Callowhill Kidz Childcare Center Corporation

Regulation: 3270.102(c)

Description: Outdoor equip.- protective surfacing

Noncompliance Area: During a renewal inspection on 6/11/26 Cert rep observed there was 0-5 inches of measurable wood mulch around the embedded playground equipment in multiple locations, including by the slides, and steps. This is less than the required 9 inches of wood mulch.

Correction Required: Outdoor equipment that requires embedded mounting must be mounted over a loose-fill or unitary playground protective surface covering that meets the recommendations of the United States Consumer Product Safety Commission. The equipment must be anchored firmly and be in good repair. TIERED LIS: 1. Embedded equipment must be made inaccessible to children until such time as 9 inches of wood mulch is acquired. This portion of the plan shall have an immediate correction date. 2. Outdoor equipment that requires embedded mounting must be mounted over a loose-fill or unitary playground protective surface covering that meets the recommendations of the United States Consumer Product Safety Commission. The equipment must be anchored firmly and be in good repair. The provider will provide a date for when this portion of the plan will be completed.

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

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

Noncompliance Area: During a complaint investigation on 6/11/26 Cert rep observed the following two incidents related to supervision: In the morning Cert rep observed Staff 1 and 2 had 17 school aged children(6 older school aged and 11 young aged children) on the playground. Staff 1 named and identified 9 children (2 OSA and 7 YSA) as being in their group. Staff 2 named and identified 7 children (4 OSA and 3 YSA)as being in their group. When Cert rep questioned this ts was determined that Child 1 was named and identified as being in both Staff 1 and 2's group. It was also determined that two children present were not named as being in either Staff's group. In the afternoon Cert rep observed Staff 1 and 2 had 17 school aged children(6 OSA and 11 YSA) in the School age room/Room 5. Staff 1 reported having 5 children (5 OSA) children in their group. Staff 2 reported having 11 children (11 YSA). When Cert rep questioned this is was determined that one child present was not named as being in either Staff's 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. 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. TIERED LIS: 1. 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. This portion of the plan shall have an immediate correction date. 2. The operator will have Staff 1 and 2 participate in in the following trainings on Better Kid Care: "Supervision: What's required?" (1 hour long) and "Supervision: Teamwork" (1 hour long) or the Spanish version of these trainings. If Staff 1 and 2 has already completed these trainings the legal entity shall have Staff 1and 2 complete 2 hours of PQAS approved trainings related to supervision. The trainings used to fulfill this portion of the plan must be approved by the NE Regional Office before completion. The legal entity shall maintain documentation of the training certificates in the staff files. The provider shall provide a date when this portion of the plan will be completed.

Regulation: 3270.123(a)

Description: Signed

Noncompliance Area: During a renewal inspection on 6/11/26 Child 3 did not have a fee agreement in their file. Child 3 was observed to be receiving care on 6/11/26.

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

Regulation: 3270.123(a)(3)

Description: Services proceeded

Noncompliance Area: During a renewal inspection on 6/11/26 Child 4's most recent Child Service report was dated 10/23/25, which is more than 6 months ago.

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

Regulation: 3270.124(b)(2)

Description: Physician name, address, phone

Noncompliance Area: During a renewal inspection on 6/11/26 Child 2's emergency contact form did not include the phone number for the child's physician or source of medical care.

Correction Required: Emergency contact information must include the name, address and telephone number of the child's physician or source of medical care.

Regulation: 3270.124(c)

Description: Each child care space

Noncompliance Area: During a renewal inspection on 6/11/26 Child 4's emergency contact form was not present in Room 2 where Cert Rep observed Child 4 receiving care.

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

Regulation: 3270.131(a)/3270.131(e)

Description: Health information/ACIP recommended immunization record

Noncompliance Area: During a renewal inspection on 6/11/26 Pre school Child 3's file did not have a health report, or immunization record. It has been more than 60 days since Child 3's date of admission, and Child 3 was observed to be receiving care on 6/11/26. See LIS code sheet for DOB and Date of admission.

Correction Required: The operator shall require the parent of an enrolled child, including a child, a foster child and a relative of an operator or a facility person, to provide an initial health report no later than 60 days following the first day of attendance at the facility. The facility may not accept or retain an infant 2 months of age or older, a toddler or a preschool child at the facility for more than 60 days following the first day of attendance at the facility unless the parent provides written verification from a physician, physician's assistant, CRNP, the Department of Health or a local health department of the dates (month, day and year) the child was administered immunizations in accordance with the recommendations of the ACIP. Child 3 must be dismissed from care by close of business on 6/11/26 until the health report and immunization record(or exemption letter) is on file.

Regulation: 3270.133(3)/3270.133(5)

Description: Name on bottle/Original label

Noncompliance Area: During a renewal inspection on 6/11/26 Cert rep observed Calamine lotion expiration date 2/2026, Destin expiration date 5/2026, and Aquaphor expiration date 3/2025. Cert rep also observed the Calamine lotion did not have the child's name labeled on it. Additionally Cert rep observed multiple container of Butt Paste and Destin which were not labeled with the respective children's names.

Correction Required: The label of a medication container shall identify the name of the medication and the name of the child for whom the medication is intended. Medication shall be administered to only the child whose name appears on the container. Medication shall be stored in accordance with the manufacturer's or health professional's instructions on the original label.

Regulation: 3270.135(b)

Description: Surfaces cleaned

Noncompliance Area: During a renewal inspection on 6/11/26 Cert rep observed multiple tears in the changing mats in Rooms 2 & 3. These tear prevented proper sanitation of the changing mat surface.

Correction Required: Diaper changing surfaces shall be cleaned after each use by wiping the surface with a sanitizing solution or by changing a pad or other surface covering.

Regulation: 3270.161(d)

Description: Potentially hazardous food refrigerated

Noncompliance Area: During a renewal inspection on 6/11/26 Cert rep observed a jar of Beech Nut baby Food which appeared to have been previously opened on a shelf in room 5. The jar was labeled "refrigerate after opening."

Correction Required: Potentially hazardous food brought from the child's home or provided by the facility shall be refrigerated.

Regulation: 3270.181(c)

Description: Emergency info/agreement updated 6 mos

Noncompliance Area: During a renewal inspection on 6/11/26 Child 1's most recent parent review of fee agreement and emergency contact forms were done on 11/14/25, which is more than 6 months ago.

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: 3270.27(a)(6)

Description: Emergency plan

Noncompliance Area: During a renewal inspection on 6/11/26 the most recent emergency drill was dated 1/2/25, which is more than 12 months ago.

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

Regulation: 3270.31(e)

Description: Age and Training

Noncompliance Area: During a renewal inspection on 6/11/26 the following staff did not have 12 training hours during their training year: Staff 3 (5.5 hours recorded during training year 2/2025-2/2026), Staff 4 (3 hours recorded during training year 5/2025-5/2026) and Staff 6 (8.5 hours recorded during training year 8/2024-8/2025)

Correction Required: A staff person shall obtain an annual minimum of 12 clock hours of child care training. Staff person 3 must take 6.5 hours of professional development to fulfill requirement for training year 2/2025-2/2026. Hours used to fulfill training year 2/2025-2/2026 cannot be used to fulfill current training year or any other training years. Staff person 4 must take 9 hours of professional development to fulfill requirement for training year 5/2025-5/2026. Hours used to fulfill training year 5/2025-5/2026 cannot be used to fulfill current training year or any other training years. Staff person 6 must take 3.5 hours of professional development to fulfill requirement for training year 8/2024-8/2025. Hours used to fulfill training year 8/2024-8/2025 cannot be used to fulfill current training year or any other training years.

Regulation: 3270.35(e)

Description: 46 or more children- additional group sups

Noncompliance Area: During a renewal inspection on 6/11/26 the facility did not have any staff who had been working as group supervisors. It was reported that the facility had 85 children enrolled, and a maximum of 55 children present at any given time, which would require 2 group supervisors.

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.

Regulation: 3270.36(b)(5)/3270.37(b)(3)

Description: HS/GED + 2 yrs/8th grade + 2 yrs

Noncompliance Area: During a renewal inspection on 6/11/26 Staff 2 had a high school diploma and 0 hours of verified experience in their staff file. Staff 2 has been working as an AGS.Staff 5 had verification they completed 8th grade and 0 hours of verified experience in their staff file. Staff 5 has been working as an aide.

Correction Required: An assistant group supervisor shall have a high school diploma or a general educational development certificate and 2 years experience with children. An aide shall have a minimum of an 8th grade education and 2 years of experience with children.

Regulation: 3270.94(a)(1)

Description: Every 60 days

Noncompliance Area: During a renewal inspection on 6/11/26 review of fire drill log noted there was more than 60 days between fire drills dated 3/6/26-5/6/26.

Correction Required: The Director or designated staff person who is responsible for compliance with this chapter ensure fire drills are conducted at least once every 60 days.

Regulation: 3270.95(a)/3270.95(b)

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

Noncompliance Area: During a renewal inspection on 6/11/26 review of fire detection log noted there was more than 30 days between fire detection testing dates 3/4/26-4/7/26.

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: 3270.111(b)/3270.124(e)

Description: Posted in group space/Written emergency plan posted

Noncompliance Area: CONTINUED NON_COMPLIANCE: During a renewal inspection on 12/19/25 Cert rep observed that the daily activities and emergency medical transportation plan were not posted in Room 1. Cert rep also observed that the emergency medical transportation plan was not in the 4 vans(license plates: LKG 2920, ZHZ4112, OB 90914, & ZSH 8536) used for transporting children to and from the facility. An acceptable plan of correction was received on 2/12/26 with a correction date of 12/19/25. On 2/20/26 an unannounced visit was conducted where cert rep observed the emergency medical transportation plan was not posted in Room 1. Cert rep also observed that the emergency medical transportation plan was not in the 3 vans(license plates: OB 90914, & ZSH 8536) used for transporting children to and from the facility. It was reported the emergency medical transportation plan was not being taken during transportation of children in these vans. Cert rep observed the daily schedule was posted in Room 1 and the van with license plate ZHZ 4112 had the emergency medical transportation plan in the van. The van with license plate LKG 2920 is no longer used for transportation of children.

Correction Required: The written plan of daily activities shall be posted in the group space. A written plan identifying the means of transporting a child to emergency care and staffing provisions in the event of an emergency shall be displayed conspicuously in every child care space and shall accompany a staff person who leaves on an excursion with children.

Regulation: 3270.113(a)(1)/3270.113(a)(2)

Description: Staff assigned to specific children/Supervision on and facility premises

Noncompliance Area: During an unannounced inspection on 2/20/26 Cert rep observed the following incident involving staff's assigned supervision groups: Staff 3 and Staff 8 were present in the toddler room with 11 children(5 young toddlers, and 6 older toddlers). Staff 3 named and identified 3 young toddlers, and 2 older toddlers as being in their assigned group. Staff 8 named and identified 2 young toddlers and 4 older toddlers in their assigned group. Staff 8's group exceeded the Ratio for mixed aged groups when the youngest child in the group is a young toddler.

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. The requirement for supervision on and off the facility premises includes compliance with the staff:child ratio requirements in §§ 3270.51--3270.55. TIERED LIS: 1.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 requirement for supervision on and off the facility premises includes compliance with the staff:child ratio requirements in §§ 3270.51--3270.55. This portion of the plan shall have an immediate correction date. 2. The legal entity must update their supervision and ratio policies to include information regarding mixed aged ratios and mixed age supervision groups. This policy will ensure that all children are properly assigned to a specific staff person and supervised at all times. This policy must address supervision group sizes, and assignment to ensure no individual staff exceeds ratios for the children they are assigned. This policy must address the steps staff and the operator will take in order to maintain both similar and mixed aged ratios and supervision group sizes. The legal entity must receive approval of the policy from the Regional Office. Once approved by the Regional Office, the legal entity must review policy with all staff and have staff sign off that the understand and will follow the supervision policy. The operator shall provide a correction date for when this portion of the plan will be completed.

Regulation: 3270.178

Description: Transportation First Aid Kit

Noncompliance Area: CONTINUED NON-COMPLIANCE: During a renewal inspection on 12/19/25 Cert rep observed the first aid kit in the van with license plate LKG 2920 was missing tape and water bottle, the first aid kit in the van with license plate OB 90914 was missing tweezers, soap and water bottle, and the first aid kit in the van with license plate ZSH 8536 was missing a water bottle. The vans are used for transportation of children and it was reported no other first aid kits were taken with staff when transportations occur. An acceptable plan of correction was received on 2/12/26 with a correction date of 2/10/26. On 2/20/26 an unannounced visit was conducted where cert rep observed the first aid kit in the vans with license plates OB 90914 and ZSH 8536 were missing the required water bottle. It was reported no other first aid kits were taken with staff when transportation occurred. Cert rep observed the first aid kits in the vans with license plates OB 90914 and ZSH 8536 had all other items required to be present in the first aid. The van with license plate LKG 2920 is no longer used for transportation of children.

Correction Required: A first-aid kit, including the contents as specified in §3270.75 (relating to first-aid kit) shall be in the vehicle when children are being transported.

Regulation: 3270.76

Description: Building Surfaces

Noncompliance Area: CONTINUED NON COMPLIANCE: During a renewal inspection on 12/19/25 Cert rep observed a tipping/falling hazard due to stacked boxed furniture in Room 1. Cert rep also observed the power cord to a mounted tv was loose and would be accessible to children creating a falling/pulling hazard in Room 1. An acceptable plan of correction was received on 2/12/26 with a correction date of 12/19/25. On 2/20/26 an unannounced visit was conducted where cert rep observed pieces of broken ceiling and a large hole in the ceiling of the hallway where children walk to and from Rooms 1, the toddler room, and the infants room. Cert rep did observe the furniture was no longer stacked in Room 1 and the tv power cord was taped down in Room 1.

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

Regulation: 3270.102(c)

Description: Outdoor equip.- protective surfacing

Noncompliance Area: During a renewal inspection on 12/19/25 cert rep observed less than 9 inches of wood mulch in the following locations around embedded equipment in all ages playspace: around all swings (6 inches of wood mulch observed) and around the rainbow monkey bar climber(7 inches of mulch observed)..

Correction Required: Outdoor equipment that requires embedded mounting must be mounted over a loose-fill or unitary playground protective surface covering that meets the recommendations of the United States Consumer Product Safety Commission. The equipment must be anchored firmly and be in good repair. TIERED LIS: 1. Embedded equipment must be made inaccessible to children until such time as 9 inches of wood mulch is acquired. This portion of the plan shall have an immediate correction date. 2. Outdoor equipment that requires embedded mounting must be mounted over a loose-fill or unitary playground protective surface covering that meets the recommendations of the United States Consumer Product Safety Commission. The equipment must be anchored firmly and be in good repair. The provider willl provide a date for when this portion of the plan will be completed.

Regulation: 3270.111(b)/3270.124(e)

Description: Posted in group space/Written emergency plan posted

Noncompliance Area: During a renewal inspection on 12/19/25 Cert rep observed that the daily activities and emergency medical transportation plan were not posted in Room 1. Cert rep also observed that the emergency medical transportation plan was not in the 4 vans(license plates: LKG 2920, ZHZ4112, OB 90914, & ZSH 8536) used for transporting children to and from the facility.

Correction Required: The written plan of daily activities shall be posted in the group space. A written plan identifying the means of transporting a child to emergency care and staffing provisions in the event of an emergency shall be displayed conspicuously in every child care space and shall accompany a staff person who leaves on an excursion with children.

Regulation: 3270.123(a)(3)

Description: Services proceeded

Noncompliance Area: During a renewal inspection on 12/19/25 the most recent Child Service report(CSR) for Children 5 & 6 was more than 6 months ago. Child 5's most recent CSR was dated 12/20/24, and Child 6's most recent CSR was dated 10/4/24.

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

Regulation: 3270.131(b)(1)

Description: Infant: updated health report every 6 months

Noncompliance Area: During a renewal inspection on 12/19/25 infant Child 4's most recent health assessment was dated 5/1/25 which is more than 6 months ago. See LIS code sheet for Date of birth.

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

Regulation: 3270.133(4)

Description: Locked

Noncompliance Area: During a renewal inspection on 12/19/25 Cert rep observed a staff's prescription medications in their personal bag on the floor of Room 1.

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

Regulation: 3270.151(a)/3270.151(c)(2)

Description: 12 months prior to service and every 24 months thereafter/Mantoux TB

Noncompliance Area: During a renewal inspection on 12/19/25 Staff 10 did not have an initial health assessment or initial TB test. Staff 11 did not have an initial TB test. See LIS code sheet for staffs' first day with children.

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

Regulation: 3270.151(c)(3)

Description: Exam communicable disease

Noncompliance Area: During a renewal inspection on 12/19/25 Staff 11 had a health assessment dated 2/18/25 which did not include an examination for communicable diseases and the results of that examination.

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

Regulation: 3270.175(a)

Description: Age appropriate restraints

Noncompliance Area: During a renewal inspection on 12/19/25 Cert rep observed the 4 facility vans (license plates: LKG 2920, ZHZ4112, OB 90914, & ZSH 8536), did not have child booster or child car seats. It was reported that children ages 5, 6, and 7 years old were being transported without child booster or child car seats in the 4 facility vans.

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).

Regulation: 3270.176(f)

Description: Prohibition using an 11-15 passenger vans

Noncompliance Area: During a renewal inspection on 12/19/25 Cert rep observed that the van with license plate: LKG 2920 did not have the manufacturer's sticker showing the capacity. Compliance is unable to be verified, as the capacity sticker is missing.

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. Effective 12/19/25 the van with license plate: LKG 2920 can not be used for transporting children, until such time as the van is verified to meet the requirements of 67 Pa. Code Chapter 171 and is verified through the manufacturer's sticker to not be an 11-15 passenger van.

Regulation: 3270.178

Description: Transportation First Aid Kit

Noncompliance Area: During a renewal inspection on 12/19/25 Cert rep observed the first aid kit in the van with license plate LKG 2920 was missing tape and water bottle, the first aid kit in the van with license plate OB 90914 was missing tweezers, soap and water bottle, and the first aid kit in the van with license plate ZSH 8536 was missing a water bottle. The vans are used for transportation of children and it was reported no other first aid kits were taken with staff when transportations occur.

Correction Required: A first-aid kit, including the contents as specified in §3270.75 (relating to first-aid kit) shall be in the vehicle when children are being transported.

Regulation: 3270.192(5)

Description: Two written references

Noncompliance Area: During a renewal inspection on 12/19/25 Staff 2 had one reference in their staff 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: 3270.27(c)

Description: Training regarding plan

Noncompliance Area: During a renewal inspection on 12/19/25 Staff 2, 3, 6, & 7, had more than 12 months between emergency plan trainings. Staff 1, & 10 did not receive emergency plan training within 90 days of their date of hire(See LIS code sheet for dates of hire). These were evidenced by review of documentation at the facility: Staff 2, 6, & 7 received emergency plan training on 10/17/24 and 11/12/25. Staff 3 had emergency plan training on 10/17/24, and did not have emergency plan training documentation for 2025 available for review. Staff 9 received emergency plan training on 8/8/24 and 11/12/25. Staff 1 did not receive emergency plan training and has been employed for more than 90 days. Staff 10 received initial emergency plan training on 11/12/25 which is more than 90 days since their date of hire.

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

Regulation: 3270.27(e)

Description: Letter to parents

Noncompliance Area: During a renewal inspection on 12/19/25 the letter to the parents regarding the emergency procedures did not address lockdown or the accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions.

Correction Required: The operator shall provide to the parent of each enrolled child a letter explaining the emergency procedures. The operator shall also provide to the parent of each enrolled child a letter explaining any subsequent update to the plan.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: CONTINUED NONCOMPLIANCE: During an unannounced inspection on 10/9/25 Staff 5 did not have a signed disclosure statement or valid NSOR Certificate in their staff file. Staff 5 signed a disclosure statement on 10/9/25 however this is after their first day with children. See LIS code sheet for the staff's first day working with children (1DwCHN). The facility's acceptable plan of correction indicated the correction would be implemented by 12/1/25. During a renewal inspection on 12/19/25 Cert rep noted the following violations of the CPSL: Cert Rep observed a NSOR clearance certificate on file for Staff 4 dated 7/18/2025. The NSOR clearance certificate appeared to be altered. Cert Rep spoke with the ChildLine Verification Unit(CVU) who confirmed that the NSOR clearance certificate for Staff 4 dated 7/18/25 is fraudulent and not valid. Staff 4 did not have another valid NSOR clearance certificate on file. Staff 4 had a PSP clearance request dated 7/17/25. Staff 4 is beyond her 45 day provisional hire window. Cert rep also observed the date of birth listed on the PSP clearance request for Staff 4 was 12/10/1991. Cert rep confirmed through review of Staff 4's PA issued Driver's license this is not Staff 4's date of birth(see LIS code sheet for DOB). Staff 1 had a PSP clearance request dated 6/6/25. Staff 1 is beyond her 45 day provisional hire window. Staff 7 had Child Abuse clearances dated 6/16/20 & 7/15/25 and NSOR clearances dated 3/2/20 and 3/18/25. This is more than 60 months between clearance dates. It was reported Staff 7 worked as staff between 3/3/25-3/18/25 and 6/17/25-7/15/25. Staff 11 was provisionally hired but did not have all required clearances on file before their first day with children. Staff 11 had an NSOR clearance dated 12/2/25, which is after their first day with children. Staff 11 had a PSP clearance request dated 9/4/25. Cert rep was able to verify that Staff 5 had an NSOR on file dated 10/14/25 and a disclosure statement dated 10/9/25.

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. TIERED LIS: 1. The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). Staff 4 may not work in a child care position at the facility or have direct contact with children until there is a valid PSP clearance certificate and valid NSOR clearance certificate on file. Staff 1, & 11 may not work in a child care position at the facility or have direct contact with children until their valid PSP clearance certificates are on file. The portion of the plan will have an immediate correction date. 2. The Legal Entity, Director, and any Staff responsible for the hiring of staff or maintaining staff files will be required to attend Existing Provider Orientation conducted by one of the four Regional Offices. The legal entity must contact the Regional Office where they wish to attend the training in order to schedule this training. The operator shall provider a correction date for when this portion of the plan will be completed. 3. The legal entity will submit complete files for any newly hired staff, volunteers or other facility persons for a period of 3 months to the NE Regional Office. During that time, staff, volunteers or other facility persons, may not begin to work or volunteer in child care until their file has been approved by the NE Regional Office. Submitted files will be reviewed by the NE regional office within 1 week of submission. The operator shall provide a correction date that is a minimum of 3 months from the date an acceptable plan is received.

Regulation: 3270.36(b)(5)

Description: HS/GED + 2 yrs

Noncompliance Area: During a renewal inspection on 12/19/25 the following staff had a high school diploma and 0 hours of experience working with children on file: Staff 1, 5, 10, & 11. Staff 1, 5, 10, & 11 have been working as assistant group supervisors.

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

Regulation: 3270.37(b)(3)

Description: 8th grade + 2 yrs

Noncompliance Area: During a renewal inspection on 12/19/25 Staff 4 had verification they completed at least 8th grade and 0 hours of experience working with children on file: Staff 4 has been working as an aide.

Correction Required: An aide shall have a minimum of an 8th grade education and 2 years of experience with children.

Regulation: 3270.65

Description: Protective Outlet Covers 5 yrs. or less

Noncompliance Area: During a renewal inspection on 12/19/25 Cert rep observed accessible uncovered outlets in Room 1 by the sink and on the wall against the hallway.

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

Regulation: 3270.66(a)/3270.103

Description: Locked or inaccessible/Small Toys and Objects

Noncompliance Area: During a renewal inspection on 12/19/25 Cert rep observed Spic and Span, and Lysol in an unlocked accessible cabinet under the sink in Room 1, hand sanitizer in a staff's accessible bag on Room 1, laundry soap in an unlocked accessible closet in Room 4(school age room), and Febreeze, a child's Vasoline, hand sanitizer and Lysol in the unlocked accessible storage cabinet in Room 5. These items were all labeled "keep out of reach of children." These locations/items were accessible to children. Cert rep also observed plastic bags in the unlocked accessible storage cabinet and in an accessible box in Room 2, plastic bags and balloons in the unlocked accessible drawer on the older toddler side of Room 3 and plastic bags and gloves in the unlocked accessible storage cabinet in Room 5. These rooms are used by infants and toddlers. These plastic bags, gloves and balloons were accessible to children who may still be placing objects in their mouths.

Correction Required: Cleaning materials and other toxic materials shall be kept in an area or container that is locked or made inaccessible to children. Toys and objects with a diameter of less than 1 inch, objects with removable parts that have a diameter of less than 1 inch, plastic bags and styrofoam objects may not be accessible to children who are still placing objects in their mouths. TIERED LIS: 1. Cleaning materials and other toxic materials shall be kept in an area or container that is locked or made inaccessible to children. Toys and objects with a diameter of less than 1 inch, objects with removable parts that have a diameter of less than 1 inch, plastic bags and styrofoam objects may not be accessible to children who are still placing objects in their mouths. This portion of the plan shall have an immediate correction date. 2. The legal entity must arrange for all facility staff hired as of the date of the training to receive a minimum of 2 hours of PQAS-approved training regarding Health & Safety- Healthy Environments. The training must be in-person and completed outside of child care hours. The legal entity must receive DHS approval of the training content prior to scheduling the training. The operator shall provide a correction date for this training will be completed by.

Regulation: 3270.75(a)/3270.75(b)

Description: In child care spaces/Inaccessible to children

Noncompliance Area: During a renewal inspection on 12/19/25 Cert rep observed that Room 1 and Room 2(the older toddler room) did not have a first aid kit. Cert rep also observed that the first aid kit in Room 4(the school age room) was on a shelf that would be accessible to children.

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

Regulation: 3270.76

Description: Building Surfaces

Noncompliance Area: During a renewal inspection on 12/19/25 Cert rep observed a tipping/falling hazard due to stacked boxed furniture in Room 1. Cert rep also observed the power cord to a mounted tv was loose and would be accessible to children creating a falling/pulling hazard in Room 1.

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

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

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

Noncompliance Area: During a complaint investigation on 10/9/25 Cert Rep observed Staff 1 and 2 present in the infant room with 8 children(6 infants and 2 young toddlers). Staff 1 named and identified 3 infant children as being in their assigned group. Staff 2 named and identified 3 separate infant children as being in their assigned group. No staff identified the 2 young toddlers as being in their assigned group. Staff reported these children were in Staff 3's assigned group. Staff 3 was in the older toddler room and not present with these children.

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. TIERED LIS: 1. 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. This portion of the plan shall have an immediate correction date. 2. The legal entity must update their supervision policy in order to maintain proper supervision. This policy will ensure that all children are properly assigned to a staff person and supervised at all times. This policy shall address the need for staff to be physically present with the children they are supervising. This policy must address supervision during transition times, such as visiting the bathroom and supervision when transition to different rooms. This policy must include the use of name-to-face checks as a means of maintaining proper supervision. The legal entity must receive approval of the policy from the Regional Office. Once approved by the Regional Office, the legal entity must review policy with all staff and have staff sign off that the understand and will follow the supervision policy. The provider will provide a date for when this portion of the plan will be completed.

Regulation: 3270.119

Description: Infant sleep position

Noncompliance Area: During an unannounced inspection on 10/9/25 Cert rep observed infant Children 2 and 3(See LIS code sheet for DOBs) sleeping in bouncer seats. This sleep position is not recommended by the American Academy of Pediatrics. These children did not have documentation on file from a physician that required the children sleep in this position.

Correction Required: Infants shall be placed in the sleeping position recommended by the American Academy of Pediatrics unless there is a medical reason an infant should not sleep in this position. The medical reason shall be documented in a statement signed by a physician, physician's assistant or CRNP and placed in the child's record at the facility.

Regulation: 3270.182(7)

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

Noncompliance Area: Complaint investigation 10/9/25-10/17/25 verified that the facility did not provide the parents with a report of injuries Child 1 obtained while in child care on 9/12/25 and around 9/15/25.

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

Regulation: 3270.192(4)

Description: CPSL information

Noncompliance Area: During an unannounced inspection on 10/9/25 Staff 1, and Staff 4 did not have a signed disclosure statement in their staff files. Staff 1 and 4 were not provisionally hired. Staff 1 and 4 signed a disclosure statement on 10/9/25 however this is after their first day with children. See LIS code sheet for the staff's first day working with children (1DwCHN).

Correction Required: A facility person's record shall include a copy of requests for the criminal history record and child abuse registry clearance information, a copy of the disclosure statement and a copy of the completed clearance information required under the CPSL.

Regulation: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: During an unannounced inspection on 10/9/25 Staff 5 did not have a signed disclosure statement or valid NSOR Certificate in their staff file. Staff 5 signed a disclosure statement on 10/9/25 however this is after their first day with children. See LIS code sheet for the staff's first day working with children (1DwCHN).

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

Regulation: 3270.95(a)/3270.95(b)

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

Noncompliance Area: During an unannounced inspection Cert rep noted more than 30 days between fire detection testing (2/3/25-3/7/25).

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

Regulation: 3270.102(a)

Description: Clean and good repair

Noncompliance Area: During a renewal inspection on 12/4/24 the following rough edges were observed: Rough edges on the doorway of the brown house in all ages play space, and rough edges on the exposed corner of the closet in the school aged classroom. The following tears in equipment that would prevent proper sanitation were observed: Tears in the changing table mat in the toddler classroom diaper area, and a tear in the changing table mat in the infant classroom.

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

Regulation: 3270.102(c)

Description: Outdoor equip.- protective surfacing

Noncompliance Area: During a renewal inspection on 12/4/24 cert rep observed less than 9 inches of wood mulch in the following locations around embedded equipment in all ages playspace: around the Little Tikes' Equipment (6 inches of mulch observed) and around all swings (1/2 inch of wood mulch observed.

Correction Required: Outdoor equipment that requires embedded mounting must be mounted over a loose-fill or unitary playground protective surface covering that meets the recommendations of the United States Consumer Product Safety Commission. The equipment must be anchored firmly and be in good repair.

Regulation: 3270.102(c)

Description: Outdoor equip.- protective surfacing

Noncompliance Area: During a renewal inspection on 12/4/24 cert rep observed less than 9 inches of wood mulch in the following locations around embedded equipment in all ages playspace: around the Little Tikes' Equipment (6 inches of mulch observed) and around all swings (1/2 inch of wood mulch observed.

Correction Required: Outdoor equipment that requires embedded mounting must be mounted over a loose-fill or unitary playground protective surface covering that meets the recommendations of the United States Consumer Product Safety Commission. The equipment must be anchored firmly and be in good repair. Embedded equipment must be made inaccessible to children until such time as 9 inches of wood mulch is acquired.

Regulation: 3270.103

Description: Small Toys and Objects

Noncompliance Area: During a renewal inspection on 12/4/24 plastic bags were located in an unassigned accessible child cubie in the toddler classroom. This classroom has young toddlers who may still be placing objects in their mouths.

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

Regulation: 3270.121(b)

Description: Given parents in writing

Noncompliance Area: During a renewal inspection 12/4/24 it was noted that parents were not being provided information about the facility supervision policy in writing.

Correction Required: At the time of enrollment, a parent shall receive in writing the facility's general daily schedule, hours for which care is provided, fees, responsibilities for meals, clothing, health policies, supervision policies, night care policies, dismissal policies, transportation and pick-up arrangements.

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

Description: Amount of fee/Date fee to be paid

Noncompliance Area: During a renewal inspection on 12/4/24 Child 2's fee agreement did not specify the fee amount to be paid. Child 3's fee agreement did not specify the date 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: 3270.124(b)(3)

Description: Parent home/work address, phone

Noncompliance Area: During a renewal inspection on 12/4/24 Child 2's emergency contact form did not have the father's work address or work phone number documented.

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

Regulation: 3270.131(a)

Description: Health information

Noncompliance Area: During a renewal inspection on 12/4/24 Child 3's did not have an initial health assessment within 60 days of enrollment. Child 3's initial health assessment was dated 10/3/24(see code sheet for date of enrollment)

Correction Required: The operator shall require the parent of an enrolled child, including a child, a foster child and a relative of an operator or a facility person, to provide an initial health report no later than 60 days following the first day of attendance at the facility.

Regulation: 3270.131(c)

Description: Completed or signed by physician, PA, or CRNP

Noncompliance Area: During a renewal inspection on 12/4/24 Child 1's Health assessment was not signed by a physician, physician's assistant or a CRNP.

Correction Required: A health report must be written and signed by a physician, physician's assistant or a CRNP. The signature must include the individual's professional title.

Regulation: 3270.131(d)(7)

Description: Free from contagious/communicable disease

Noncompliance Area: During a renewal inspection on 12/4/24 Child 1's Health assessment did not specify if the child is able to participate in child care and appears to be free from contagious or communicable disease.

Correction Required: A health report shall include a statement that the child is able to participate in child care and appears to be free from contagious or communicable disease.

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

Description: 12 months prior to service and every 24 months thereafter/Exam communicable disease

Noncompliance Area: During a renewal inspection on 12/4/24 Staff 1 did not have an acceptable health assessment on file that clarified the staff received a physical examination and an examination for communicable diseases and the results of that examination.

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 an examination for communicable diseases and the results of that examination.

Regulation: 3270.192(5)

Description: Two written references

Noncompliance Area: During a renewal inspection on 12/4/24 the following staff did not have 2 references from individuals attesting to the person's suitability to serve as a facility person on file: Staff 1 (0 reference on file), Staff 2 (0 references on file), Staff 4 (1 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: 3270.27(a)/3270.27(d)

Description: Emergency plan/Plan posted

Noncompliance Area: During a renewal inspection on 12/4/24 the facility's emergency plan was not available for review by the cert rep. During the inspection the facility's emergency plan was not available in a conspicuous location at the facility.

Correction Required: The facility shall have an emergency plan. The operator shall post the emergency plan in the facility at a conspicuous location.

Regulation: 3270.27(c)

Description: Training regarding plan

Noncompliance Area: During a renewal inspection on 12/4/24 Staff 4 has not received emergency plan training since 10/27/2023. Staff 3 received emergency plan training 2/24/23 and 10/17/24. This is more than 12 months between emergency plan training.

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

Regulation: 3270.31(e)

Description: Age and Training

Noncompliance Area: During a renewal inspection on 12/4/24 Staff 3 had 10 hours of annual training on file (Training year 2/2023-2/2024), Staff 5 had 3 hours of annual training on file(Training year 5/2023-5/2024), and Staff 6 had 6 hours of annual training on file(Training year 2/2023-2/2024). This does not meet the required 12 hours of annual childcare training. See code sheets for DOH.

Correction Required: A staff person shall obtain an annual minimum of 12 clock hours of child care training. Staff person 3 must take 2 hours of professional development to fulfill requirement for training year 2/2023-2/2024. Hours used to fulfill training year 2/2023-2/2024 cannot be used to fulfill current training year. Staff person 5 must take 9 hours of professional development to fulfill requirement for training year 5/2023-5/2024. Hours used to fulfill training year 5/2023-5/2024) cannot be used to fulfill current training year. Staff person 6 must take 6 hours of professional development to fulfill requirement for training year 2/2023-2/2024. Hours used to fulfill training year 2/2023-2/2024 cannot be used to fulfill current training year.

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

Description: Fire safety - 1 yr.

Noncompliance Area: During a renewal inspection on 12/4/24 Staff 4's file had documentation fire safety training was completed on 10/4/23 and 11/12/24. This is more than 12 months between annual fire safety trainings.

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: 3270.66(a)

Description: Locked or inaccessible

Noncompliance Area: During a renewal inspection on 12/4/24 the following were found in areas noted that were accessible to children: 1) Child 4's Aquaphor labeled keep out of reach of children (located under the changing table in the infant classroom) 2) Parent's choice wipes labeled keep out of reach of children (located in a child 5 and child 6's cubies in preschool classroom) 3) Windex and Shaving cream labeled keep out of reach of children (located on the arts table on the left side of the back of the preschool classroom) 4) Foam Cleaner (located in in an unlocked accessible closet in the school age classroom) 5) White out labeled keep out of reach of children (located on the office desk which children must walk past to enter the facility).

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: 3270.75(c)

Description: Has all items

Noncompliance Area: During renewal inspection on 12/4/24 the first aid kit in the school age classroom was missing tweezers and tape.

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: 3270.77(a)

Description: No peeling paint or plaster

Noncompliance Area: During a renewal inspection on 12/4/24 cert rep observed peeling paint in the following locations: back wall of the school age classroom, and the two white monkey bars in all ages play space.

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

Regulation: 3270.94(a)(1)

Description: Every 60 days

Noncompliance Area: During a renewal inspection on 12/4/24 fire drills were conducted with more than 60 days between each drill on the following occasions: 3/1/24-5/1/24, 5/1/24-7/1/24, and 7/1/24-9/2/24.

Correction Required: The Director or designated staff person who is responsible for compliance with this chapter shall conduct fire drills and ensure that fire drills are conducted at least once every 60 days.

Regulation: 3270.95(a)/3270.95(b)

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

Noncompliance Area: During a renewal inspection on 12/4/24 fire detection testing was conducted with more than 30 days between each testing on the following occasions: 3/1/24-4/1/24, 5/1/24-6/3/24, 7/1/24-8/1/24, 8/1/24-9/2/24, 11/1/24-12/2/24.

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: 3270.32(a)/3270.192(4)

Description: Comply with CPSL/CPSL information

Noncompliance Area: Repeated noncompliance observed on 7/10/24, from inspection dated 5/21/24. On 5/21/24, it was observed in the preschool room that staff person #1 and #2 were present in that child care space unsupervised by any other staff persons, and both are hired provisionally. The file for staff person #2 does not contain a completed FBI clearance or NSOR verification certificate, and file for staff person #1 does not contain a NSOR verification certificate. On 7/10/24 it was observed that the facility's plan of correction, provided from the 5/21/24 inspection, was not implemented. Although staff person #1 had obtained their NSOR verification certificate, staff person #2 still did not have both clearances on file. Staff person #2 provided their completed FBI clearance during inspection once it was brought to the operator's attention, and staff person #2 did not have their NSOR verification certificate on file. In addition, file for staff person #3, did not contain a completed NSOR verification certificate. Staff #2 and #3 were both being supervised at the time of inspection, but both are now outside of their 45 day provisional hire period.

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 #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: Repeated noncompliance observed on 7/10/24, from inspection dated 5/21/24. On 5/21/24, it was observed in the preschool room that staff person #1 and #2 were present in that child care space unsupervised by any other staff persons, and both are hired provisionally. The file for staff person #2 does not contain a completed FBI clearance or NSOR verification certificate, and file for staff person #1 does not contain a NSOR verification certificate. On 7/10/24 it was observed that the facility's plan of correction, provided from the 5/21/24 inspection, was not implemented. Although staff person #1 had obtained their NSOR verification certificate, staff person #2 still did not have both clearances on file. Staff person #2 provided their completed FBI clearance during inspection once it was brought to the operator's attention, and staff person #2 did not have their NSOR verification certificate on file. In addition, file for staff person #3, did not contain a completed NSOR verification certificate. Staff #2 and #3 were both being supervised at the time of inspection, but both are now outside of their 45 day provisional hire period.

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 #3 may not work in a child care position at the facility. The Director, Legal Entity Representative, or any person in charge of maintaining staff or facility persons files must create a written policy and plan to establish new and maintain existing staff and facility person files, including clearance updates, to remain compliant with all applicable laws and regulations. This plan must be approved by the Regional Office and followed by the facility for all staff files in the future.

Regulation: 3270.102(c)

Description: Outdoor equip.- protective surfacing

Noncompliance Area: It was observed in the toddler play space that a play climber structure and a car spring rider were both embedded into the ground without protective surfacing that meets the recommendations of the United States Consumer Product Safety Commission.

Correction Required: Outdoor equipment that requires embedded mounting must be mounted over a loose-fill or unitary playground protective surface covering that meets the recommendations of the United States Consumer Product Safety Commission. The equipment must be anchored firmly and be in good repair.

Regulation: 3270.102(c)

Description: Outdoor equip.- protective surfacing

Noncompliance Area: It was observed in the toddler play space that a play climber structure and a car spring rider were both embedded into the ground without protective surfacing that meets the recommendations of the United States Consumer Product Safety Commission.

Correction Required: Outdoor equipment that requires embedded mounting must be mounted over a loose-fill or unitary playground protective surface covering that meets the recommendations of the United States Consumer Product Safety Commission. The equipment must be anchored firmly and be in good repair. The play climber structure and car spring rider must immediately be made inaccessible to children until such time as an acceptable protective surfacing has been established and approved by the OCDEL NE regional office.

Regulation: 3270.106(f)

Description: 2 feet apart

Noncompliance Area: It was observed in the infant room that several infants were sleeping or placed in a crib that did not have 2 feet of space on at least three sides of their crib; there was approximately only a foot of space between them.

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

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: Staff person #1 and #2 were observed to be caring for children unsupervised. Staff person #1 and #2 have not completed the following pre-service training required prior to caring for children unsupervised: Health and Safety Topics and mandated reporter 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.

Regulation: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: It was observed in the preschool room that staff person #1 and #2 were present in that child care space unsupervised by any other staff persons, and both are hired provisionally. The file for staff person #2 does not contain a completed FBI clearance or NSOR verification certificate, and file for staff person #1 does not contain a NSOR verification certificate.

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

Regulation: 3270.113(a)(1)

Description: Staff assigned to specific children

Noncompliance Area: During a complaint investigation on 5/21/24, staff in the preschool, infant, and toddler rooms were asked which children where assigned to them in their primary care groups. None of the staff in any classroom could adequately identify their primary care groups. Although staff were physically present with child #1 on 5/3/21, staff are not adequately supervising children throughout the center, as there is a lapse in the staff's assignment of responsibility for supervision of specific children in these classrooms.

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

Regulation: 3270.113(a)(1)

Description: Staff assigned to specific children

Noncompliance Area: During a complaint investigation on 5/21/24, staff in the preschool, infant, and toddler rooms were asked which children where assigned to them in their primary care groups. None of the staff in any classroom could adequately identify their primary care groups. Although staff were physically present with child #1 on 5/3/21, staff are not adequately supervising children throughout the center, as there is a lapse in the staff's assignment of responsibility for supervision of specific children in these classrooms.

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. The legal entity must develop a written supervision policy and procedure to be implemented in the facility. The written policy must address all subsections of 3270.113(a). The policy must also address how these groups will be transitioned from one staff person to another during staffing changes and expectations when transitioning from one child care space or play space to another. The legal entity will submit policy/procedure to the Northeast Regional Office for approval. Once approved, all existing staff and new hires must be trained on the approved policy and procedure and it must be documented in their files.

Regulation: 3270.113(a)(1)

Description: Staff assigned to specific children

Noncompliance Area: During a complaint investigation on 5/21/24, staff in the preschool, infant, and toddler rooms were asked which children where assigned to them in their primary care groups. None of the staff in any classroom could adequately identify their primary care groups. Although staff were physically present with child #1 on 5/3/21, staff are not adequately supervising children throughout the center, as there is a lapse in the staff's assignment of responsibility for supervision of specific children in these classrooms.

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. The legal entity must arrange for all facility staff to receive a minimum of three hours of approved in-person training, including technical assistance, regarding supervision of children. The legal entity must receive DHS approval of the training content prior to scheduling the training. Training may not be conducted while children are in care.

Regulation: 3270.20(a)(1)/3270.20(b)

Description: Inpatient hospitalization or ER treatment of child/Mail or deliver written report to regional office within 72 hours

Noncompliance Area: It was stated by the facility that the parent's of child #1 notified them on 5/6/24, that their child broke their toe while in care on 5/3/24. The facility did not report this injury to the appropriate OCDEL regional office. The facility neither called the OCDEL regional office within 24 hours of knowledge of the medical treatment nor provided a written report to the OCDEL regional office within 72 hours of the medical treatment.

Correction Required: The operator shall immediately notify a child's parent and shall telephone notice to the appropriate regional office within 24 hours if a child in care at the facility is hospitalized or receives emergency room treatment. The operator shall mail or deliver a written report to the appropriate regional office within 72 hours after hospitalization of a child in care, emergency room treatment of a child in care, death of a child in care, a facility fire requiring the services of a fire department.

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: Staff person #1 and #2 have not completed the following required pre-service trainings within 90 days of their date of hire (see LIS code sheet): the 10 health and safety training topics. Staff person #2 has also not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): pediatric first aid/CPR from a PQAS approved trainer and a PQAS approved curriculum.

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 and #2 will have until 5/21/24, to complete the required training. Until such time as the required training has been completed, staff person #1 and #2 must be supervised, when interacting with children, by an AGS, GS, or director who has completed the required training related to this citation. If there are no staff available to supervise staff person #1 and #2, then staff person #1 and #2 may not work in a child-care position at the facility.

Regulation: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: Staff person #1 and #2 have not completed the mandated reporter training within 90 days of their date of hire (see LIS code sheet).

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to Child Protective Services). Staff person #1 and #2 will have until 5/21/24, to complete the mandated reporter training. Until such time as the required training has been completed, staff person #1 and #2 must be supervised, when interacting with children, by an AGS, GS, or director who has completed the required training related to this citation. If there are no staff person(s) available to supervise staff person #1 and #2, then staff person #1 and #2 may not work in a child-care position at the facility.

Regulation: 3270.102(c)

Description: Outdoor equip.- protective surfacing

Noncompliance Area: During the Renewal Inspection on 12/19/2023, it was observed that the swings and each of the climbers in the outdoor play area did not have at least 9 inches of mulch surrounding the fall areas for this equipment that requires embedded mounting. An acceptable plan of correction was received on 1/3/2024 that was to be implemented by 1/31/2024. During a verification visit on 2/7/2024, the swings and each of the climbers in the outdoor play area still did not have at least 9 inches of mulch surrounding the fall areas.

Correction Required: Outdoor equipment that requires embedded mounting must be mounted over a loose-fill or unitary playground protective surface covering that meets the recommendations of the United States Consumer Product Safety Commission. The equipment must be anchored firmly and be in good repair.

Regulation: 3270.76

Description: Building Surfaces

Noncompliance Area: During the Renewal Inspection on 12/19/2023, the carpet in the outdoor play area used by the toddlers was torn in several areas. This causes a tripping hazard. An acceptable plan of correction was received on 1/3/2024 that was to be implemented by 1/31/2024. During a verification visit on 2/7/2024, the carpet in the outdoor play area used by the toddlers was still torn in several areas which causes a tripping hazard.

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

Regulation: 3270.102(c)

Description: Outdoor equip.- protective surfacing

Noncompliance Area: During the Renewal Inspection on 12/19/2023, it was observed that the swings and each of the climbers in the outdoor play area did not have at least 9 inches of mulch surrounding the fall areas for this equipment that requires embedded mounting.

Correction Required: Outdoor equipment that requires embedded mounting must be mounted over a loose-fill or unitary playground protective surface covering that meets the recommendations of the United States Consumer Product Safety Commission. The equipment must be anchored firmly and be in good repair.

Regulation: 3270.119

Description: Infant sleep position

Noncompliance Area: During the Renewal Inspection on 12/19/2023, Child #1 (See code sheet for date of birth) was observed sleeping on his stomach in the crib. Staff in the classroom verified that the child was put down on their stomach and was unable to roll. There is no medical reason in the file for Child #1 to document why the child should not be placed in the sleeping position recommended by the American Academy of Pediatrics.

Correction Required: Infants shall be placed in the sleeping position recommended by the American Academy of Pediatrics unless there is a medical reason an infant should not sleep in this position. The medical reason shall be documented in a statement signed by a physician, physician's assistant or CRNP and placed in the child's record at the facility.

Regulation: 3270.131(b)(2)

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

Noncompliance Area: On 12/19/2023, the most recent health report on file for Child #3, a preschool child was dated 11/17/2022.

Correction Required: The operator shall require the parent to provide an updated health report at least every 12 months for an older toddler or preschool child.

Regulation: 3270.151(a)/3270.151(c)(2)

Description: 12 months prior to service and every 24 months thereafter/Mantoux TB

Noncompliance Area: Staff #3 (See LIS code sheet) obtained a health assessment and tuberculosis screening after the first day of service in a childcare setting.

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.

Regulation: 3270.31(f)

Description: Health and Safety Training

Noncompliance Area: Staff persons #1 and #2 did not complete the required one-hour 2022 update to the health and safety training by 12/30/2022. See LIS code sheet.

Correction Required: Staff persons #1 and #2 shall complete the required one-hour 2022 update to the health and safety training by 1/18/2024.

Regulation: 3270.66(a)

Description: Locked or inaccessible

Noncompliance Area: During the Renewal Inspection on 12/19/2023, a container of floor cleaner was seen in an unlocked cabinet underneath the sink in the bathroom used by children in the preschool and school age classrooms. The floor cleaner was labeled keep out of reach of children.

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

Regulation: 3270.75(c)

Description: Has all items

Noncompliance Area: On 12/19/2023, the first-aid kit in the infant classroom was missing tape. The first-aid kit in the school age classroom was missing tweezers.

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

Regulation: 3270.76

Description: Building Surfaces

Noncompliance Area: During the Renewal Inspection on 12/19/2023, the carpet in the outdoor play area used by the toddlers was torn in several areas. This causes a tripping hazard.

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

Regulation: 3270.14/3270.21

Description: Pertinent Laws & Regulations/General Health and Safety

Noncompliance Area: On 8/15/2023, Staff #2 and Staff #3 were observed working unsupervised with children. Staff #2 and Staff #3 are both new staff that have not completed the following required pre-service trainings required prior to caring for children unsupervised: Pediatric First Aid and CPR, mandated reporter and the required pre-service 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 re completed, staff person #2 and staff person #3 must be supervised, when interacting with children, by an AGS who has completed the required trainings related to this citation. If there are no staff person(s) available to supervise staff person #2 and staff person #3, staff person #2 and staff person #3 may not work in a child-care position at the facility.

Regulation: 3270.21/3270.113(b)

Description: General Health and Safety/No physical punishment

Noncompliance Area: Video surveillance from 8/1/2023 was reviewed at the facility on 8/15/2023. At 2:11 PM on 8/1/2023, Staff #1 was observed lifting one end of a cot up to knee-level and pushing that cot forcefully across the floor. During this action, Child #1 was laying on the cot for naptime.

Correction Required: Conditions at the facility may not pose a threat to the health or safety of the children. A facility person may not use any form of physical punishment, including spanking a child. A facility person may not use any form of physical punishment, including spanking a child. The legal entity must arrange for all facility staff employed as of the date of the training to receive a minimum of two hours of PQAS-approved training on appropriate behavior management techniques while working with children. This training must be completed as a live training or in-person. The legal entity must receive DHS approval of the training content prior to scheduling the training.

Regulation: 3270.21/3270.113(b)

Description: General Health and Safety/No physical punishment

Noncompliance Area: Video surveillance from 8/1/2023 was reviewed at the facility on 8/15/2023. At 2:11 PM on 8/1/2023, Staff #1 was observed lifting one end of a cot up to knee-level and pushing that cot forcefully across the floor. During this action, Child #1 was laying on the cot for naptime.

Correction Required: Conditions at the facility may not pose a threat to the health or safety of the children. A facility person may not use any form of physical punishment, including spanking a child.

Regulation: 3270.32(a)

Description: Comply with CPSL

Noncompliance Area: On 8/15/2023, Staff #2 and Staff #3 were observed working unsupervised with a mixed age group of young toddler and older toddler children. Neither Staff #2 nor Staff #3 had the completed National Sex Offender Registry (NSOR) clearance on file on 8/15/2023.

Correction Required: The operator shall comply with the CPSL and with Chapter 3490 (relating to protective services). A provisional employee may not be permitted to work alone with children and must work within the vicinity of a permanent employee.

Regulation: 3270.35(d)/3270.35(e)

Description: Director only 45 children enrolled/46 or more children- additional group sups

Noncompliance Area: On 8/15/2023, Staff #4, the director was the only staff person employed at the facility that qualifies as a director or a group supervisor. There were 49 children observed to be in attendance on 8/15/2023, which requires at least two group supervisors and a director.

Correction Required: A director may not function as a group supervisor in a facility in which more than 45 children are enrolled. 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.

Regulation: 3270.52

Description: Mixed Age Level

Noncompliance Area: On 8/15/2023 at 10:30 AM, Staff #1 was observed working alone with a mixed age group of 15 young school age and older school age children. The required staff to child ratio for this mixed age group is 1 staff to 12 children. At 11:45 AM, Staff #2 and Staff #3 were observed to be working with a mixed age group of 12 young toddlers and older toddlers. A 3rd staff person is required to meet the required staff to child ratio for this mixed age group.

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). The required staff:child ratios must be maintained at all times.

Regulation: 3270.52

Description: Mixed Age Level

Noncompliance Area: On 8/15/2023 at 10:30 AM, Staff #1 was observed working alone with a mixed age group of 15 young school age and older school age children. The required staff to child ratio for this mixed age group is 1 staff to 12 children. At 11:45 AM, Staff #2 and Staff #3 were observed to be working with a mixed age group of 12 young toddlers and older toddlers. A 3rd staff person is required to meet the required staff to child ratio for this mixed age group.

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). The required staff:child ratios must be maintained at all times. The operator must post the required staff:child ratios and the age-level breakdown of children under 3270.4 in each classroom.

Regulation: 3270.111(b)

Description: Posted in group space

Noncompliance Area: On 12/21/2022, during the renewal inspection, the written plan of daily activities was not posted the preschool, school age and older toddler classrooms.

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

Regulation: 3270.124(e)

Description: Written emergency plan posted

Noncompliance Area: On 12/21/2022, during the renewal inspection, the childcare spaces did not have a written plan displayed identifying the means of transporting a child to emergency care and staffing provisions in the event of an emergency.

Correction Required: A written plan identifying the means of transporting a child to emergency care and staffing provisions in the event of an emergency shall be displayed conspicuously in every child care space and shall accompany a staff person who leaves on an excursion with children.