the PS Room, had two garbage cans in front of the door, but the PS children could move them. Therefore, the toxics were accessible to the 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: 3270.71

Description: Heat Source

Noncompliance Area: In the Downstairs PS Room, observed an accessible stove top without protective guards on the handles. The kitchen, which can be entered directly from the PS Room, had two garbage cans in front of the door, but the PS children could move them. Therefore, the stove top, capable of exceeding 110 degrees F was accessible to the children in care.

Correction Required: Hot water pipes and other sources of heat exceeding 110° F that are accessible to children shall be equipped with protective guards or shall be insulated to prevent direct contact.

Regulation: 3270.76

Description: Building Surfaces

Noncompliance Area: On the main entrance floor of the facility, observed that the first stair, which leads to areas where the children are in care, had part of the plastic back which was coming loose and creating a tripping hazard to the children in care. In the preschool bathroom, observed a vent which had partially fallen off and was accessible to the children in care.

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: 3270.94(a)(9)

Description: Written record

Noncompliance Area: Fire drills conducted on 5/19 23 and 8/1/23, did not contain the number of children who participated in the fire drills.

Correction Required: The Director or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that a written record is maintained on file at the facility indicating the specific time of day of the drill, the hypothetical location of the fire, the evacuation time, and the names of the facility persons and the number of children who participate in the fire drill.

Regulation: 3270.113(a)

Description: Supervised at all times

Noncompliance Area: During an interview with Staff person #1, Staff person #1 reported that on 6/1/23, Child #1 stepped out of the open doors of the facility while the child was under the care of Staff person #1.

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: During an interview with Staff person #1, Staff person #1 reported that on 6/1/23, Child #1 stepped out of the open doors of the facility while the child was under the care of Staff person #1.

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.