Friedens Lutheran Church Child Care Center

3270.151(b) Conducted by physician, PA or CRNP

“Continued non-compliance: During a renewal inspection on 9/24/25-9/25/25 Facility Person 3's health assessment dated 7/31/2024 was signed, but the signature did not include the individual who complete the form's professional title. The facility's acceptable plan of correction indicated the correction would be implemented by 10/31/2025. On 11/6/2025 an unannounced inspection was conducted. IT was reported that Facility Person 3's health assessment was not updated, nor did Facility Person 3 obtain a new acceptable health assessment. Facility Person 3 was observed to have direct contact with children on 11/6/25.”

Correction date in the state record: Nov 6, 2025

3270.192(5) Two written references

“During a renewal inspection on 9/24/25-9/25/25 Staff 1's file had 0 references available for Cert rep review.”

Correction date in the state record: Oct 14, 2025

3270.192(2)(iv) Transcript, diploma and letters

“During a renewal inspection on 9/24/25-9/25/25 Staff 2's file did not contain acceptable verification that the staff completed at least 8th grade. Staff 2 had a letter from a representative of the educational entity that verified Staff 2's enrollment in a training curriculum described at § 3270.31(c) (relating to age and training) was present, however this did not verify that Staff 2, had completed at least 8th grade.”

Correction date in the state record: Oct 23, 2025

3270.151(b) Conducted by physician, PA or CRNP

“During a renewal inspection on 9/24/25-9/25/25 Facility Person 3's health assessment dated 7/31/2024 was signed, but the signature did not include the individual who complete the form's professional title.”

3270.133(7)(iv)/3270.133(7)(vii) Amount to administer/Staff initials

“During a renewal inspection on 9/24/25 the medication log for Child 10's "Pataday" medication did not list the amount of the medication that was administered or the initials of the staff who administered the medication for the documented administration of the medication on 5/1/25.”

Correction date in the state record: Oct 14, 2025

3270.133(6) Written consent

“During a renewal inspection on 9/24/25 Cert rep reviewed a medication log for Child 9's Tylenol in which it was noted this medication was administered to Child 9 on 6/24/25. The was no parental consent documented on the medication log, with the medication, or in the Child's file for the administration of this medication to this child.”

Correction date in the state record: Oct 14, 2025

3270.27(e) Letter to parents

“During a renewal inspection on 9/24/25-9/25/25 the emergency plan letter to the parents did not include the facility lock down procedures and accommodations for infants, toddlers, children with disabilities and children with chronic medical conditions.”

Correction date in the state record: Oct 17, 2025

3270.133(3) Name on bottle

“During a renewal inspection on 9/24/25 Cert rep observed a bottle of Benadryl in Room K that did not have a child's name on it. It was reported that the Bendryal was Child 8's medication.”

Correction date in the state record: Sep 24, 2025

3270.131(d)(7)/3270.131(d)(8) Free from contagious/communicable disease/Age appropriate screenings complete

“During a renewal inspection 9/24/25-9/25/25 Child 8's health assessment dated 9/3/25 did not include a statement that the child is able to participate in child care and appears to be free from contagious or communicable disease. Child 8's health assessment also did not include a statement that age-appropriate developmental screenings were conducted since the child's previous health report.”

Correction date in the state record: Oct 23, 2025

3270.124(b)(3)/3270.124(b)(7) Parent home/work address, phone/Name/address/phone release person

“During a renewal inspection 9/24/25-9/25/25 Child 5 did not have the parents' work addresses, and Children 1, 3, 5, 6, & 8 did not have their parents' work phone numbers on their respective emergency contact forms. Child 1's emergency contact form did not have the addresses for all of the child's release persons.”

Correction date in the state record: Oct 24, 2025

3270.124(b)(2)/3270.124(b)(6) Physician name, address, phone/Insurance coverage information

“During a renewal inspection 9/24/25-9/25/25 Children 1, 2, 3, 4, 5, 6, 7, 8, & 9 did not have the address of the child's source of medical care listed on their emergency contact form. Child 1 did not have the insurance policy number listed on the emergency contact form.”

Correction date in the state record: Oct 24, 2025

3270.123(a)(2) Date fee to be paid

“During a renewal inspection on 9/24/25-9/25/25 Children 1 and 9's fee agreements did not specify the date which the fee is to be paid.”

Correction date in the state record: Oct 17, 2025

3270.111(b) Posted in group space

“During a renewal inspection on 9/24/25 Cert rep observed Rooms 1, 2, 3 , 5, and 6 did not have the daily schedule posted.”

Correction date in the state record: Oct 31, 2025

3270.107 Refrigerator

“During a renewal inspection on 9/24/25 Cert rep observed the refrigerator in Room A/B registered at 46° F.”

Correction date in the state record: Sep 25, 2025

3270.101(a) Age appropriate

“During a renewal inspection on 9/24/25 Cert rep observed Rooms 1, 3 and 5 did not have play equipment and materials for school age children children. It was reported these rooms would be used by the school aged children.”

Correction date in the state record: Oct 31, 2025

3270.66(a)/3270.75(b) Locked or inaccessible/Inaccessible to children

“During a renewal inspection on 9/24/25 Cert rep observed multiple bottles of Dawn dish soap in an open box on the floor and bottle of [name] on a table in Room 3. These items were labeled keep out of reach of children. Cert rep also observed the First aid kit in room 1 was on an accessible table and the first aid kit in Room 2 was on an accessible shelf. While their were no children present in Rooms 1, 2, and 3, these items and first aid kits were observed to be in areas that would have been accessible to the children that would have been receiving care in those rooms.”

Correction date in the state record: Oct 17, 2025

3270.31(e)(4)(ii) Fire safety - 1 yr.

“During a renewal inspection on 9/24/25-9/25/25 Staff 1 did not have fire safety training available to review from 2023 or 2024. Staff 1 completed fire safety training 6/24/25 which is more than 12 months since their previous fire safety training.”

Correction date in the state record: Sep 24, 2025

3270.133(5) Original label

“During a renewal inspection on 9/24/25 Cert rep observed the following expired Sunscreens, diaper creams, and medications were present in the noted child care rooms: Sunscreen (exp. date 11/2024) in Room A/B , Butt Paste (exp.date 6/2024) in Room C/D, Child's Epipen (exp. date 7/2025), Sunscreen (exp. date 11/2024) in Room H, and Aquaphor (exp. dates 12/2023 and 7/2025) in Room J.”

Correction date in the state record: Sep 24, 2025

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

“Self reported non-compliance investigation on 5/7/25 verified that on 5/1/25 at approximately 5:32PM Child 1 was left alone and unsupervised inside the gated outdoor playground for 6 minutes until Child 1 was found by a parent.”

Correction date in the state record: Jun 20, 2025

3270.70(a) 65º F minimum

“During an incident inspection on 1/3/25 Staff reported that childcare rooms A-K were not able to maintain an indoor temperature of at least 65° F because a fire has made the boiler inoperable. Cert rep observed these rooms were not able to reach at least 65° F.”

Correction date in the state record: Jan 3, 2025

3270.70(a) 65º F minimum

“During an incident inspection on 1/3/25 Staff reported that childcare rooms A-K were not able to maintain an indoor temperature of at least 65° F because a fire has made the boiler inoperable. Cert rep observed these rooms were not able to reach at least 65° F.”

Correction date in the state record: Apr 25, 2025

3270.70(a) 65º F minimum

“During an incident inspection on 1/3/25 Staff reported that childcare rooms A-K were not able to maintain an indoor temperature of at least 65° F because a fire has made the boiler inoperable. Cert rep observed these rooms were not able to reach at least 65° F.”

Correction date in the state record: Jan 3, 2025

3270.70(a) 65º F minimum

“During an incident inspection on 1/3/25 Staff reported that childcare rooms A-K were not able to maintain an indoor temperature of at least 65° F because a fire has made the boiler inoperable. Cert rep observed these rooms were not able to reach at least 65° F.”

Correction date in the state record: Apr 25, 2025

3270.192(5) Two written references

“During the inspection, volunteer #32 only had one written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person.”

Correction date in the state record: Nov 1, 2024

3270.124(b)(3)/3270.124(b)(6) Parent home/work address, phone/Insurance coverage information

“During the inspection on 10/4/24, child #1 through child #8 and child #10's emergency contact form did not include the work address of the enrolling parent. The emergency contact form for child #4 also did not include the health insurance policy number for the child.”

Correction date in the state record: Nov 1, 2024

3270.151(a)/3270.151(c)(2) 12 months prior to service and every 24 months thereafter/Mantoux TB

“During the inspection on 10/4/24, volunteer #4, #15, #22, #23, #24, #25, #27, #29, #30, #31, #35 from Berks CTC did not have a TB screening conducted within 12 months of initial service in the facility. This is evidenced by the TB screening on file dated 8/22/22, 8/29/22, 8/26/22, 7/31/23, 7/16/21, 8/1/22, 8/5/23, 10/12/22, 6/1/23, 8/15/22 and 8/18/22, respectively. (see LIS code sheet for date of volunteering). Volunteer #4, #15, #23, #27, #30 did not have a health assessment conducted within 12 months of initial service in the facility. This is evidenced by the health assessment on file dated 8/19/22, 8/30/22, 7/24/23, 8/3/23, 5/30/23, 8/15/22 and 8/11/22, respectively (see LIS code sheet for date of volunteering).”

Correction date in the state record: Nov 27, 2024

3270.124(e) Written emergency plan posted

“During the inspection on 10/4/24, there was no written plan identifying the means of transporting a child to emergency care and staffing provisions in the event of an emergency posted in the gym.”

Correction date in the state record: Oct 25, 2024

3270.27(c) Training regarding plan

“During the inspection, volunteers #21, #24, #25, #28, #31, #32, #34 were not trained in the emergency plan when it was updated in September 2024.”

Correction date in the state record: Oct 30, 2024

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

“During the inspection on 10/4/24, the operator did not have a policy and procedure in place to identify the prevention of shaken baby syndrome, abusive head trauma, and child maltreatment. The policy must include, but is not limited to: Recognition of potential signs and symptoms of shaken baby syndrome and abusive head trauma; strategies for coping with a crying, fussing, or distraught child; and address the prevention and identification of child maltreatment.”

Correction date in the state record: Oct 30, 2024

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

“During the inspection on 10/4/24, the emergency plan did not include continuity of operations during and after an emergency that includes continuing daily operations, backing up or retrieving health and other key records/files and managing financial issues such as paying employees and bills during the aftermath of the disaster.”

Correction date in the state record: Oct 25, 2024

3270.34(a)(6) Staff evaluations

“During the inspection, staff person #1, staff person #6, staff person #9, staff person #14 and staff person #17 did not have a written evaluation on file every 12 months. This is evidenced by the current evaluations on file dated 6/13/24, 6/12/24, 6/17/24, 6/12/24, 6/12/24, respectively. The previous evaluations are dated 4/28/23, 4/24/23, 9/17/22, 4/19/23, 4/25/23, respectively.”

Correction date in the state record: Oct 18, 2024

3270.32(a)/3270.192(4) Comply with CPSL/CPSL information

“During the inspection, volunteer #4, volunteer #22 through volunteer #36 from Berks CTC did not have a signed disclosure statement at time of volunteering. This is evidenced by the disclosure statements on file dated 8/17/22, 8/29/22, 7/23/23, 8/31/21, 8/20/22, 7/16/23, 7/12/23, 6/15/23, 2/27/24, 8/23/23, 8/22/22, 6/28/23, 7/29/22, 8/22/22, 8/19/22 and 8/23/23, respectively. (see LIS code sheet for date of volunteering).”

Correction date in the state record: Nov 27, 2024

3270.81 Glass

“During the inspection on 10/4/24, there was no visual strip or other visual identification on the glass in the older toddler room.”

Correction date in the state record: Oct 18, 2024

3270.192(5) Two written references

“During the inspection, volunteer #32 only had one written, nonfamily references from individuals attesting to the person's suitability to serve as a facility person.”

Correction date in the state record: Nov 1, 2024

3270.124(b)(3)/3270.124(b)(6) Parent home/work address, phone/Insurance coverage information

“During the inspection on 10/4/24, child #1 through child #8 and child #10's emergency contact form did not include the work address of the enrolling parent. The emergency contact form for child #4 also did not include the health insurance policy number for the child.”

Correction date in the state record: Nov 1, 2024

3270.151(a)/3270.151(c)(2) 12 months prior to service and every 24 months thereafter/Mantoux TB

“During the inspection on 10/4/24, volunteer #4, #15, #22, #23, #24, #25, #27, #29, #30, #31, #35 from Berks CTC did not have a TB screening conducted within 12 months of initial service in the facility. This is evidenced by the TB screening on file dated 8/22/22, 8/29/22, 8/26/22, 7/31/23, 7/16/21, 8/1/22, 8/5/23, 10/12/22, 6/1/23, 8/15/22 and 8/18/22, respectively. (see LIS code sheet for date of volunteering). Volunteer #4, #15, #23, #27, #30 did not have a health assessment conducted within 12 months of initial service in the facility. This is evidenced by the health assessment on file dated 8/19/22, 8/30/22, 7/24/23, 8/3/23, 5/30/23, 8/15/22 and 8/11/22, respectively (see LIS code sheet for date of volunteering).”

Correction date in the state record: Nov 27, 2024

3270.124(e) Written emergency plan posted

“During the inspection on 10/4/24, there was no written plan identifying the means of transporting a child to emergency care and staffing provisions in the event of an emergency posted in the gym.”

Correction date in the state record: Oct 25, 2024

3270.27(c) Training regarding plan

“During the inspection, volunteers #21, #24, #25, #28, #31, #32, #34 were not trained in the emergency plan when it was updated in September 2024.”

Correction date in the state record: Oct 30, 2024

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

“During the inspection on 10/4/24, the operator did not have a policy and procedure in place to identify the prevention of shaken baby syndrome, abusive head trauma, and child maltreatment. The policy must include, but is not limited to: Recognition of potential signs and symptoms of shaken baby syndrome and abusive head trauma; strategies for coping with a crying, fussing, or distraught child; and address the prevention and identification of child maltreatment.”

Correction date in the state record: Oct 30, 2024

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

“During the inspection on 10/4/24, the emergency plan did not include continuity of operations during and after an emergency that includes continuing daily operations, backing up or retrieving health and other key records/files and managing financial issues such as paying employees and bills during the aftermath of the disaster.”

Correction date in the state record: Oct 25, 2024

3270.34(a)(6) Staff evaluations

“During the inspection, staff person #1, staff person #6, staff person #9, staff person #14 and staff person #17 did not have a written evaluation on file every 12 months. This is evidenced by the current evaluations on file dated 6/13/24, 6/12/24, 6/17/24, 6/12/24, 6/12/24, respectively. The previous evaluations are dated 4/28/23, 4/24/23, 9/17/22, 4/19/23, 4/25/23, respectively.”

Correction date in the state record: Oct 18, 2024

3270.32(a)/3270.192(4) Comply with CPSL/CPSL information

“During the inspection, volunteer #4, volunteer #22 through volunteer #36 from Berks CTC did not have a signed disclosure statement at time of volunteering. This is evidenced by the disclosure statements on file dated 8/17/22, 8/29/22, 7/23/23, 8/31/21, 8/20/22, 7/16/23, 7/12/23, 6/15/23, 2/27/24, 8/23/23, 8/22/22, 6/28/23, 7/29/22, 8/22/22, 8/19/22 and 8/23/23, respectively. (see LIS code sheet for date of volunteering).”

Correction date in the state record: Nov 27, 2024

3270.81 Glass

“During the inspection on 10/4/24, there was no visual strip or other visual identification on the glass in the older toddler room.”

Correction date in the state record: Oct 18, 2024

3270.113(b) No physical punishment

“On 6/4/24 staff #1 was sitting on the floor. Child #1 approached staff #1 several times and staff #1 redirected child away. The third time the child approached, staff #1 lifted the child up, aggressively placed him on the other side of her and pushed him from behind causing the child to fall and hit his face on a table resulting in a swollen and black eye.”

Correction date in the state record: Jul 16, 2024

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

“On 6/4/24 staff #1 was sitting on the floor. Child #1 approached staff #1 several times and staff #1 redirected child away. The third time the child approached, staff #1 lifted the child up, aggressively placed him on the other side of her and pushed him from behind causing the child to fall and hit his face on a table resulting in a swollen and black eye. Staff #1 reported on the incident report that the child slipped out of her hands causing him to fall.”

Correction date in the state record: Jun 5, 2024

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

“On 6/4/24 staff #1 was sitting on the floor. Child #1 approached staff #1 several times and staff #1 redirected child away. The third time the child approached, staff #1 lifted the child up, aggressively placed him on the other side of her and pushed him from behind causing the child to fall and hit his face on a table resulting in a swollen and black eye. Staff #1 reported on the incident report that the child slipped out of her hands causing him to fall.”

Correction date in the state record: Jul 16, 2024

20.71(b)(5) Perpetrator in an indicated or founded report of child abuse

“Staff person #1 has been named as a perpetrator in a founded/indicated report of child abuse.”

Correction date in the state record: Jun 5, 2024

3270.113(b) No physical punishment

“On 6/4/24 staff #1 was sitting on the floor. Child #1 approached staff #1 several times and staff #1 redirected child away. The third time the child approached, staff #1 lifted the child up, aggressively placed him on the other side of her and pushed him from behind causing the child to fall and hit his face on a table resulting in a swollen and black eye.”

Correction date in the state record: Jun 5, 2024

3270.32(a)/3270.192(4) Comply with CPSL/CPSL information

“On 2/22/2024, Staff #2 was observed working at the facility. Staff #2 did not have a current DHS FBI clearance on file and also did not have verification of being fingerprinted for the DHS FBI clearance prior to beginning employment. See LIS code sheet.”

Correction date in the state record: Feb 22, 2024

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

“Staff #1 has not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Professional development in pediatric first aid and pediatric cardiopulmonary resuscitation (CPR).”

Correction date in the state record: Feb 27, 2024