Zion Lutheran Church Child Care

Noncompliance Area: FILE RECORD FOR STAFF #4 DID NOT INCLUDE A CUURENT 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.

Noncompliance Area: FILE RECORD FOR STAFF #1, STAFF#2 AND STAFF #3 DID NOT INCLUDE CURRENT FBI CLEARANCE(STAFF #1 LAST COMPLETED ON 5/6/15),MANDATED REPORTER TRAINING( STAFF #2 LAST COMPLETED ON 8/11/15) AND NATIONAL SEX OFFENDER (STAFF#3 )

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, MADATED REPORTER TRAINING,NATIONAL SEX OFFENDER REGISTRY and a copy of the completed clearance information required under the CPSL. Facility Person #--- may not work in a child care position at the facility.

Noncompliance Area: File record for Child #1 , #2 and #3 were not present in the child care space where the children were receiving care in the space

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.

Noncompliance Area: During the inspection on 10/18/19 the file records for child # 1 ,# 2 #3, #4, and #5 did not include a health assessment that included 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.

Noncompliance Area: During the inspection on 10/18/19 the file records for child # 1 ,# 2 #3, #4, and #5 did not include a health assessment that included a statement that age-appropriate screenings recommended by the American Academy of Pediatrics were conducted since the time of the previous health report required by this section.

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

Noncompliance Area: During the inspection the file records for staff persons # 1, # 3, #4 and #7 did not include acceptable verification of education or training is a transcript or a diploma or a letter signed by a representative of the experiential, educational or training entity.

Correction Required: A facility person's record shall include acceptable verification of experience, education or training is a transcript or a diploma or a letter signed by a representative of the experiential, educational or training entity.

Noncompliance Area: File record for staff #2 and #4 did not include an annual 6 hours of childcare training

Correction Required: A staff person shall obtain an annual minimum of 6 clock hours of child care training.

Noncompliance Area: File record for staff #1(hired 8/9/19) did not include PA State police clearance; file record for staff #5 (hired 9/2014) did not include current State police(last completed on 4/7/14),child abuse clearance (last completed 10/4/14) and FBI clearance (last completed on 5/13/14); file record for staff #3 (7/8/19) did not include FBI clearance

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). LACKING REQUIRED HIRING DOCUMENTS: Facility Person # 5 may not work in a child care position at the facility. PROVISIONAL HIRE UNSUPERVISED: A provisional employee may not be permitted to work alone with children and must work within the vicinity of a permanent employee.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 #5- may not work in a child care position at the facility.

Noncompliance Area: During the inspection on 10/18/19 Certification Representative observed a space heater being used in the "Little Angels" classroom

Correction Required: Portable space heaters are not permitted.

Noncompliance Area: CERTIFICATION REPRESENTATIVE OBSERVED CHILDREN GOING TO THE FACILITY RESTROOMS WITHOUT STAFF

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. TIERED LIS: Children must be supervised at all times. The legal entity must arrange for all facility staff to receive a minimum of two hours of training regarding supervision of children. The legal entity must receive DHS approval of the training content prior to scheduling the training. The legal entity must submit documentation in a format approved by DHS proving that the facility procedure for counting children is followed at all times e.g., a checklist. The legal entity will confirm continuing compliance by sending copies of the documentation to the Regional Office of Child Development and Early Learning on a weekly basis for a period of three months after DHS approves the documentation format.

Noncompliance Area: FILE RECORD FOR STAFF #1, STAFF #2, AND STAFF #3 DID NOT INCLUDE EMERGENCY PLAN TRAINING; STAFF #1 HIRED ON 5/20/19, STAFF #2 HIRED ON 7/8/19, AND STAFF #3 HIRED ON 6/10/19

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

Noncompliance Area: FILE RECORD FOR STAFF #1 STAFF #2 AND STAFF #3 DID NOT INCLUDE FBI CLEARANCES AND MANDATED REPORTER TRAINING

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). LACKING REQUIRED HIRING DOCUMENTS: Facility Person #1,2,3 may not work in a child care position at the facility. PROVISIONAL HIRE UNSUPERVISED: 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,MANDATED REPORTER TRAINING and a copy of the completed clearance information required under the CPSL. Facility Person #1,2,3 may not work in a child care position at the facility.

Noncompliance Area: CERTIFICATION REPRESENTATIVE OBSERVED 14 CHILDREN YOUNGEST CHILD BEING 6 SIX YEARS OLD IN CLASSROOM #9/10 WITH 1 STAFF MEMBER ; CERTIFICATION REPRESENTATIVE OBSERVED 15 CHILDREN YOUNGEST BEING 1 YEARS OLD WITH 2 STAFF

Correction Required: When children are grouped in mixed age levels, the age of the youngest child in the group determines the staff:child ratio and maximum group size in accordance with the requirements in 3270.51 (relating to similar age level).

Noncompliance Area: CERTIFICATION REPRESENTATIVE OBSERVED CEILING TILES MISSING AND I NEED OF REPAIR IN ROOM #7 AND ROOM #9/10

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

Noncompliance Area: FACILITY DIRECTOR WAS NOT AVAILABLE AT THE TIME OF INSPECTION BETWEEN THE HOURS OF 9:30 AM AND 5:15 PM

Correction Required: A director shall be employed by a facility and be present at the facility site a minimum of 30 hours per week.

Noncompliance Area: CERTIFICATION REPRESENTATIVE OBSERVED THE FACILITY TEMPERATURE BETWEEN 62 AND 63 DEGREES BETWEEN THE HOURS OF 9:30 AM AND 5:30PM

Correction Required: The indoor temperature shall be at least 65 F.

Noncompliance Area: CERTIFICATION REPRESENTATIVE OBSERVED SPACE HEATERS IN OPERATION IN THE FACILITY CLASSROOMS

Correction Required: Portable space heaters are not permitted.

Noncompliance Area: FILE RECORD FOR CHILD #1 AND CHILD #4 DID NOT INCLUDE AN AGREEMENT SIFGNED BY THE PARENT

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

Noncompliance Area: FILE RECORD FOR CHILD #1 AND CHILD #5 DID NOT INCLUDE SERVICES PROVIDED TO THE PARENT AND CHILD ON THE AGREEMENT

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

Noncompliance Area: FILE RECORD FOR CHILD #5 DID NOT INCLUDE DESIGNATED RELEASE PERSONS ON THE AGREEMENT

Correction Required: An agreement shall specify the persons designated by a parent to whom the child may be released.

Noncompliance Area: FILE RECORD FOR CHILD #5 DID NOT INCLUDE THE CHILD'S DATE OF ADMISSION ON THE AGREEMENT

Correction Required: An agreement shall specify the date of the child's admission.

Noncompliance Area: FILE RECORD FOR CHILD #2 DID NOT INCLUDE THE ADDRESS 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.

Noncompliance Area: FILE RECORD FOR CHILD #1 DID NOT INCLUDE HEALTH INSURANCE COVERAGE POLICY NUMBER

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.

Noncompliance Area: FILE RECORD FOR CHILD #2 DID NOT INCLUDE DESIGNATED 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.

Noncompliance Area: FILE RECORD FOR CHILD #4 DID NOT INCLUDE A SIX MONTH REVIEW AND UPDATE OF THE EMERGENCY CONTACT INFORMATION; LAST COMPLETED ON 3/29/18

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

Noncompliance Area: FILE RECORD FOR STAFF #1 DID NOT INCLUDE SUBSEQUENT TUBERCULOSIS SCREENING

Correction Required: An adult health assessment must include tuberculosis screening by the Mantoux method at initial employment. Subsequent tuberculosis screening is not required unless directed by a physician, physician's assistant, CRNP, the Department of Health or a local health department.

Noncompliance Area: FILE RECORD FOR CHILD #3 DID NOT INCLUDE A UPDATE AND REVIEW OF THE FINANCIAL AGREEMENT

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.

Noncompliance Area: FILE RECORD FOR CHILD #5 DID NOT INCLUDE SIGNED CONSENT FOR EMERGENCY MEDICAL CARE AND ADMINISTRATION OF MINOR FIRST AID

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

Noncompliance Area: FILE RECORD FOR STAFF #1 DID NOT INCLUDE VERIFICATION OF CHILD CARE EXPERIENCE

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

Noncompliance Area: FILE RECORD FOR STAFF #1 DID NOT INCLUDE EMERGENCY PLAN TRAINING; LAST COMPLETED 9/29/17

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

Noncompliance Area: The file record for staff #2 did not include proof of submission for fingerprints for FBI clearance and mandated reporter training. Staff #2 was hired on 4/9/18

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). LACKING REQUIRED HIRING DOCUMENTS: Facility Person #2 -- 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. Facility Person #2--- may not work in a child care position at the facility.

Noncompliance Area: A review of the staff records found that Staff #11 did not have a Health Assessment on file.

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

Noncompliance Area: A review of the staff records found that Staff #11 did not have a Health Assessment on file.

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

Noncompliance Area: During a review of the staff records, Staff #8 did not have a MantouxTB test on file.

Correction Required: An adult health assessment must include tuberculosis screening by the Mantoux method at initial employment. Subsequent tuberculosis screening is not required unless directed by a physician, physician's assistant, CRNP, the Department of Health or a local health department.

Noncompliance Area: During a review of the staff records, Staff #8 did not have a MantouxTB test on file.

Correction Required: An adult health assessment must include tuberculosis screening by the Mantoux method at initial employment. Subsequent tuberculosis screening is not required unless directed by a physician, physician's assistant, CRNP, the Department of Health or a local health department.

Noncompliance Area: Facility Staff #2-#10 have not completed 6 clock hours of child care training within the last year.

Correction Required: A staff person shall obtain an annual minimum of 6 clock hours of child care training.

Noncompliance Area: Facility Staff #2-#10 have not completed 6 clock hours of child care training within the last year.

Correction Required: A staff person shall obtain an annual minimum of 6 clock hours of child care training.

Noncompliance Area: Staff #1-10 have not completed a Fire Safety Training within the last year.

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

Noncompliance Area: Staff #1-10 have not completed a Fire Safety Training within the last year.

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

Noncompliance Area: During a review of the staff records, Staff #12 did not have verification of completing the Mandated Reporter Training. Staff #12 did not have a complete Disclosure Statement in their record.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). SAFETY PLAN: The operator is required to submit to the Children and Youth Agency a plan of supervision or alternate arrangement as required by the Child Protective Services Law. LACKING REQUIRED HIRING DOCUMENTS: Facility Person # -- may not work in a child care position at the facility. PROVISIONAL HIRE UNSUPERVISED: A provisional employee may not be permitted to work alone with children and must work within the vicinity of a permanent employee.

Noncompliance Area: During a review of the staff records, Staff #12 did not have verification of completing the Mandated Reporter Training. Staff #12 did not have a complete Disclosure Statement in their record.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). SAFETY PLAN: The operator is required to submit to the Children and Youth Agency a plan of supervision or alternate arrangement as required by the Child Protective Services Law. LACKING REQUIRED HIRING DOCUMENTS: Facility Person # -- may not work in a child care position at the facility. PROVISIONAL HIRE UNSUPERVISED: A provisional employee may not be permitted to work alone with children and must work within the vicinity of a permanent employee.

Noncompliance Area: At the time of the inspection, the facility did not have verification that at least 2 staff members qualified as Group Supervisors. *THIS IS A REPEATED NON-COMPLIANCE.*

Correction Required: In a facility in which more than 45 children are enrolled, a group supervisor is required for the first group of 45 enrolled children and for each group or partial group of 45 additional enrolled children.

Noncompliance Area: At the time of the inspection, the facility did not have verification that at least 2 staff members qualified as Group Supervisors. *THIS IS A REPEATED NON-COMPLIANCE.*

Correction Required: In a facility in which more than 45 children are enrolled, a group supervisor is required for the first group of 45 enrolled children and for each group or partial group of 45 additional enrolled children.

Noncompliance Area: During the renewal inspection, a review of the staff records found that Staff #1, #4, and #8 did not have an evaluation of their foreign education credentials to determine the U.S. equivalency. *THIS IS A REPEATED NON-COMPLIANCE.*

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

Noncompliance Area: During the renewal inspection, a review of the staff records found that Staff #1, #4, and #8 did not have an evaluation of their foreign education credentials to determine the U.S. equivalency. *THIS IS A REPEATED NON-COMPLIANCE.*

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

Noncompliance Area: During the complaint investigation, a review of the staff records found that Staff #1-4 did not have health assessments with TB skin tests on file.

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

Noncompliance Area: During the compliant investigation, it was found that the facility was using an 11-15 passenger van to transport children.

Correction Required: In accordance with the requirements of 67 Pa. Code Chapter 171 (relating to school buses and school vehicles), the facility may not transport a child in an 11-15 passenger van.

Noncompliance Area: During the complaint invesitigation, it was found that Staff #1 was in need of the mandated reporter training. Staff #2 was in need of the complete rap sheet from their FBI record. Staff #3 was in need of the 3 required clearances and the mandated reporter training. Staff #4 was in need of the PA criminal background check and the mandated reporter training.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). SAFETY PLAN: The operator is required to submit to the Children and Youth Agency a plan of supervision or alternate arrangement as required by the Child Protective Services Law. LACKING REQUIRED HIRING DOCUMENTS: Facility Person # -- may not work in a child care position at the facility. PROVISIONAL HIRE UNSUPERVISED: A provisional employee may not be permitted to work alone with children and must work within the vicinity of a permanent employee.

Noncompliance Area: During the complaint investigation, the facility disclosed that they did not currently have a director. A new director had been hired and was scheduled to start at the facility on the following day, Friday, September 29th.

Correction Required: A director shall be employed by a facility and be present at the facility site a minimum of 30 hours per week.

Noncompliance Area: An inspection by the Department of Health on 6/14/2017 revealed the facility had an infestation of mice. On 7/14/2017 Certification Representatives observed evidence of mouse droppings in a upstairs classroom cubby.

Correction Required: Evidence of infestation of insects or rodents in the facility is not permitted.

Noncompliance Area: The emergency contact forms for facility children #2, #3 and #4 did not contain the addresses of the individuals designated 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.

Noncompliance Area: The emergency contact form for facility child #1 was not updated since 9/27/2016. The emergency contact form for facility child #4 was not updated since 9/12/2016. The emergency contact form for facilty child #5 was not updated since 9/9/2016. The emergency contact forms inside the classrooms were not updated at least every 6 months. Certification Representative observed this issue in all classrooms.

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 informationIf emergency information is updated in a master file, it shall be updated accordingly in other facility records.

Noncompliance Area: The record of facility child #1 did not have a current health assessment. The last health assessment in the record was dated 4/4/2016.

Correction Required: The initial health report for an older toddler or preschool child shall be dated no more than 1 year prior to the first day of attendance at the facility.

Noncompliance Area: The financial agreement for facility child #1 was not updated since 5/4/2016. The financial agreement for facility child #2 was not updated since 9/12/2016. The financial agreement for facility child #5 was not updated since 9/9/2016.

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.

Noncompliance Area: The records for facility staff #1 and #2 do not contain an evaluation of the US equivalency for education credentials. This is an on-going issue identified during the 11/8/2016 inspection that has not been corrected. This is a repeated non-compliance. The record for facilty staff #5 did not contain verification of education.

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

Noncompliance Area: The record for facility staff #3, hired on 3/6/2017 did not contain Mandated Reporter training. The Child Abuse Clearance for facility staff #1, hired on 11/1/2016 could not be verified as the spelling of the staff's name was different on the clearance. The State Police clearance for facility staff #4, hired on5/8/17 could not be verified as the spelling of the staff's name was different on the clearance. There was not a receipt in the record of facility staff #4 verifying that the Child Abuse clearance or FBI clearance was obtained.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). LACKING REQUIRED HIRING DOCUMENTS: Facility Person # 1 and #4 may not work in a child care position at the facility.

Noncompliance Area: The facility has 1 group supervisor employed. Due to 82 children currently enrolled, a second group supervisor is required. This is a repeated non-compliance.

Correction Required: In a facility in which more than 45 children are enrolled, a group supervisor is required for the first group of 45 enrolled children and for each group or partial group of 45 additional enrolled children.

Noncompliance Area: Certification Representative observed that the walls, railings and play equipment in the outdoor playspace had mold and/or mildew on its surfaces. Certification Representative observed ceiling panels that were missing or damaged in several areas of the facility including the office and the gym area. Certification Representative observed that there were missing floor tiles in the facility kitchen. This is a repeated non-compliance.

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

Noncompliance Area: The facility did not conduct a fire drill at least every 60 days. There was documentation of a fire drill on 12/08/2016 and then 3/15/2017. There was not a fire drill conducted after 3/15/2017.

Correction Required: A fire drill shall be held at least every 60 days. Facility persons and children in attendance shall participate in the fire drill. Facility persons and children shall exit the building, weather permitting.

Noncompliance Area: Certification Representative observed two children sleeping on pillows inside their crib.

Correction Required: Toys, bumper pads, or pillows may not be present in a crib while an infant is sleeping in the crib.

Noncompliance Area: On January 18th, 2016 7 children were transported in a van without all children in the proper safety restraints by facility staff #1.

Correction Required: A child 7 years of age or younger shall be transported in accordance with the requirements for parents and guardians as stated in 75 Pa.C.S. 4581 (relating to restraint systems). Safety restraints installed in the vehicle at the time of manufacturing shall be used by all occupants.

Noncompliance Area: The facility did not have a qualified director during the timeframe of January 23, 2017 and March 6th, 2017.

Correction Required: A director is responsible for the general management of the facility, including the minimum duties described at 3270.34(a)(1) - (6).