Chesterbrook Academy

3270.31(f)(10) Health and Safety Training - Pediatric First Aid and CPR

“Staff person #1 did not compete professional development in pediatric first aid and pediatric cardiopulmonary resuscitation within 90 days of hire. The training was completed 122 days after the date of hire.”

Correction date in the state record: Mar 3, 2025

3270.113(a)/3270.113(a)(1) Supervised at all times /Staff assigned to specific children

“Facility self-reported: On the afternoon of 2/6/25, staff person #1 was transitioning a group of 3 toddlers from the Toddler 2 room to the next-door Toddler 1 room. After staff person #1 entered the room, a parent found child #1 (young toddler) in the hallway unsupervised. Staff person #1 was unaware the child had walked away and reported not closing the door after entering into the room.”

3270.77(a) No peeling paint or plaster

“Peeling/water damaged paint was observed on the wall near the edge of the bathroom counter in the Beginners 1 room.”

Correction date in the state record: Dec 27, 2024

3270.182(7) Reports of accidents, injuries and illnesses. Original report - parent same day Copy - facility accident file. Copy - child's file

“From June 5, 2024 through October 25th, 2024, 46 incident reports have been completed for child #1. The child's parent did not receive at least 7 of the 46 incident reports on the day of the incidents. 7 of the incident reports were not in the accident file. None of the incident reports were found in the child's file. Staff reported not writing incident reports after every time child #1 banged his head off of the floor.”

Correction date in the state record: Feb 17, 2025

3270.182(7) Reports of accidents, injuries and illnesses. Original report - parent same day Copy - facility accident file. Copy - child's file

“From June 5, 2024 through October 25th, 2024, 46 incident reports have been completed for child #1. The child's parent did not receive at least 7 of the 46 incident reports on the day of the incidents. 7 of the incident reports were not in the accident file. None of the incident reports were found in the child's file. Staff reported not writing incident reports after every time child #1 banged his head off of the floor.”

Correction date in the state record: Nov 11, 2024

3270.182(7) Reports of accidents, injuries and illnesses. Original report - parent same day Copy - facility accident file. Copy - child's file

“From June 5, 2024 through October 25th, 2024, 46 incident reports have been completed for child #1. The child's parent did not receive at least 7 of the 46 incident reports on the day of the incidents. 7 of the incident reports were not in the accident file. None of the incident reports were found in the child's file. Staff reported not writing incident reports after every time child #1 banged his head off of the floor.”

Correction date in the state record: Nov 11, 2024

3270.24(a)/3270.191 Immediate access/Individual Records

“Staff person 9 was observed caring for children. The staff on site were unable to provide certification staff (agent of the department) with a file for the staff person at the time of inspection. The staff person was helping for the day as she typically works at another location.”

Correction date in the state record: Nov 4, 2024

3270.95(a)/3270.95(b) Devices must be compliant/Director or designated staff person ensure compliance

“32 days lapsed between the manual tests of the fire detection system that took place on 8/22/24 and subsequently 9/23/24.”

Correction date in the state record: Nov 4, 2024

3270.113(a)(1) Staff assigned to specific children

“Staff persons #1 and #2 were present with a group of 20 preschoolers. The staff were unable to identify which specific children they were each responsible for. Staff persons #3 and #4 were present with a group of 12 older toddlers. The staff persons identified 6 children in each of their care groups, but 1 child was accounted for in each group. One child in the group was not accounted for. Staff persons #5 and #6 were present with a group of 10 young toddlers. 8 of the children were accounted for when staff identified which children they were each responsible for. Staff persons #7 and #8 were present with a group of 10 young toddlers. 9 of the children were accounted for when staff identified which children they were each responsible for.”

Correction date in the state record: Nov 4, 2024

3270.102(a) Clean and good repair

“A stepping stone located on the preschool playground was broken. It was cracked in multiple areas, creating sharp edges. (CORRECTED ON SITE)”

Correction date in the state record: Nov 11, 2024

3270.76 Building Surfaces

“A discarded cigarette was observed on the toddler playground while children were playing in the area. An open and full can of beer was observed sitting on the ledge within reach of the preschool aged children lining up outside of the playground.”

Correction date in the state record: Nov 4, 2024

3270.32(a) Comply with CPSL

“A complete state police clearance was not on file for staff person #10.”

Correction date in the state record: Nov 4, 2024

3270.135(e) 2 hour diaper check

“More than 2 hours lapsed between diaper changes on multiple occasions for child 1. -On 9/10/24, the report stated the child's diaper was checked and dry at 11:46am and then she was changed more than 2 hours later at 2:55pm (woke from nap at 2:11pm). -On 9/11/24, the report stated she was changed at 9:45am and then more than 2 hours later at 12:12pm. The next diaper change was more than 2 hours later at 3:20pm (woke from nap at 2:08pm). The last diaper change of the day was more than 2 hours later at 5:29pm. -On 9/12/24, the report stated she was changed at 11:00am and then more than 2 hours later at 3:15pm (woke from nap at 2:20pm). -On 9/16/24, the report stated she was changed at 9:52am and then more than 2 hours later at 3:05pm (woke from nap at 2:37pm). -On 9/19/24, the report stated she was changed at 11:13am and then more than 2 hours later at 3:14pm (woke from nap at 2:33pm). -On 9/20/24, the report stated the child's diaper was checked and dry at 12:10pm and then changed more than 2 hours later at 3:08pm (woke from nap at 2:31pm). -On 9/24/24, the report stated she was changed at 12:10pm and then more than 2 hours later at 3:29pm (woke from nap at 2:40pm). -On 9/26/24, the report stated she was changed at 9:27am and then more than 2 hours later at 11:38am. The third diaper change of the day took place more than two hours after that at 3:37pm (child woke from nap at 2:31pm). -On 9/27/24, the report stated she was changed at 10:27am and then more than 2 hours later at 2:55pm (woke up from nap at 2:11pm). -On 10/4/24, the report stated she was changed at 12:04pm, and then more than 2 hours later at 3:15pm (woke up from nap at 2:27pm).”

Correction date in the state record: Nov 4, 2024

3270.21/3270.111(c) General Health and Safety/Promote development

“Child 1, a young toddler, received the following 5 injuries at the facility from 9/4/24 to 10/7/24. The daily activities of the infant and then young toddler rooms presented multiple opportunities for the child to get injured. The multiple injuries in a short period of time demonstrate a lack of responsive caregiving. On 9/4/24, staff person #1 let child #1 (young toddler) climb up the steps to the changing table without active supervision. The child slipped, hitting her head off the side of the ladder. On the same day as the first incident, staff person #2 was putting child #1 down for a nap. The child was getting into a crawling position, and the staff reported that the child hit her head on the edge of the rest equipment as staff person was laying the child down. The child had bruises on the front and sides of her head after these two incidents (noticed by staff after nap). The parents of the child did not receive an incident report on the day of the incident. On a subsequent day, child 1 received a large bite mark on her arm. Staff person #3 reported being on the other side of the room changing a diaper. A second staff person was present in the room. The parents of the child did not receive an incident report on the day of the incident. On a separate day, staff person #4 was present when the child received multiple scratch marks on her arm from another child. The parents of the child did not receive an incident report on the day of the incident. The last incident took place on 10/7/24. Staff person #5 was putting child #1 down for nap. The child was reportedly squirming and fell from the staff person's arms. The child hit her head on the edge of the rest equipment. The child was put down for nap immediately following a bump to the head. The child had a dark red mark on her forehead after the woke up from nap. The parents were given an incomplete incident report on the day of the incident. Appropriate response to head bumps was not implemented. Notification to the facility leadership, child's parents, and the child being laid down for nap following head bumps (resulting in bruising) were not responsive to the child's needs.”

Correction date in the state record: Mar 7, 2025

3270.21/3270.111(c) General Health and Safety/Promote development

“Child 1, a young toddler, received the following 5 injuries at the facility from 9/4/24 to 10/7/24. The daily activities of the infant and then young toddler rooms presented multiple opportunities for the child to get injured. The multiple injuries in a short period of time demonstrate a lack of responsive caregiving. On 9/4/24, staff person #1 let child #1 (young toddler) climb up the steps to the changing table without active supervision. The child slipped, hitting her head off the side of the ladder. On the same day as the first incident, staff person #2 was putting child #1 down for a nap. The child was getting into a crawling position, and the staff reported that the child hit her head on the edge of the rest equipment as staff person was laying the child down. The child had bruises on the front and sides of her head after these two incidents (noticed by staff after nap). The parents of the child did not receive an incident report on the day of the incident. On a subsequent day, child 1 received a large bite mark on her arm. Staff person #3 reported being on the other side of the room changing a diaper. A second staff person was present in the room. The parents of the child did not receive an incident report on the day of the incident. On a separate day, staff person #4 was present when the child received multiple scratch marks on her arm from another child. The parents of the child did not receive an incident report on the day of the incident. The last incident took place on 10/7/24. Staff person #5 was putting child #1 down for nap. The child was reportedly squirming and fell from the staff person's arms. The child hit her head on the edge of the rest equipment. The child was put down for nap immediately following a bump to the head. The child had a dark red mark on her forehead after the woke up from nap. The parents were given an incomplete incident report on the day of the incident. Appropriate response to head bumps was not implemented. Notification to the facility leadership, child's parents, and the child being laid down for nap following head bumps (resulting in bruising) were not responsive to the child's needs.”

Correction date in the state record: Nov 11, 2024

3270.182(7) Reports of accidents, injuries and illnesses. Original report - parent same day Copy - facility accident file. Copy - child's file

“Child 1, a young toddler, received 5 injuries at the facility in approximately a 6 week period. The child's parents did not receive the original of completed incident reports on the day of the incidents for at least 4 of the 5 incidents. The facility's accident file included just two of the five reports. The child's file did not include any incident reports.”

Correction date in the state record: Oct 15, 2024

3270.21/3270.111(c) General Health and Safety/Promote development

“Child 1, a young toddler, received the following 5 injuries at the facility from 9/4/24 to 10/7/24. The daily activities of the infant and then young toddler rooms presented multiple opportunities for the child to get injured. The multiple injuries in a short period of time demonstrate a lack of responsive caregiving. On 9/4/24, staff person #1 let child #1 (young toddler) climb up the steps to the changing table without active supervision. The child slipped, hitting her head off the side of the ladder. On the same day as the first incident, staff person #2 was putting child #1 down for a nap. The child was getting into a crawling position, and the staff reported that the child hit her head on the edge of the rest equipment as staff person was laying the child down. The child had bruises on the front and sides of her head after these two incidents (noticed by staff after nap). The parents of the child did not receive an incident report on the day of the incident. On a subsequent day, child 1 received a large bite mark on her arm. Staff person #3 reported being on the other side of the room changing a diaper. A second staff person was present in the room. The parents of the child did not receive an incident report on the day of the incident. On a separate day, staff person #4 was present when the child received multiple scratch marks on her arm from another child. The parents of the child did not receive an incident report on the day of the incident. The last incident took place on 10/7/24. Staff person #5 was putting child #1 down for nap. The child was reportedly squirming and fell from the staff person's arms. The child hit her head on the edge of the rest equipment. The child was put down for nap immediately following a bump to the head. The child had a dark red mark on her forehead after the woke up from nap. The parents were given an incomplete incident report on the day of the incident. Appropriate response to head bumps was not implemented. Notification to the facility leadership, child's parents, and the child being laid down for nap following head bumps (resulting in bruising) were not responsive to the child's needs.”

Correction date in the state record: Feb 17, 2025

3270.24(a)/3270.191 Immediate access/Individual Records

“Staff person 9 was observed caring for children. The staff on site were unable to provide certification staff (agent of the department) with a file for the staff person at the time of inspection. The staff person was helping for the day as she typically works at another location.”

Correction date in the state record: Nov 4, 2024

3270.95(a)/3270.95(b) Devices must be compliant/Director or designated staff person ensure compliance

“32 days lapsed between the manual tests of the fire detection system that took place on 8/22/24 and subsequently 9/23/24.”

Correction date in the state record: Nov 4, 2024

3270.113(a)(1) Staff assigned to specific children

“Staff persons #1 and #2 were present with a group of 20 preschoolers. The staff were unable to identify which specific children they were each responsible for. Staff persons #3 and #4 were present with a group of 12 older toddlers. The staff persons identified 6 children in each of their care groups, but 1 child was accounted for in each group. One child in the group was not accounted for. Staff persons #5 and #6 were present with a group of 10 young toddlers. 8 of the children were accounted for when staff identified which children they were each responsible for. Staff persons #7 and #8 were present with a group of 10 young toddlers. 9 of the children were accounted for when staff identified which children they were each responsible for.”

Correction date in the state record: Nov 4, 2024

3270.102(a) Clean and good repair

“A stepping stone located on the preschool playground was broken. It was cracked in multiple areas, creating sharp edges. (CORRECTED ON SITE)”

Correction date in the state record: Nov 11, 2024

3270.76 Building Surfaces

“A discarded cigarette was observed on the toddler playground while children were playing in the area. An open and full can of beer was observed sitting on the ledge within reach of the preschool aged children lining up outside of the playground.”

Correction date in the state record: Nov 4, 2024

3270.32(a) Comply with CPSL

“A complete state police clearance was not on file for staff person #10.”

Correction date in the state record: Nov 4, 2024

3270.135(e) 2 hour diaper check

“More than 2 hours lapsed between diaper changes on multiple occasions for child 1. -On 9/10/24, the report stated the child's diaper was checked and dry at 11:46am and then she was changed more than 2 hours later at 2:55pm (woke from nap at 2:11pm). -On 9/11/24, the report stated she was changed at 9:45am and then more than 2 hours later at 12:12pm. The next diaper change was more than 2 hours later at 3:20pm (woke from nap at 2:08pm). The last diaper change of the day was more than 2 hours later at 5:29pm. -On 9/12/24, the report stated she was changed at 11:00am and then more than 2 hours later at 3:15pm (woke from nap at 2:20pm). -On 9/16/24, the report stated she was changed at 9:52am and then more than 2 hours later at 3:05pm (woke from nap at 2:37pm). -On 9/19/24, the report stated she was changed at 11:13am and then more than 2 hours later at 3:14pm (woke from nap at 2:33pm). -On 9/20/24, the report stated the child's diaper was checked and dry at 12:10pm and then changed more than 2 hours later at 3:08pm (woke from nap at 2:31pm). -On 9/24/24, the report stated she was changed at 12:10pm and then more than 2 hours later at 3:29pm (woke from nap at 2:40pm). -On 9/26/24, the report stated she was changed at 9:27am and then more than 2 hours later at 11:38am. The third diaper change of the day took place more than two hours after that at 3:37pm (child woke from nap at 2:31pm). -On 9/27/24, the report stated she was changed at 10:27am and then more than 2 hours later at 2:55pm (woke up from nap at 2:11pm). -On 10/4/24, the report stated she was changed at 12:04pm, and then more than 2 hours later at 3:15pm (woke up from nap at 2:27pm).”

Correction date in the state record: Nov 4, 2024

3270.21/3270.111(c) General Health and Safety/Promote development

“Child 1, a young toddler, received the following 5 injuries at the facility from 9/4/24 to 10/7/24. The daily activities of the infant and then young toddler rooms presented multiple opportunities for the child to get injured. The multiple injuries in a short period of time demonstrate a lack of responsive caregiving. On 9/4/24, staff person #1 let child #1 (young toddler) climb up the steps to the changing table without active supervision. The child slipped, hitting her head off the side of the ladder. On the same day as the first incident, staff person #2 was putting child #1 down for a nap. The child was getting into a crawling position, and the staff reported that the child hit her head on the edge of the rest equipment as staff person was laying the child down. The child had bruises on the front and sides of her head after these two incidents (noticed by staff after nap). The parents of the child did not receive an incident report on the day of the incident. On a subsequent day, child 1 received a large bite mark on her arm. Staff person #3 reported being on the other side of the room changing a diaper. A second staff person was present in the room. The parents of the child did not receive an incident report on the day of the incident. On a separate day, staff person #4 was present when the child received multiple scratch marks on her arm from another child. The parents of the child did not receive an incident report on the day of the incident. The last incident took place on 10/7/24. Staff person #5 was putting child #1 down for nap. The child was reportedly squirming and fell from the staff person's arms. The child hit her head on the edge of the rest equipment. The child was put down for nap immediately following a bump to the head. The child had a dark red mark on her forehead after the woke up from nap. The parents were given an incomplete incident report on the day of the incident. Appropriate response to head bumps was not implemented. Notification to the facility leadership, child's parents, and the child being laid down for nap following head bumps (resulting in bruising) were not responsive to the child's needs.”

Correction date in the state record: Mar 7, 2025

3270.21/3270.111(c) General Health and Safety/Promote development

“Child 1, a young toddler, received the following 5 injuries at the facility from 9/4/24 to 10/7/24. The daily activities of the infant and then young toddler rooms presented multiple opportunities for the child to get injured. The multiple injuries in a short period of time demonstrate a lack of responsive caregiving. On 9/4/24, staff person #1 let child #1 (young toddler) climb up the steps to the changing table without active supervision. The child slipped, hitting her head off the side of the ladder. On the same day as the first incident, staff person #2 was putting child #1 down for a nap. The child was getting into a crawling position, and the staff reported that the child hit her head on the edge of the rest equipment as staff person was laying the child down. The child had bruises on the front and sides of her head after these two incidents (noticed by staff after nap). The parents of the child did not receive an incident report on the day of the incident. On a subsequent day, child 1 received a large bite mark on her arm. Staff person #3 reported being on the other side of the room changing a diaper. A second staff person was present in the room. The parents of the child did not receive an incident report on the day of the incident. On a separate day, staff person #4 was present when the child received multiple scratch marks on her arm from another child. The parents of the child did not receive an incident report on the day of the incident. The last incident took place on 10/7/24. Staff person #5 was putting child #1 down for nap. The child was reportedly squirming and fell from the staff person's arms. The child hit her head on the edge of the rest equipment. The child was put down for nap immediately following a bump to the head. The child had a dark red mark on her forehead after the woke up from nap. The parents were given an incomplete incident report on the day of the incident. Appropriate response to head bumps was not implemented. Notification to the facility leadership, child's parents, and the child being laid down for nap following head bumps (resulting in bruising) were not responsive to the child's needs.”

Correction date in the state record: Nov 11, 2024

3270.182(7) Reports of accidents, injuries and illnesses. Original report - parent same day Copy - facility accident file. Copy - child's file

“Child 1, a young toddler, received 5 injuries at the facility in approximately a 6 week period. The child's parents did not receive the original of completed incident reports on the day of the incidents for at least 4 of the 5 incidents. The facility's accident file included just two of the five reports. The child's file did not include any incident reports.”

Correction date in the state record: Oct 15, 2024

3270.21/3270.111(c) General Health and Safety/Promote development

“Child 1, a young toddler, received the following 5 injuries at the facility from 9/4/24 to 10/7/24. The daily activities of the infant and then young toddler rooms presented multiple opportunities for the child to get injured. The multiple injuries in a short period of time demonstrate a lack of responsive caregiving. On 9/4/24, staff person #1 let child #1 (young toddler) climb up the steps to the changing table without active supervision. The child slipped, hitting her head off the side of the ladder. On the same day as the first incident, staff person #2 was putting child #1 down for a nap. The child was getting into a crawling position, and the staff reported that the child hit her head on the edge of the rest equipment as staff person was laying the child down. The child had bruises on the front and sides of her head after these two incidents (noticed by staff after nap). The parents of the child did not receive an incident report on the day of the incident. On a subsequent day, child 1 received a large bite mark on her arm. Staff person #3 reported being on the other side of the room changing a diaper. A second staff person was present in the room. The parents of the child did not receive an incident report on the day of the incident. On a separate day, staff person #4 was present when the child received multiple scratch marks on her arm from another child. The parents of the child did not receive an incident report on the day of the incident. The last incident took place on 10/7/24. Staff person #5 was putting child #1 down for nap. The child was reportedly squirming and fell from the staff person's arms. The child hit her head on the edge of the rest equipment. The child was put down for nap immediately following a bump to the head. The child had a dark red mark on her forehead after the woke up from nap. The parents were given an incomplete incident report on the day of the incident. Appropriate response to head bumps was not implemented. Notification to the facility leadership, child's parents, and the child being laid down for nap following head bumps (resulting in bruising) were not responsive to the child's needs.”

Correction date in the state record: Feb 17, 2025

3270.124(b)(3) Parent home/work address, phone

“At the time of the renewal inspection follow up visit to verify corrections, the plan of corrections for the violation citing 3270,124(b)(3) on SIN-00243166 had not been fully implemented. On 5/15/24, the emergency contact information on file for children 1, and 8 did not include the work addresses and work telephone numbers of the enrolling parent. On 7/3/24, the emergency contact information on file for children 1, and 8 still did not include the work addresses and work telephone numbers of the enrolling parent.”

Correction date in the state record: Jul 12, 2024

3270.76 Building Surfaces

“A broken glass windowpane was observed in Intermediates 2.”

Correction date in the state record: Jul 17, 2024

3270.107 Refrigerator

“At the time of the renewal inspection follow up visit to verify corrections, the plan of corrections for the violation citing 3270.107 on SIN-00243166 had not been fully implemented. On 5/15/24, the thermometer located in the refrigerator in the 2nd floor infant room was reading at 48° F. On 7/3/24, the thermometer located in the refrigerator in the 2nd floor infant room was reading at 46° F.”

Correction date in the state record: Jul 3, 2024

3270.102(a) Clean and good repair

“At the time of the renewal inspection follow up visit to verify corrections, the plan of corrections for the violation citing 3270.102a on SIN-00243166 had not been fully implemented. On 5/15/24, baseboards in classrooms and bathrooms throughout the facility were dirty/dusty. On 7/3/24, the baseboards in classrooms and bathrooms throughout the facility were still dirty/dusty.”

Correction date in the state record: Jul 17, 2024

3270.182(5) Consent for administration of minor first-aid required prior to admission

“At the time of the renewal inspection follow up visit to verify corrections, the plan of corrections for the violation citing 3270.182(5) on SIN-00243166 had not been fully implemented. On 5/15/24, the record for child 3 did not contain signed parental consent for administration of minor first-aid procedures by facility staff. On 7/3/24, the record for child 3 did not contain signed parental consent for administration of minor first-aid procedures by facility staff.”

Correction date in the state record: Jul 12, 2024

3270.124(b)(7) Name/address/phone release person

“At the time of the renewal inspection follow up visit to verify corrections, the plan of corrections for the violation citing 3270,124(b)(7) on SIN-00243166 had not been fully implemented. On 5/15/24, the emergency contact information on file for child 4 did not include complete contact information for listed release persons (missing a complete address for the listed release person). On 7/3/24, the emergency contact information on file for child 4 still did not include complete contact information for listed release persons (missing a complete address for the listed release person).”

Correction date in the state record: Jul 12, 2024

3270.181(c)/3270.181(e) Emergency info/agreement updated 6 mos/Emergency master file updated

“At the time of the renewal inspection follow up visit to verify corrections, the plan of corrections for the violation citing 3270.181(c)/3270.181(e) on SIN-00243166 had not been fully implemented. On 5/15/24, a portion of the emergency contact forms in the following rooms were past due for updates (signatures more than 6 months old): -1st room on left in main hallway -beginners 1 -beginners 3 - toddler 3. On 7/3/24, a portion of the emergency contact forms in the following rooms were past due for updates (signatures more than 6 months old): -1st room on left in main hallway -beginners 1 -beginners 3 - toddler 3.”

Correction date in the state record: Jul 12, 2024

3270.77(a) No peeling paint or plaster

“At the time of the renewal inspection follow up visit to verify corrections, the plan of corrections for the violation citing 3270.77a on SIN-00243166 had not been fully implemented. On 5/15/24, peeling paint was observed behind the sink in the Intermediates 1 room, on a windowsill in Intermediates 2, and below the sink the Beginners 1. On 7/3/24, the peeling paint was still observed on the windowsill in Intermediates 2, and below the sink the Beginners 1.”

Correction date in the state record: Jul 17, 2024

3270.124(b)(4)/3270.182(3) Written consent/Consent for emergency medical care required prior to admission

“At the time of the renewal inspection follow up visit to verify corrections, the plan of corrections for the violation citing 3270,124(b)(4)/3270.182(3) on SIN-00243166 had not been fully implemented. On 5/15/24, the emergency contact forms on file for child 3 did not include written consent signed by a parent for emergency medical care. On 7/3/24, the emergency form on file for child 3 still did not include written consent signed by a parent for emergency medical care.”

Correction date in the state record: Jul 12, 2024

3270.27(c) Training regarding plan

“The facility did not have documentation that staff person 11 had been trained on the emergency plan.”

Correction date in the state record: May 29, 2024

3270.32(a) Comply with CPSL

“According to documentation on file at the time of inspection, when staff person #1 began work in the facility, the staff person's record did not contain completed child abuse clearance information required under the CPSL and did not contain a copy of the requests for a remaining out-of state clearance as required for provisional hiring under the CPSL. The staff person worked beyond a 45 day provisional hire period with incomplete clearances on file. The child abuse clearance was obtained 2 days after start date. At the time of inspection, the missing out of state clearance was not on file. (CORRECTED ON SITE) Facility person 8's rap sheet was not submitted to the regional office for review at the time of hire. According to documentation on file at the time of inspection, when staff person #13 began work in the facility, the staff record did not contain a complete NSOR clearance as required under the CPSL and did not contain a copy of the requests for the NSOR clearance as required for provisional hiring under the CPSL. According to documentation on file at the time of inspection, when staff person #16 began work in the facility, the staff record did not contain a complete Child Abuse clearance as required under the CPSL.”

Correction date in the state record: Jun 14, 2024

3270.34(a)(6) Staff evaluations

“Staff persons 2 and 11 have not received a written evaluation in the past 12 months. Staff persons 3, 5, and 7 - Written evaluations were due in May of 2023, but the evaluations were completed late in June of 2023. Staff 4 - Written evaluations on file were dated in May of 22 and subsequently more than 12 months later in July of 2023.”

Correction date in the state record: Jun 3, 2024

3270.35(b)/3270.192(2)(ii) Group sup qualifications/Exp, educ., training prior to facility

“Staff person 9 is serving as a GS at the facility. The staff record does not include documentation that the staff person has attained one of the qualification levels specified at §3270.35(b)(1)-(4)”

Correction date in the state record: May 31, 2024

3270.36(b)(5)/3270.192(2)(ii) HS/GED + 2 yrs/Exp, educ., training prior to facility

“Staff persons 10, 12, and 15 are serving as assistant group supervisors at the facility. Their records include documentation of high school diplomas, but do not include documentation of 2 years (2,500 hours) of child care experience.”

Correction date in the state record: May 29, 2024

3270.66(a) Locked or inaccessible

“A cleaning material (bleach water) was observed in an area accessible to the children in the 1st room on the left. (CORRECTED ON SITE) Sanitizer was observed in an area accessible to the children in the Intermediates 1 room. (CORRECTED ON SITE)”

Correction date in the state record: May 29, 2024

3270.77(a) No peeling paint or plaster

“Peeling paint was observed behind the sink in the Intermediates 1 room, on a windowsill in Intermediates 2, and below the sink the Beginners 1.”

3270.102(a) Clean and good repair

“Toy shelves in Intermediates 2 were visibly dirty/dusty. Baseboards in classrooms and bathrooms throughout the facility were dirty/dusty.”

3270.103 Small Toys and Objects

“Pom Poms (diameter of less than 1 inch) were observed in the sensory table (accessible to children) in Beginners 2 (toddler classroom).”

Correction date in the state record: May 29, 2024

3270.107 Refrigerator

“The thermometer located in the refrigerator in the 2nd floor infant room was reading at 48° F. The refrigerator located in the one-year-old room (next to 2nd floor infant room) contained a bin filled with old water and a mold-like substance. (CORRECTED ON SITE)”

3270.113(c) No ridicule or threaten harm

“Staff person 9 asked a child, "Do you know why you are at the front of the line? Because you weren't listening." The comment was loud enough for the other children to hear.”

Correction date in the state record: May 29, 2024

3270.123(a) Signed

“The agreements on file for children 5 and 9 each were not signed by the operator.”

Correction date in the state record: May 29, 2024

3270.123(a)(3) Services proceeded

“The records for children 2, 4, 5, 7, 8, and 10 did not contain documentation that Child Service Reports (or another approved form) was being completed at least every 6 months.”

Correction date in the state record: May 31, 2024

3270.123(a)(4) Arrival/departure times

“The agreement on file for child 4 did not specify the child's arrival and departure times.”

Correction date in the state record: May 31, 2024

3270.123(a)(6) Admission date

“The agreements on file for children 4, 5, and 9 did not specify the date of the child's admission.”

Correction date in the state record: May 31, 2024

3270.123(b)/3270.182(8) Parent receives original/Copy of initial and subsequent agreements. Parent receives original.

“Originals of agreements were on file for children 1, 2, 4, 5, 7, 9, and 10. There was no agreement on file for child 3. Copies of initial agreements were not on file for children 1, 6, and 9. Child 1 - first agreement on file dated 3 months after start date. Child 6 - first agreement on file dated 3.5 months after start date. Child 9 - first agreement on file dated 1.5 months after start date.”

Correction date in the state record: May 31, 2024

3270.124(b)(2) Physician name, address, phone

“The emergency contact information on file for children 3 and 10 each did not include a phone number for the child's physician or source of medical care.”

Correction date in the state record: May 31, 2024

3270.124(b)(3) Parent home/work address, phone

“The emergency contact information on file for children 1, 4, 8, 9, and 10 do not include the work addresses and work telephone numbers of the enrolling parent. The emergency contact information on file for child 5 did not include the work telephone number of the enrolling parent.”

3270.124(b)(4)/3270.182(3) Written consent/Consent for emergency medical care required prior to admission

“The emergency contact forms on file for children 3, 8, 9, and 10 each did not include the written consent signed by a parent for emergency medical care”

3270.124(b)(6) Insurance coverage information

“The emergency contact information on file for children 1 and 5 each did not include the child's health insurance policy number. The emergency contact information on file for children 6, 8, and 9 each did not include the child's health insurance coverage and policy number.”

Correction date in the state record: May 31, 2024

3270.124(b)(7) Name/address/phone release person

“The emergency contact information on file for children 4 and 10 did not include complete contact information for listed release persons. -Child 4 - missing a complete address for the listed release person. -Child 10 - missing addresses and phone numbers for listed release persons”

3270.131(b)(2) Toddler/preschool: updated health report every 12 months

“The updated health assessments on file for children 2 and 7 were not obtained timely. The health reports for child 2 were dated in September of 2022, and subsequently more than 12 months later in November of 2023. The health reports for child 7 were dated in June of 2022 and subsequently more than 12 months later in February of 2024. The children were older toddlers or preschoolers at the time of the lapse.”

Correction date in the state record: Jun 14, 2024

3270.131(e) ACIP recommended immunization record

“The records for children 1, 4, 6, 8, 9 and 10 did not include documentation that the children were vaccinated according to the ACIP schedule (or appropriate exemption notes) by the 60 day mark. The children remained in care during the time of the lapse in documentation. The records have since been obtained.”

Correction date in the state record: Jun 14, 2024

3270.135(a)(3) Disposable diapers

“Intermediates 1 - A child was observed opening a trash can with their hands and disposing of their pullup into the trash can. Beginners 3 - A diaper was observed in an unlidded trash can. The trash can by the changing table was unlined.”

Correction date in the state record: May 31, 2024

3270.151(a) 12 months prior to service and every 24 months thereafter

“The updated health assessment on file for staff persons 6 and 7 were not obtained timely. Staff 6 - The health assessments were dated in November of 2021, and subsequently more than 24 months later in May of 2024. Staff 7 -The health assessments were dated in September of 2021, and subsequently more than 24 months later in October of 2023.”

Correction date in the state record: Jun 7, 2024

3270.151(c)(3)/3270.151(c)(5) Exam communicable disease/Physician/CRNP assessment

“The health assessments on file for staff persons 7 and 15 did not include an examination for communicable diseases and the results of that examination, nor the physician's or CRNP's assessment of the person's suitability to provide child care. The health assessment on file for staff person 18 does not include the physician's or CRNP's assessment of the person's suitability to provide child care.”

Correction date in the state record: Jun 7, 2024

3270.161(d) Potentially hazardous food refrigerated

“A child's lunchbox was observed in her cubby in pre-k 1. The lunchbox contained potentially hazardous food. (CORRECTED ON SITE)”

Correction date in the state record: May 31, 2024

3270.181(c)/3270.181(e) Emergency info/agreement updated 6 mos/Emergency master file updated

“A portion of the emergency contact forms in the following rooms were past due for updates (signatures more than 6 months old): -1st room on left in main hallway -beginners 1 -beginners 3 -pre-k 1 -toddler 3”

3270.181(c) Emergency info/agreement updated 6 mos

“Emergency contact forms and/or financial agreements were not updated timely during the previous year for children 3, 4, 8, and 10. Children 3 and 10 - Emergency contact forms past due for update - most recently signed in August of 2023. Child 4 - 8 months lapsed between updates of the emergency contact form Child 8 - 7 months lapsed between updates of the emergency contact form and financial agreement.”

Correction date in the state record: Jun 14, 2024

3270.182(5) Consent for administration of minor first-aid required prior to admission

“The record for children 3, 8, 9, and 10 each did not contain signed parental consent for administration of minor first-aid procedures by facility staff.”

3270.192(5) Two written references

“The record for staff person 14 included one written, nonfamily reference. The second reference on file was written by a relative. The record for staff person 17 did not include two written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person.”

Correction date in the state record: Jun 14, 2024

3270.31(e)/3270.192(2)(iii) Age and Training/Exp, educ., training at facility

“The record for staff person 7 included documentation of 4 clock hours of child care training from the previous year.”

Correction date in the state record: Jun 14, 2024

3270.131(a)/3270.182(1) Health information/Initial and subsequent health reports

“Initial health reports were not obtained within 60 days for children 1, 4, 6, 8, 9, and 10. They were obtained late for children 1, 6, 8, and 9. The records for children 4, and 10 still did not include health reports (CORRECTED ON SITE).”

Correction date in the state record: Jun 14, 2024

3270.124(e) Written emergency plan posted

“The written plan identifying the means of transporting a child to emergency care and staffing provisions in the event of an emergency was not displayed conspicuously in Pre-k 1 and in Toddler 3. (CORRECTED ON SITE)”

Correction date in the state record: May 30, 2024

3270.113(a)/3270.113(a)(1) Supervised at all times /Staff assigned to specific children

“Staff person #1 left [3 year old] child #1 alone on the facility's playground for a period of approximately 3-4 minutes.”

Correction date in the state record: Apr 22, 2024

3270.113(a)/3270.113(a)(1) Supervised at all times /Staff assigned to specific children

“Staff person #1 left [3 year old] child #1 alone on the facility's playground for a period of approximately 3-4 minutes.”

Correction date in the state record: Jan 22, 2024

3270.113(a)/3270.113(a)(1) Supervised at all times /Staff assigned to specific children

“Staff person #1 left [3 year old] child #1 alone on the facility's playground for a period of approximately 3-4 minutes.”

Correction date in the state record: Jan 17, 2024

3270.113(a)/3270.113(a)(1) Supervised at all times /Staff assigned to specific children

“The facility self-reported the following incident: At 11:43 am on 8/24/23, staff person 1 transitioned a group of preschoolers from their room to combine with another group of children in a neighboring room. During the transition, child 1 was able to walk away from the group un-noticed and return to the empty room. The child was unsupervised in the room for 8 minutes before being found by staff person 2.”

Correction date in the state record: Oct 1, 2023

3270.113(a)/3270.113(a)(1) Supervised at all times /Staff assigned to specific children

“The facility self-reported the following incident: At 11:43 am on 8/24/23, staff person 1 transitioned a group of preschoolers from their room to combine with another group of children in a neighboring room. During the transition, child 1 was able to walk away from the group un-noticed and return to the empty room. The child was unsupervised in the room for 8 minutes before being found by staff person 2.”

Correction date in the state record: Nov 24, 2023

3270.113(a)/3270.113(a)(1) Supervised at all times /Staff assigned to specific children

“The facility self-reported the following incident: At 11:43 am on 8/24/23, staff person 1 transitioned a group of preschoolers from their room to combine with another group of children in a neighboring room. During the transition, child 1 was able to walk away from the group un-noticed and return to the empty room. The child was unsupervised in the room for 8 minutes before being found by staff person 2.”

Correction date in the state record: Nov 24, 2023

3270.113(a)/3270.113(a)(1) Supervised at all times /Staff assigned to specific children

“The facility self-reported: On 6/1/2023, staff persons 1 and 2 were transitioning a group of older toddlers to the playground when child 1 was left behind in the Beginners 3 room. Staff 1 and 2 realized the child was not with the group when they got to the bottom of the stairwell and staff person 3 ran up to the room and found the child alone in the classroom. Facility staff estimated that the child was alone for approximately 2 minutes.”

Correction date in the state record: Sep 1, 2023

3270.113(a)/3270.113(a)(1) Supervised at all times /Staff assigned to specific children

“The facility self-reported: On 6/1/2023, staff persons 1 and 2 were transitioning a group of older toddlers to the playground when child 1 was left behind in the Beginners 3 room. Staff 1 and 2 realized the child was not with the group when they got to the bottom of the stairwell and staff person 3 ran up to the room and found the child alone in the classroom. Facility staff estimated that the child was alone for approximately 2 minutes.”

Correction date in the state record: Sep 1, 2023

3270.113(a)/3270.113(a)(1) Supervised at all times /Staff assigned to specific children

“The facility self-reported: On 6/1/2023, staff persons 1 and 2 were transitioning a group of older toddlers to the playground when child 1 was left behind in the Beginners 3 room. Staff 1 and 2 realized the child was not with the group when they got to the bottom of the stairwell and staff person 3 ran up to the room and found the child alone in the classroom. Facility staff estimated that the child was alone for approximately 2 minutes.”

Correction date in the state record: Jun 1, 2023

3270.181(c)/3270.181(e) Emergency info/agreement updated 6 mos/Emergency master file updated

“During the corrections verification visit for SIN-00223808, it was observed that the plan of corrections submitted for the following non-compliance had not implemented by the provider: Emergency contact forms in the childcare spaces were past due to be updated (parent signatures more than 6 months old).”

Correction date in the state record: May 26, 2023

3270.102(a) Clean and good repair

“During the corrections verification visit for SIN-00219392, it was observed that the plan of corrections submitted for the following non-compliance had not implemented by the provider: A children's chair located in Beginners 1 was in poor repair. The surface of the chair was peeling, and the inner foam was exposed through the holes.”

Correction date in the state record: May 5, 2023

3270.181(c)/3270.181(e) Emergency info/agreement updated 6 mos/Emergency master file updated

“During the corrections verification visit for SIN-00219392, it was observed that the plan of corrections submitted for the following non-compliance had not implemented by the provider: Emergency contact forms in the childcare spaces were past due to be updated (parent signatures more than 6 months old).”

3270.76 Building Surfaces

“During the corrections verification visit for SIN-00219392, it was observed that the plan of corrections submitted for the following non-compliance had not implemented by the provider: Intermediates 1 - Ceiling tile in the restroom showed evidence of a water leak (staining).”

Correction date in the state record: May 17, 2023

3270.81 Glass

“The was not a visual strip or other visual identification placed on glass door entering into the Intermediates 1 room.”

Correction date in the state record: Mar 27, 2023

3270.124(b)(2) Physician name, address, phone

“The emergency contact information on file for child 3 did not include the address and telephone number of the child's physician or source of medical care.”

Correction date in the state record: Apr 21, 2023

3270.124(b)(3) Parent home/work address, phone

“The emergency contact information on file for children 1, 2, and 3 did not include the following information: Child 1: Enrolling parent's work address and telephone number Child 2: Enrolling parent's work telephone number Child 3: Enrolling parent's work address”

Correction date in the state record: Apr 21, 2023

3270.124(b)(7) Name/address/phone release person

“The emergency contact information on file for child 2 did not include an address for a listed release person.”

Correction date in the state record: Mar 27, 2023

3270.32(a) Comply with CPSL

“At the time of inspection, the record for staff person 2 did not include a criminal history clearance for a state the individual resided in during the past 5 years. (CORRECTED ON SITE)”

Correction date in the state record: Mar 27, 2023

3270.14/3270.21 Pertinent Laws & Regulations/General Health and Safety

“The record for staff persons 1 did not include the Pennsylvania Health and Safety update training which was to be completed by 12/30/2022 per Announcement C-22-06.”

Correction date in the state record: Mar 31, 2023

3270.31(f)(10) Health and Safety Training - Pediatric First Aid and CPR

“Staff person #1 has acceptable pediatric first aid/CPR training in an approved curriculum; however, the trainer has not provided documentation that they are PQAS-certified in that training topic.”

Correction date in the state record: Apr 6, 2023

3270.181(c)/3270.181(e) Emergency info/agreement updated 6 mos/Emergency master file updated

“Emergency contact forms in the childcare spaces were past due to be updated (parent signatures more than 6 months old).”

3270.77(a) No peeling paint or plaster

“Areas of peeling paint were observed in the following spaces: Pre-k 1 - Near block area Beginners 2 - Near book area Intermediates 2 - Baseboard near sink”

Correction date in the state record: Apr 5, 2023

3270.76 Building Surfaces

“Intermediates 1 - Ceiling tile in the restroom showed evidence of a water leak (staining).”

3270.66(e) Arts and crafts non-toxic

“A toddler was observed painting with shaving cream.”

Correction date in the state record: Mar 22, 2023

3270.102(a) Clean and good repair

“A children's chair located in Beginners 1 was in poor repair. The surface of the chair was peeling, and the inner foam was exposed through the holes.”