Pocono Family Ymca

Regulation: 3270.107

Description: Refrigerator

Noncompliance Area: An unannounced inspection occurred at the facility on 6/30/26. A physical site review was conducted. Refrigerators were observed in the infant and young toddler classroom on the second floor and in the preschool room on the third floor and these refrigerators did not contain thermometers. The temperature of the refrigerators were unable to be determined at the time of this inspection.

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: 3270.21/3270.76

Description: General Health and Safety/Building Surfaces

Noncompliance Area: An unannounced inspection occurred at the facility on 6/30/26. A physical site review was conducted. Two in-room air conditioners were observed that required access to water. Five-gallon buckets were observed filled with water and were accessible to children. During this inspection, children were observed receiving care near these air conditioners and accessible water. The protective coverings over the heating units on the third floor were broken and missing parts that exposed and allowed access to the inside heating units. Children were observed receiving care in this room during this inspection.

Correction Required: Conditions at the facility may not pose a threat to the health or safety of the children. 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: An unannounced inspection occurred at the facility on 6/30/26. A physical site review was conducted. Children ages 5 years and younger were observed receiving care in classrooms on the second- and third-level floors. Several outlet covers were not protected from access to the children. The outlets needing covers were addressed with staff during this inspection.

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

Regulation: 3270.71

Description: Heat Source

Noncompliance Area: An unannounced inspection occurred at the facility on 6/30/26. A physical site review was conducted. The preschool child's classroom on the second floor was not restricted from accessing a room that contained a stove. Children were observed receiving care in this room during this inspection.

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: 3270.72(d)

Description: Above ground window opening restricted to 6"

Noncompliance Area: An unannounced inspection occurred at the facility on 6/30/26. A physical site review was conducted. Children were observed receiving care on the second- and third-floor levels during this inspection. These classrooms contained accessible windows that were not restricted to opening 6 or fewer inches. The windows in the third-floor bathroom used by the children were not restricted to opening 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: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: CONTINUED NON COMPLIANCE An unannounced inspection occurred at the facility on 8/4/25. A review of staff files was conducted. Staff person #4 has not completed the following required pre-service training, is within 90 days of their date of hire, but was working unsupervised (see LIS code sheet): pediatric first aid/CPR and health and safety training. An acceptable plan of correction was received on 9/10/25. A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. Staff person #1 has not completed the following required pre-service training, is within 90 days of their date of hire, and was working unsupervised (see LIS code sheet): pediatric first aid/CPR. An acceptable plan of correction was received on 12/19/25 that corrections would be made by 10/28/25. An unannounced inspection occurred at the facility on 3/26/26. Staff #1, #11 and #13 have not completed the following required pre-service training, is within 90 days of their date of hire, but was working unsupervised (see LIS code sheet): pediatric first aid/CPR. Staff #11 and #13 have not completed the following required pre-service training, is within 90 days of their date of hire, but was working unsupervised (see LIS code sheet): health and safety topics. Staff #11 and # 13 are within 90 days of their date of hire but were working unsupervised and did not have the following pre-service training completed (see LIS code sheet): mandated reporter.

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. The operator shall comply with the CPSL and with Chapter 3490 (relating to Child Protective Services). TIERED LIS: 1. Until such time as the required pre- service trainings are completed, staff #1, #11 and #13 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 available to supervise staff #1, #11 and #13, staff #1, #11 and #13 may not work in a child-care position at the facility. (THIS PORTION OF THE PLAN SHALL HAVE AN IMMEDIATE CORRECTION DATE.) 2. For a period of 3 months, the facility shall have no areas of non-compliance of staff working unsupervised without having completed the required 90-day pre-service trainings. This will be monitored by the Department making at least 2 unannounced visits during this period to confirm that all staff who require supervision are working appropriately supervised. (THIS PORTION OF THE PLAN REQUIRES A DATE OF CORRECTION THAT IS AT LEAST 3 MONTHS FROM WHEN AN ACCEPTABLE PLAN OF CORRECTION IS RECEIVED BY THE REGIONAL OFFICE.)

Regulation: 3270.151(a)/3270.192(3)

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

Noncompliance Area: CONTINUED NONCOMPLIANCE An unannounced inspection occurred at the facility on 8/4/25. A review of staff files was conducted. Staff #3 was observed during this inspection providing child care and the file was missing a health assessment. A health assessment is required to be on file prior to a staff providing child care. An acceptable plan of correction was received on 9/10/25. A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. See the code sheet for the date of hire. Regulation requires staff to update their health assessment at least every 24 months. The following staff did not update their health assessments at least every 24 months: Staff #9 (previous 8/28/23, current 9/4/25). The following staff did not receive a health assessment prior to working in a child care role at the facility: Staff #1 (received 7/23/25) and Staff # 6 (none). An acceptable plan of correction was received on 12/19/25 that corrections would be made by 12/14/25. An unannounced inspection occurred at the facility on 3/26/26. A review of staff files was conducted. See the code sheet for the date of hire. Regulation requires staff to update their health assessment at least every 24 months. The following staff did not receive a health assessment prior to working in a child care role at the facility: Staff #11.

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: CONTINUED NONCOMPLIANCE An unannounced inspection occurred at the facility on 8/4/25. A review of staff files was conducted. Staff #3 was observed working in a child care role at the time of this inspection and the file was missing two letters of written reference. An acceptable plan of correction was received on 9/10/25. A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. The files of Staff #5, #6 and #7 were missing two letters of written reference. An acceptable plan of correction was received on 12/19/25 that corrections would be made by 12/10/25. An unannounced inspection occurred at the facility on 3/26/26. A review of staff files was conducted. The files of Staff #5, #7, #10, #11 (1 reference letter only) and #12 were missing two letters of written 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(e)(4)(iv)/3270.115(a)(8)

Description: Water safety/Included in ratio/annual training

Noncompliance Area: CONTINUED NON COMPLIANCE A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. At the time of the inspection, the director indicted the children in the program swim, and the following were staff listed as staff that would supervise the children swimming, but these staff files did not contain documentation of current water safety training: Staff #1, #3, #6 and #8. An acceptable plan of correction was received on 12/19/25 that corrections would be made by 12/10/25. An unannounced inspection occurred at the facility on 3/26/26. At the time of the inspection, the director indicted the children in the program swim, and the following were staff listed as staff that would supervise the children swimming, but these staff files did not contain documentation of current water safety training: Staff #1, #3 and #8.

Correction Required: Competence in water safety instruction is demonstrated by the completion of basic instruction in water safety from a certified lifeguard. A facility person who is counted in the staff-child swimming ratio shall annually complete water safety instruction. TIERED LIS: 1. The facility must not swim until all staff who supervise children at the pool have completed water safety training. (THIS PORTION OF THE PLAN SHALL HAVE AN IMMEDIATE CORRECTION DATE.) 2. All staff who supervise children at the pool must have completed water safety training conducted annually by a certified lifeguard. Proof of water safety training for all staff who supervise children at the pool must be provided to the Regional Office for review and approval. (THIS PORTION OF THE PLAN REQUIRES A DATE FOR WHEN THE TRIANING AND PROOF IS COMPLETED AND SENT FOR REVEW.)

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: CONTINUED NON COMPLIANCE A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. Staff persons #1 and #3 have not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): pediatric first aid/CPR. An acceptable plan of correction was received on 12/19/25 that corrections would be made by 10/28/25. An unannounced inspection occurred at the facility on 3/26/26. A review of staff files was conducted. Staff #1 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.

Correction Required: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)10. Until such time as the required pre- service trainings are completed, staff #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 available to supervise staff #1, staff #1 may not work in a child-care position at the facility. TIERED LIS: 1. All staff must complete required pre-service training within 90 days of hire. The Legal Entity shall demonstrate ongoing compliance with this regulation by providing proof of completion of all pre-service trainings to the Regional Office within 90 days of hire for any staff hired since the last renewal inspection on 10/28/25 or who are hired for the next 3-month period. (THIS PORTION OF THE PLAN REQUIRES A DATE OF CORRECTION THAT IS AT LEAST THREE MONTHS FROM THE DATE AN ACCEPTABLE PLAN OF CORRECTION IS RECEIVED BY THE REGIONAL OFFICE.) 2. For a period of 3 months, the facility shall have no areas of non-compliance of staff working beyond 90 days having not complete the required pre-service trainings as required by regulation. This will be monitored by the Department making at least 2 unannounced visits during this period to confirm. (THIS PORTION OF THE PLAN REQUIRES A DATE OF CORRECTION THAT IS AT LEST THREE MONTHS FROM THE DATE AN ACCEPTABLE PLAN OF CORRECTION IS RECEICED BY THE REGIONAL OFFICE.)

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: CONTINUED NONCOMPLIANCE An unannounced inspection occurred at the facility on 8/4/25. A review of staff files was conducted. The following staff did not have the correct documents on file to be hired as a provisional hire per the CPSL: Staff #1 and #2 were missing the NSOR clearance and the disclosure statement. Staff #3 was missing the state police clearance, child abuse clearance and the NSOR clearance. Staff #4 was missing the NSOR clearance and was observed working unsupervised with children. These staff were observed working in a child care role at the facility at the time of the inspection but were not hired correctly as provisional hires. An acceptable plan of correction was received on 9/10/25. A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. See the code sheet for the date of hire. The following staff did not have the correct documents on file to be hired as a provisional hire per the CPSL: Staff #3 was still missing the child abuse clearance. An acceptable plan of correction was received on 12/19/25 that corrections would be made by 3/19/26. An unannounced inspection occurred at the facility on 3/26/26. A review of staff files was conducted. See the code sheet for the date of hire. The following staff did not have the correct documents on file to be hired as a provisional hire per the CPSL: Staff #10 did not apply for the DHS FBI clearance prior to working in a child care role at the facility. Staff #10 did not have the correct signed or dated disclosure statement on file either as required by the CPSL. Staff #11 was working unsupervised at the time of this inspection. Staff #11 was hired using a volunteer child abuse clearance dated 5/23/24, which is not an appropriate clearance to work in child care according to the CPSL. Staff #12 did not have the correct signed or dated disclosure statement on file either as required by the CPSL.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Facility Person #10, #11 and #12 may not work in a child care position at the facility. TIERED LIS: 1. The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Facility Person #10, #11 and #12 may not work in a child care position with direct contact with routine interaction with children until all clearances are on file at the facility. (THIS PORTION OF THE PLAN SHALL HAVE AN IMMEDIATE CORRECTION DATE.) 2. The legal entity will submit complete files to the Regional Office for any new hires for a period of three months from the date an acceptable plan is received. During that time, new hires may not begin to work in child care until their file has been approved by the Regional Office. Submitted files will be reviewed within 1 week of submission. (THE CORRECTION DATE FOR THIS PORTION OF THE PLAN SHALL BE AT MINIMUM OF 3 MONTHS FROM THE DATE AN ACCEPTABLE PLAN IS SUBMITTED.) 3. For a period of 3 months, the facility shall have no areas of non-compliance related to the CPSL or staff beginning to work prior to approval by the Regional Office. This will be monitored by the Department making at least 2 unannounced visits during this period to confirm. (THIS PORTION OF THE PLAN REQUIRES A DATE OF CORRECTION THAT IS ATLEAST THREE MONTHS FROM THE DATE AN ACCEPTABLE PLAN OF CORRECTION IS RECEIVED BY THE REGIONAL OFFICE.)

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

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

Noncompliance Area: CONTINUED NONCOMPLIANCE An unannounced inspection occurred at the facility on 8/4/25. A review of staff files was conducted. The following staff were observed in a child care role at the time of this inspection, but their file was missing proof of education, and these staff could not be appropriately qualified to work in a child care role at the facility: Staff #2, #3 and #4. An acceptable plan of correction was received on 9/10/25. A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. The following staff were observed in a child care role at the time of this inspection, but their file was missing proof of education, and these staff could not be appropriately qualified to work in a child care role at the facility: Staff #3, #5 and #6. An acceptable plan of correction was received on 12/19/25 that corrections would be made by 12/10/25. An unannounced inspection occurred at the facility on 3/26/26. The following staff were observed in a child care role at the time of this inspection, but their file was missing proof of education, and these staff could not be appropriately qualified to work in a child care role at the facility: Staff #3, #5, #11, #12 and #13.

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: 3270.124(b)(4)/3270.182(3)

Description: Written consent/Consent for emergency medical care required prior to admission

Noncompliance Area: A renewal inspection occurred at the facility on 10/28/25. A review of children's files was conducted. Regulation requires consent for emergency medical care for children prior to admission. Child #6 is enrolled and attends the facility, and the file did not contain consent for emergency medical care.

Correction Required: Emergency contact information must include the written consent signed by a parent for emergency medical care. A child's record shall contain signed parental consent for emergency medical care for the child. Written consent is required prior to admission.

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: CONTINUED NONCOMPLIANCE An unannounced inspection occurred at the facility on 8/4/25. A review of staff files was conducted. Staff person #4 has not completed the following required pre-service training, is within 90 days of their date of hire, but was working unsupervised (see LIS code sheet): pediatric first aid/CPR and health and safety training. An acceptable plan of correction was received on 9/10/25. A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. Staff person #1 has not completed the following required pre-service training, is within 90 days of their date of hire, and was working unsupervised (see LIS code sheet): pediatric first aid/CPR.

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. Until such time as the required pre- service trainings are 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 #1, staff person #1 may not work in a child-care position at the facility.

Regulation: 3270.151(a)/3270.192(3)

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

Noncompliance Area: CONTINUED NONCOMPLIANCE An unannounced inspection occurred at the facility on 8/4/25. A review of staff files was conducted. Staff #3 was observed during this inspection providing child care and the file was missing a health assessment. A health assessment is required to be on file prior to a staff providing child care. An acceptable plan of correction was received on 9/10/25. A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. Regulation requires staff to update their health assessment at least every 24 months. The following staff did not update their health assessments at least every 24 months: Staff #9 (previous 8/28/23, current 9/4/25). The following staff did not receive a health assessment prior to working in a child care role at the facility: Staff #1 (received 7/23/25) and Staff # 6 (none). See code sheet for the date of hire.

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: 3270.182(5)

Description: Consent for administration of minor first-aid required prior to admission

Noncompliance Area: A renewal inspection occurred at the facility on 10/28/25. A review of children's files was conducted. Regulation requires consent for administration of minor first-aid procedures by staff for children prior to admission. Child #6 is enrolled and attends the facility, and the file did not contain consent for administration of minor first-aid procedures by staff.

Correction Required: 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.

Regulation: 3270.192(5)

Description: Two written references

Noncompliance Area: CONTINUED NONCOMPLIANCE An unannounced inspection occurred at the facility on 8/4/25. A review of staff files was conducted. Staff #3 was observed working in a child care role at the time of this inspection and the file was missing two letters of written reference. An acceptable plan of correction was received on 9/10/25. A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. The files of Staff #5, #6 and #7 were missing two letters of written 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: 3270.27(c)

Description: Training regarding plan

Noncompliance Area: A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. Regulation requires staff to review the facility's emergency plan on an annual basis. Staff #7 did not review the facility's emergency plan on annual basis (previous review 6/21/21).

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

Regulation: 3270.31(e)(4)(i)

Description: Age and Training

Noncompliance Area: A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. Staff person #7 has 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 5/23/25. 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 pre- service trainings are completed, staff persons #7 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 #7, staff persons #7may not work in a child-care position at the facility.

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

Description: Fire safety - 1 yr.

Noncompliance Area: A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. Regulation requires staff to participate in updated fire safety training on an annual basis. The following staff did not participate in annual fire safety training: Staff #9 (previous 9/26/24, current 10/7/25), Staff #7 (previous 3/15/23, no current) and Staff #8 (previous 9/24/24, no current).

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(e)(4)(iii)/3270.115(a)(6)

Description: Lifeguard/Lifeguard training/supervision

Noncompliance Area: A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. Staff #7 was identified by the director as the facility's lifeguard used when the children swim. The file of Staff #7 did not contain current lifeguard certification (expired 5/21/25) at the time of the inspection.

Correction Required: Competence in lifeguard training is demonstrated by completion of lifeguard training, including first-aid training and cardiopulmonary resuscitation (CPR) for child and infant. When children are swimming, supervision shall include one person certified in lifeguard training, as described in § 3270.31(e)(4)(iii) (relating to age and training). TIERED LIS: 1. When children are swimming, supervision shall include one person certified in lifeguard training, as described in § 3270.31(e)(4)(iii) (relating to age and training). Children may not swim until a lifeguard with all appropriate training and file requirements are completed. ((This portion of the plan requires an immediate correction.)) 2. Competence in lifeguard training is demonstrated by completion of lifeguard training, including first-aid training and cardiopulmonary resuscitation (CPR) for child and infant. ((This portion of the plan requires a date when the lifeguard will have completed updated lifeguard certification.))

Regulation: 3270.31(e)(4)(iv)/3270.115(a)(8)

Description: Water safety/Included in ratio/annual training

Noncompliance Area: A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. At the time of the inspection, the director indicted the children in the program swim, and the following were staff listed as staff that would supervise the children swimming, but these staff files did not contain documentation of current water safety training: Staff #1, #3, #6 and #8.

Correction Required: Competence in water safety instruction is demonstrated by the completion of basic instruction in water safety from a certified lifeguard. A facility person who is counted in the staff-child swimming ratio shall annually complete water safety instruction.

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

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

Noncompliance Area: A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. Regulation requires staff to participate in 12 hours of annual child care training. At the time of the inspection, Staff #8 was only able to provide 8 of the12 required hours of annual child care training for the training year 5/3/24 to 5/3/25.

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: A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. Staff persons #1 and #3 have not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): pediatric first aid/CPR.

Correction Required: Staff persons shall complete professional development within 90 days of hire as listed in subsections (f)10. Until such time as the required pre- service trainings are completed, staff persons #1 and #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 persons #1 and #3, staff persons #1 and #3 may not work in a child-care position at the facility.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: CONTINUED NONCOMPLIANCE An unannounced inspection occurred at the facility on 8/4/25. A review of staff files was conducted. The following staff did not have the correct documents on file to be hired as a provisional hire per the CPSL: Staff #1 and #2 were missing the NSOR clearance and the disclosure statement. Staff #3 was missing the state police clearance, child abuse clearance and the NSOR clearance. Staff #4 was missing the NSOR clearance and was observed working unsupervised with children. These staff were observed working in a child care role at the facility at the time of the inspection but were not hired correctly as provisional hires. An acceptable plan of correction was received on 9/10/25. A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. The following staff did not have the correct documents on file to be hired as a provisional hire per the CPSL: Staff #3 was still missing the child abuse clearance. See the code sheet for the date of hire.

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, #2, #3, #4may not work in a child care position at the facility. TIERED LIS: 1. The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Facility Person #3 may not work in a child care position with direct contact with routine interaction with children until all clearances are on file at the facility. (THIS PORTION OF THE PLAN SHALL HAVE AN IMMEDIATE CORRECTION DATE.) 2. The legal entity will submit complete files to the Regional Office for any new hires for a period of three months from the date an acceptable plan is received. During that time, new hires may not begin to work in child care until their file has been approved by the Regional Office. Submitted files will be reviewed within 1 week of submission. (THE CORRECTION DATE FOR THIS PORTION OF THE PLAN SHALL BE AT MINIMUM OF 3 MONTHS FROM THE DATE AN ACCEPTABLE PLAN IS SUBMITTED.) 3. The Director and any Legal Entity Representative involved in the hiring of staff will call the Regional Office (800-222-2108) to schedule the legal entity representative involved in the hiring of staff and the director to participate in the next Existing Provider Training. The Legal Entity and Director will submit documentation to the Regional Office to confirm that they have attended the training. (THIS PORTION OF THE PLAN SHALL HAVE A DATE FOR AFTER THE ATTENDING OF THE EXISTING PROVIDER ORIENTATION.)

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

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

Noncompliance Area: CONTINUED NONCOMPLIANCE An unannounced inspection occurred at the facility on 8/4/25. A review of staff files was conducted. The following staff were observed in a child care role at the time of this inspection, but their file was missing proof of education, and these staff could not be appropriately qualified to work in a child care role at the facility: Staff #2, #3 and #4. An acceptable plan of correction was received on 9/10/25. A renewal inspection occurred at the facility on 10/28/25. A review of staff files was conducted. The following staff were observed in a child care role at the time of this inspection, but their file was missing proof of education, and these staff could not be appropriately qualified to work in a child care role at the facility: Staff #3, #5 and #6.

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

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

Noncompliance Area: An unannounced inspection occurred at the facility on 8/4/25. A physical site review was conducted. Staff #5 was supervising a group of 9-younger school aged children in the Main Building 2nd Floor SACC Room. Staff #5 allowed three of these children to leave this room to enter the Main Building 2nd Floor Preschool Room to warm up their lunch. These two rooms are adjacent to each other and only separated by a double door. When the three children left the SACC room to enter the Preschool room, Staff #5 was no longer able to provide appropriate supervision as required by regulation.

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: 1. Children must be supervised at all times. (THIS PORTION OF THE PLAN SHALL HAVE AN IMMEIDATE CORRECTION DATE.) 2. The Legal Entity / Director will amend the facility's supervision/ratio policy to include the following: - How staff will communicate the transition of children from one room or group to another, while maintaining supervision and ratios. - How staff will ensure appropriate supervision and ratio is maintained during lunch preparation for school-age children. - If transitioning of children is not possible for children to prepare their meals, how staff will prepare and deliver children's lunches in other rooms to ensure supervision and appropriate ratios are maintained in all classrooms. This policy must be submitted to the Northeast Regional Office for approval. Once approved, all existing staff and any new hires must be trained on the approved policy, and documentation must be kept on file at the facility. (THE OPERATOR SHALL PROVIDE A DATE FOR WHEN THIS POLICY WILL BE WRITTEN, APPROVED AND REVEIWED WITH STAFF.)

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: An unannounced inspection occurred at the facility on 8/4/25. A review of staff files was conducted. Staff person #4 has not completed the following required pre-service training, is within 90 days of their date of hire, but was working unsupervised (see LIS code sheet): pediatric first aid/CPR and health and safety training.

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. Until such time as the required pre- service trainings are completed, staff person #4 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 #4, staff person #4 may not work in a child-care position at the facility.

Regulation: 3270.151(a)/3270.192(3)

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

Noncompliance Area: An unannounced inspection occurred at the facility on 8/4/25. A review of staff files was conducted. Staff #3 was observed during this inspection providing child care and the file was missing a health assessment. A health assessment is required to be on file prior to a staff providing child care.

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: An unannounced inspection occurred at the facility on 8/4/25. A review of staff files was conducted. Staff #3 was observed working in a child care role at the time of this inspection and the file was missing two letters of written 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: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: An unannounced inspection occurred at the facility on 8/4/25. A review of staff files was conducted. The following staff did not have the correct documents on file to be hired as a provisional hire per the CPSL: Staff #1 and #2 were missing the NSOR clearance and the disclosure statement. Staff #3 was missing the state police clearance, child abuse clearance and the NSOR clearance. Staff #4 was missing the NSOR clearance and was observed working unsupervised with children. These staff were observed working in a child care role at the facility at the time of the inspection but were not hired correctly as provisional hires.

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, #2, #3 and #4 may not work in a child care position at the facility. TIERED LIS: 1. The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Facility Person #1, #2, #3 and #4 may not work in a child care position with direct contact with routine interaction with children until all clearances are on file at the facility. (THIS PORTION OF THE PLAN SHALL HAVE AN IMMEDIATE CORRECTION DATE.) 2. The legal entity will submit complete files to the Northeast Regional Office for any new hires for a period of three months from the date an acceptable plan is received. During that time, new hires may not begin to work in child care until their file has been approved by the Northeast Regional Office. Submitted files will be reviewed within 1 week of submission. (THE CORRECTION DATE FOR THIS PORTION OF THE PLAN SHALL BE AT MINIMUM OF 3 MONTHS FROM THE DATE AN ACCEPTABLE PLAN IS SUBMITTED.)

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

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

Noncompliance Area: An unannounced inspection occurred at the facility on 8/4/25. A review of staff files was conducted. The following staff were observed in a child care role at the time of this inspection, but their file was missing proof of education, and these staff could not be appropriately qualified to work in a child care role at the facility: Staff #2, #3 and #4.

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: 3270.52

Description: Mixed Age Level

Noncompliance Area: An unannounced inspection occurred at the facility on 8/4/25. A physical site review was conducted. At the time of this inspection, Staff #4 was observed providing child care in a classroom that contained 14-older school aged children and 3-young school age children. This number of children would have required at least two 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). TIERED LIS: 1. The required staff:child ratios must be maintained at all times. (THIS PORTION OF THE PLAN SHALL HAVE AN IMMEDIATE CORRECTION DATE.) 2. The Legal Entity / Director will amend the facility's supervision/ratio policy to include the following: - How staff will communicate the transition of children from one room or group to another while maintaining supervision and ratios. - How staff will ensure appropriate supervision and ratio is maintained during lunch preparation for school age children. - If transitioning of children is not possible for children to prepare their meals, how will staff prepare and deliver children's lunches in other rooms to ensure supervision and appropriate ratios are maintained in all classrooms. This policy must be submitted to the Northeast Regional Office for approval. Once approved, all existing staff and any new hires must be trained on the approved policy, and documentation must be kept on file at the facility. (THE OPERATOR SHALL PROVIDE A DATE FOR WHEN THIS POLICY WILL BE WRITTEN, APPROVED AND REVEIWED WITH STAFF.)

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

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

Noncompliance Area: On 12/3/24, at approximately 2:30 p.m., Child #1 got stuck and was left unsupervised in the stairwell of the facility's Annex building while transitioning for gym time at the main building with Staff #1. Staff #1 realized it immediately upon reaching the supervision checkpoint at the main building, and notified Staff #4. In the meantime, Staff #2 heard Child #1 crying in the stairwell, took over supervision of the child. Through the use of the facility's policy on supervision checkpoints, the child was located and placed under the supervision of staff in less than one minute. Staff #4 self-reported the incident of non-compliance.

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 shall enhance their existing supervision procedures with regard to supervision during transition time. These procedures should specifically address an updated procedure for a staff moving the children from one building to another, especially when they are the only staff person. The legal entity will submit procedures to the Northeast Regional Office for approval. Once approved, all existing staff and new hires must be trained on the approved procedures, and it must be documented at the facility.

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

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

Noncompliance Area: On 12/3/24, at approximately 2:30 p.m., Child #1 got stuck and was left unsupervised in the stairwell of the facility's Annex building while transitioning for gym time at the main building with Staff #1. Staff #1 realized it immediately upon reaching the supervision checkpoint at the main building, and notified Staff #4. In the meantime, Staff #2 heard Child #1 crying in the stairwell, took over supervision of the child. Through the use of the facility's policy on supervision checkpoints, the child was located and placed under the supervision of staff in less than one minute. Staff #4 self-reported the incident of non-compliance.

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. Children must be supervised at all times. Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises.

Regulation: 3270.124(b)(4)/3270.182(3)

Description: Written consent/Consent for emergency medical care required prior to admission

Noncompliance Area: A renewal inspection occurred at the facility. A review of children's files was conducted. Regulation requires parental consent for emergency medical care to be obtained and maintained in the child's file. Consent for emergency medical care was missing in the following children's files: Child #2, # 6 and # 8. An acceptable plan of correction was received on 11/13/24. A verification visit occurred at the facility on 12/17/24. Consent for emergency medical care consent was still missing in the following child's file: Child #8.

Correction Required: Emergency contact information must include the written consent signed by a parent for emergency medical care. A child's record shall contain signed parental consent for emergency medical care for the child. Written consent is required prior to admission.

Regulation: 3270.151(a)/3270.192(3)

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

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. Regulation requires staff to participate in an updated health assessment every 24 months. The following staff did not participate in an updated health assessment every 24 months: Staff #3 (previous 10/6/21, current 10/8/24); Staff #4 (previous 9/15/22, not updated); Staff #5 (previous 10/25/22, not updated) and Staff #6 (previous 8/13/21, current 1/26/24). An acceptable plan of correction was received on 11/13/24. A verification visit occurred at the facility on 12/17/24. The following staff still did not participate in an updated health assessment every 24 months: Staff #4 (previous 9/15/22, not updated).

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: 3270.182(5)

Description: Consent for administration of minor first-aid required prior to admission

Noncompliance Area: A renewal inspection occurred at the facility. A review of children's files was conducted. Regulation requires parental consent for administration of minor first-aid procedures by staff to be obtained and maintained in children's files. The following children's files were missing consent for minor first-aid: Staff #2, #4, #6 and #8. An acceptable plan of correction was received on 11/13/24. A verification visit occurred at the facility on 12/17/24. The following child's file was still missing consent for minor first-aid: Child #8.

Correction Required: 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.

Regulation: 3270.31(e)(4)(i)

Description: Age and Training

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. Regulation requires staff to participate in pediatric first aid/CPR training prior to their current certification expiring. The following staff did not participate in pediatric first aid/CPR training prior to their current certification expiring: Staff #2 (previous 4/1/22, no current); Staff #3 (previous 4/4/22, current 4/13/24); Staff #5 (previous 10/15/22, no current) and Staff #6 (previous 4/1/22, current 4/13/24). An acceptable plan of correction was received 11/13/24. A verification visit occurred at the facility on 12/17/24. The following staff still did not participate in pediatric first aid/CPR training prior to their current certification expiring: Staff #2 (previous 4/1/22, no current).

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. Staff person(s) shall complete professional development in the topics of 3270.31(f)(10). Staff person #2 will have until 1/15/25 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 #2.

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

Description: Fire safety - 1 yr.

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. Regulation requires staff to participate in annual fire safety training. The following staff did not participate in annual fire safety training: Staff #2 (previous 2/19/23), Staff #3 (previous 2/7/23), Staff #4 (previous 3/12/23), Staff #5 (10/15/23), Staff #6 (previous 10/15/23) and Staff #7 (previous 7/13/23). An acceptable plan of correction was received on 11/13/24. A verification visit occurred at the facility on 12/17/24. The following staff still did not participate in annual fire safety training: Staff #2 (previous 2/19/23), Staff #4 (previous 3/12/23) and Staff #6 (previous 10/15/23).

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

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: A renewal inspection occurred at the facility. A review of files was conducted. The CPSL requires clearances to be updated every 60 months. The following staff did not update their listed clearance every 60 months: Staff #2 state police (previous 7/15/19, not updated) and child abuse (previous 7/19/19, not updated); Staff #3 state police (previous 3/18/19, current 10/2/24) and Staff #6 state police (previous 4/11/19, current 9/13/24), child abuse (previous 4/22/19, not updated) and FBI (previous 4/10/19, not updated). The CPSL requires mandated reporter training to be updated every 60 months. The following staff did not update their mandated reporter training every 60 months: Staff #2 (previous 7/17/19, no current). An acceptable plan of correction was received on 11/13/24. A verification visit occurred at the facility on 12/17/24. The following staff still did not update their listed clearance every 60 months: Staff #6 child abuse (previous 4/22/19, not updated).

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 #6 may not work in a child care position at the facility.

Regulation: 3270.123(a)(1)/3270.123(a)(2)

Description: Amount of fee/Date fee to be paid

Noncompliance Area: A renewal inspection occurred at the facility. A review of children's files was conducted. Regulation requires the agreement form to contain the amount of the fee to be charged per day or per week. The file of Child #2 was missing the amount of the fee to be charged per day/week and the date on which the fee is to be paid.

Correction Required: An agreement shall specify the amount of the fee to be charged per day or per week. An agreement shall specify the date on which the fee is to be paid.

Regulation: 3270.123(a)(4)

Description: Arrival/departure times

Noncompliance Area: A renewal inspection occurred at the facility. A review of children's files was conducted. Regulation requires an agreement form to specify the child's arrival and departure times. Child file #7 and #9 did not contain the child's arrival and departure times.

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

Regulation: 3270.124(b)(4)/3270.182(3)

Description: Written consent/Consent for emergency medical care required prior to admission

Noncompliance Area: A renewal inspection occurred at the facility. A review of children's files was conducted. Regulation requires parental consent for emergency medical care to be obtained and maintained in the child's file. Consent for emergency medical care was missing in the following children's files: Child #2, # 6 and # 8.

Correction Required: Emergency contact information must include the written consent signed by a parent for emergency medical care. A child's record shall contain signed parental consent for emergency medical care for the child. Written consent is required prior to admission.

Regulation: 3270.124(b)(6)

Description: Insurance coverage information

Noncompliance Area: A renewal inspection occurred at the facility. A review of child files was conducted. Regulation requires children's files to contain health insurance coverage and the policy number. The file of Child #3 was missing documentation of their health insurance coverage and the 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.

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. The OCDEL Announcement C-22-06 requires all current child care staff who completed the previous health and safety pre-service training modules prior to October 4, 2022 to complete the Pennsylvania Health and Safety Update 2022 by December 30, 2022. The following staff did not complete this training as required prior to December 30, 2022: Staff #3 and #5.

Correction Required: The OCDEL Announcement C-22-06 requires all current child care staff who completed the previous health and safety pre-service training modules prior to October 4, 2022 to complete the Pennsylvania Health and Safety Update 2022 by December 30, 2022.

Regulation: 3270.151(a)/3270.192(3)

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

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. Regulation requires staff to participate in an updated health assessment every 24 months. The following staff did not participate in an updated health assessment every 24 months: Staff #3 (previous 10/6/21, current 10/8/24); Staff #4 (previous 9/15/22, not updated); Staff #5 (previous 10/25/22, not updated) and Staff #6 (previous 8/13/21, current 1/26/24).

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: 3270.182(5)

Description: Consent for administration of minor first-aid required prior to admission

Noncompliance Area: A renewal inspection occurred at the facility. A review of children's files was conducted. Regulation requires parental consent for administration of minor first-aid procedures by staff to be obtained and maintained in children's files. The following children's files were missing consent for minor first-aid: Staff #2, #4, #6 and #8.

Correction Required: 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.

Regulation: 3270.27(c)

Description: Training regarding plan

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. Regulation requires staff to review the facility's emergency plan on an annual basis. The following staff did not review the facility's emergency plan on an annual basis: Staff #6 and #7 (previous review 10/9/23).

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

Regulation: 3270.31(e)(4)(i)

Description: Age and Training

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. Regulation requires staff to participate in pediatric first aid/CPR training prior to their current certification expiring. The following staff did not participate in pediatric first aid/CPR training prior to their current certification expiring: Staff #2 (previous 4/1/22, no current); Staff #3 (previous 4/4/22, current 4/13/24); Staff #5 (previous 10/15/22, no current) and Staff #6 (previous 4/1/22, current 4/13/24).

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. Staff person(s) shall complete professional development in the topics of 3270.31(f)(10). Staff person #2 and #5 will have until 11/28/24 to complete the required training. Until such time as the required training has been completed, staff person #2 and #5 must be supervised, when interacting with children, by an AGS who has completed the required training related to this citation. If there are no staff available to supervise staff person #2 and #5, staff person #2 and #5 may not work in a child-care position at the facility.

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

Description: Fire safety - 1 yr.

Noncompliance Area: A renewal inspection occurred at the facility. A review of staff files was conducted. Regulation requires staff to participate in annual fire safety training. The following staff did not participate in annual fire safety training: Staff #2 (previous 2/19/23), Staff #3 (previous 2/7/23), Staff #4 (previous 3/12/23), Staff #5 (10/15/23), Staff #6 (previous 10/15/23) and Staff #7 (previous 7/13/23).

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

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: A renewal inspection occurred at the facility. A review of files was conducted. The CPSL requires clearances to be updated every 60 months. The following staff did not update their listed clearance every 60 months: Staff #2 state police (previous 7/15/19, not updated) and child abuse (previous 7/19/19, not updated); Staff #3 state police (previous 3/18/19, current 10/2/24) and Staff #6 state police (previous 4/11/19, current 9/13/24), child abuse (previous 4/22/19, not updated) and FBI (previous 4/10/19, not updated). The CPSL requires mandated reporter training to be updated every 60 months. The following staff did not update their mandated reporter training every 60 months: Staff #2 (previous 7/17/19, no current).

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 #2 and #6 may not work in a child care position at the facility.

Regulation: 3270.66(a)

Description: Locked or inaccessible

Noncompliance Area: A renewal inspection occurred at the facility. A physical site review as conducted. Hand wash, hand lotion and hand sanitizer were found accessible in the annex toddler rear room. Two bottles of hand sanitizer and degreaser were found accessible to children. These items stated to keep out of the reach of children. Children were observed to be receiving care in these rooms during the inspection.

Correction Required: Cleaning materials and other toxic materials shall be kept in an area or container that is locked or made inaccessible to children.

Regulation: 3270.67(d)/3270.82(i)

Description: Contaminated trash in closed plastic-lined receptacle/Lidded waste receptacles

Noncompliance Area: A renewal inspection occurred at the facility. A physical site review was conducted. Several garbage cans were observed throughout the facility in child care spaces and in bathrooms that contained items as described by regulation and these garbage cans did not included lids. Children were observed to be receiving care in these spaces that contained garbage cans with no lids during this inspection. These garbage cans were identified and address with the director at the time of the inspection.

Correction Required: Trash that has been contaminated by human secretions or excrement shall be contained in closed, plastic-lined receptacles. A toilet area, training chair area, diapering area and sink area shall be equipped with a clean, lidded waste receptacle.

Regulation: 3270.72(d)

Description: Above ground window opening restricted to 6"

Noncompliance Area: A renewal inspection occurred at the facility. A physical site review was conducted. Several windows on the second and third floors of the facility had windows that were not restricted to opening less than 6 inches. Children were observed to be receiving care in rooms on the second floor of the facility that contained some of these unrestricted windows at the time of the inspection. These windows were identified and addressed with staff at the time of this inspection.

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: A renewal inspection occurred at the facility. A review of the facility's fire safety system testing logs were conducted. Regulation requires the fire safety system to be tested at least every 30 days. The following tests lapsed occurring at least every 30 days: 7/23/24, 8/23/24 and 9/23/24.

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: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: An unannounced inspection occurred at the facility. A review of staff files was conducted. At the time of the inspection, staff person #1 was unable to provide documentation that the following required pre-service training was completed within 90 days of their date of hire (see LIS code sheet): health and safety topics.

Correction Required: Staff person(s) shall complete professional development in the topics of 3270.31(f)(1 -- 10) within 90 days of hire. Staff person #1 will have until 9/4/24 to complete the required training. Until such time as the required training has been completed, staff person #1 must be supervised, when interacting with children, by an AGS who has completed the required training related to this citation. If there are no staff available to supervise staff person #1, staff person #1 may not work in a child-care position at the facility.

Regulation: 3270.113(a)(1)

Description: Staff assigned to specific children

Noncompliance Area: During an inspection on 11/16/2023, it was found that staff 1 was not able to identify her assigned group. As per staff 1 and 2, staff 1 was a substitute due to call offs and is not typically in that room.

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

Regulation: 3270.111(b)

Description: Posted in group space

Noncompliance Area: The school age room and four year old room did not havhe daily schedules posted.

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

Regulation: 3270.123(a)(3)

Description: Services proceeded

Noncompliance Area: Child 2 did not have a child service report on file.

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: 3270.134(a)/3270.152

Description: Child's hands washed/Adult Hygiene

Noncompliance Area: During the renewal inspection on 10/23/2023, it was observed that staff 3 did not wash the hands of the child being diapered or her own hands after diapering.

Correction Required: A staff person shall ensure that a child's hands are washed before meals and snacks, after toileting and after being diapered. A facility person shall wash his hands before meals and snacks, and after toileting and after diapering a child.

Regulation: 3270.181(c)

Description: Emergency info/agreement updated 6 mos

Noncompliance Area: Child 1 had an oudated fee agreement on file. The fee agreement on file was last updated February of 2023.

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

Regulation: 3270.192(2)(ii)

Description: Exp, educ., training prior to facility

Noncompliance Area: Staff 4 did not have proof of education on file.

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

Regulation: 3270.192(5)

Description: Two written references

Noncompliance Area: Staff 2 only had one letter of reference on file.

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)(10)

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

Noncompliance Area: Staff person #1 has not completed the following required pre-service training within 90 days of their date of hire: pediatric first aid/cpr.

Correction Required: Staff person(s) shall complete professional development in the topics of 3270.31(f)(10) within 90 days of hire. Staff person #1 will have until 11/30/2023 to complete the required training. Until such time as the required training has been completed, staff person #1 must be supervised, when interacting with children, by an AGS who has completed the required training related to this citation. If there are no staff available to supervise staff person #1, staff person #1 may not work in a child-care position at the facility.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: Staff 2 had a volunteer child abuse clearance on file.

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

Regulation: 3270.75(c)

Description: Has all items

Noncompliance Area: The school age room did not have soap in the first aid kit.

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: 3270.95(a)/3270.95(b)

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

Noncompliance Area: The facility did not have appropriate annual fire inspection paperwork on file. The facility also did not have documentation of testing the alarm system every 30 days on file.

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: 3270.21/3270.111(c)

Description: General Health and Safety/Promote development

Noncompliance Area: During a complaint investigation on 6/29/23, staff persons # 1 and 2 admitted that when child # 1 had a bowel movement they did not assist child # 1 while they cleaned themself. Staff # 1 and 2 believed they are not permitted to assist a potty-trained child by touching them "below the belt" to clean them.

Correction Required: Conditions at the facility may not pose a threat to the health or safety of the children. Daily activities shall promote the development of skills, social competence and self-esteem. Daily experiences shall recognize the child as an individual and give some choice of activities that respect personal privacy, lifestyle and cultural background.

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: Staff persons #1 -5 completed the required one-hour 2022 update to the health and safety training after 12/30/22.

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

Regulation: 3270.151(a)

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

Noncompliance Area: Per record review on 12/16/21 for staff number 2 ; staff 2 does not have a record of 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.

Regulation: 3270.27(a)(2)/3270.27(a)(6)

Description: Emergency plan/Emergency plan

Noncompliance Area: The emergency plan does not include evacuation of children from facility to another location. The emergency plan does not include a plan to conduct an emergency drill and a record of logged emergency drills.

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. The evacuation routes and evacuation plans to exit the building may be the same as those required by §3270.94 (relating to fire drills).Emergency drills shall be conducted annually. Annual emergency drills shall be documented and on file at the facility.

Regulation: 3270.27(a)(3)/3270.27(a)(5)

Description: Contact when arises/Emergency plan

Noncompliance Area: The emergency plan does not include a method to contact parents. The emergency plan does not include accommodations for infants, toddlers and children with disabilities and chronic conditions.

Correction Required: The facility shall have an emergency plan that provides for a method for facility persons to contact parents as soon as reasonably possible when an emergency situation arises. The facility shall have an emergency plan that provides for accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: During inspection on 12/16/21 it was revealed: that staff number 1 start date in child care 6/10/21 does not have a record of application of clearance request or clearance for the New Jersey child abuse clearance per the CPSL guideline. Staff number 2 start date 10/26/21 does not have a record of the New York child abuse clearance per the CPSL guideline.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). LACKING REQUIRED HIRING DOCUMENTS: Staff Person # -1- & # 2 may not work in a child care position at the facility.

Noncompliance Area: There is no physician name or phone number provided on the emergency contact form for child # 1.

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: More than 24 months passed between health assessments for staff person # 3. The health assessments on file are dated 5/2017 and 11/2019

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: Staff person # 4 was hired on 8/26/2019. The FBI clearance on file is for Department of Education, therefore is not valid. Staff person # 5 was hired on 1/10/20; there is no NSOR clearance on file.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Staff Persons # 4 and 5 may not work in a child care position at the facility. A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL. Staff person # 4 and 5 may not work in a child care position at the facility.

Noncompliance Area: Staff person # 2 started on 2/1/2018; there is no staff evaluation on file. Staff person # 3 started on 8/17/2011; there is only one staff evaluation on file with no date on it.

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

Noncompliance Area: The first aid kits located in the Toddler B and Infant rooms did not have band-aids.

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.

Noncompliance Area: There is a hole in the baseboard molding under the window in the preschool room. There are 2 stained ceiling tiles in the toddler lunch are.

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: There is peeling paint on the molding near the portable sink in the Toddler 2 classroom.

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

Noncompliance Area: On 7/11/2019, during a complaint investigation, staff person # 1 and # 2 reported that child # 1 was left sleeping alone in a classroom while the rest of the class went to the pool. It was estimated that the child was alone for 5-10 minutes. Staff person # 1 had child # 1 in their assigned group.

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 legal entity must arrange for all facility staff to receive a minimum of four (4) hours of in person training regarding supervision of children especially during transition times. The legal entity must receive DHS approval of the training content prior to scheduling the training. Each staff person shall be assigned the responsibility for supervision of specific children. The staff person shall know the names and whereabouts of the children in his assigned group. The staff person shall be physically present with the children in his group on the facility premises and on facility excursions off the facility premises.

Noncompliance Area: On 7/16/19, during a complaint investigation, the certification rep observed 13 preschool children swimming with only 2 staff members present. Three staff members are required to meet the swimming staff-child ratios for 13 preschool children.

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

Noncompliance Area: On 7/11/19, during a complaint investigation, it was determined that on 7/8/2019 two male minor children walked through the child care space to get to another area of the building and addressed the children in child care in a threatening manner. Staff person # 1 reported one of the boys stated "don't mess with me" while showing a toy gun to the children.

Correction Required: Conditions at the facility may not pose a threat to the health or safety of the children. Indoor space in which children are receiving care may not be used simultaneously for other business, commercial, social or another purpose unrelated to the child care being offered.

Noncompliance Area: On 7/2/2019, during a complaint investigation, staff admitted to using a gym that is also used by the YMCA for Zumba classes for child care. This room is not part of the measured child care space listed on the certificate of compliance.

Correction Required: Conditions at the facility may not pose a threat to the health or safety of the children.Indoor child care space is measured within permanent stationary partitions or walls. The allowable number of children in a space is determined by dividing the total square feet in a space by 40.

Noncompliance Area: On 7/2/2019, during a complaint investigation, certification rep observed 4 infants, 14 toddlers, 14 preschool children, 21 pre k children, and 63 school aged children on site. School aged camp directors reported that 2 additional groups of school aged children were receiving child care off site at community parks; one group had 30 children and one group had 28. This is a total of 174 children exceeding the facility capacity by 27 children; the maximum capacity for the facility is 147 children.

Correction Required: Conditions at the facility may not pose a threat to the health or safety of the children. The total number of children receiving child day care services at the facility at any one time may not exceed the facility's maximum capacity. The legal entity will immediately reduce the number of children in child care on and off the premises to 147 or less.

Noncompliance Area: On 7/2/2019, during a complaint investigation, certification representative observed 32 school aged children in a classroom with a measured capacity of 24.

Correction Required: Indoor child care space is measured within permanent stationary partitions or walls. The allowable number of children in a space is determined by dividing the total square feet in a space by 40. The capacity established for an indoor space may not be exceeded.

Noncompliance Area: The fee agreement on file for child # 1 does not have the fee amount or the date in which the fee is to be paid. The fee agreement on file for child # 4 does not include the date in which the fee is to be paid.

Correction Required: An agreement shall specify the amount of the fee to be charged per day or per week. An agreement shall specify the date on which the fee is to be paid.

Noncompliance Area: The financial agreements on file for children # 3 and # 4 do not include the children's date of admission and are not signed by the operator.

Correction Required: An agreement shall specify the date of the child's admission. An agreement shall be signed by the operator and the parent.

Noncompliance Area: The emergency contact information provided for children # 4 and # 6 did not include the health insurance coverage and 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: There is no immunization record attached to the health assessment on file for child # 7, DOB 1/17/08.

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

Noncompliance Area: The health assessment on file for staff person # 1, dated 10/18/2016, is older than 24 months and therefore no longer valid. The health assessment on file for staff person # 3, dated 2/4/17, is older than 24 months and therefore no longer valid.

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: The emergency contact form and financial agreement on file for children # 2 and # 5 and 6 were not updated at least once in a six month period The date of the emergency contact form for child # 2 is 8/27/18; the financial agreement is dated 9/4/2018. The emergency contact form and financial agreement forms on file for child # 5 were dated 10/24/18. The emergency contact form and financial agreement forms on file for child # 6 were dated 7/24/2018.

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: There is no written consent for emergency medical care or consent for the administration of minor first aid on file for children # 4 and # 5.

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: Staff person # 1 was hired on 3/4/19; there is no documentation that they have been trained on the emergency plan procedures on file.

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. Staff shall be trained within one week of hire and within one week of any and all updates.

Noncompliance Area: Staff person # 4 was hired on 4/19/19 and their state police clearance was requested and dated 4/22/2019.

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

Noncompliance Area: There is a stove accessible to the children an unlocked room connected to the school age room inside the facility.

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.

Noncompliance Area: There is no hand washing sign posted in the Pre K bathroom as required.

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.