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

“According to the Fire Detection System Test Log, the tests were greater than 30 days apart from 8/17/23 to 9/18/23 and 9/18/23 to 10/27/23..”

Correction date in the state record: Nov 20, 2023

3270.161(d) Potentially hazardous food refrigerated

“There was a yogurt in a backpack in the Pre k 3 room.”

Correction date in the state record: Nov 14, 2023

3270.131(d)(5)/3270.131(e)(3) Immunization record/Dismissal policy

“The files for child # 1, 2,3 and 5 are missing a dose of the influenza vaccine.”

Correction date in the state record: Nov 15, 2023

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

“The files for children # 1,2,3 and 4 lacked the work addresses and telephone numbers of the enrolling parent on the emergency contact form. The files for children # 5 lacked the work telephone numbers of the enrolling parent on the emergency contact form.”

Correction date in the state record: Nov 16, 2023

3270.124(a) Each child emergency contact person

“The file for child # 2 lacked the emergency contact information, who shall be contacted in an emergency on the Emergency contact form.”

Correction date in the state record: Nov 16, 2023

3270.113(a) Supervised at all times

“Around 8:35am on 11/15/23, 3 children were observed to be unsupervised in the hallway between the Preschool 1 room and the bathroom. Staff # 8 was in the bathroom with a group of 7 preschoolers, unaware of the 3 children sent from the preschool room. Staff # 9 sent the 3 children alone to the bathroom and the children stay in the hallway playing together, until Staff # 8 was notified by the certification representative, that the children were playing in the hallway unsupervised. CR also, asked staff # 9 to not sent children to the bathroom unsupervised.”

Correction date in the state record: Nov 14, 2023

3270.108(c) No styrofoam

“There was a bag of styrofoam cups in the Pre k 3 cabinet.”

Correction date in the state record: Nov 14, 2023

3270.107 Refrigerator

“The refrigerator in Preschool 1 room lacked a thermometer. The refrigerator in the toddler two room contained sticky yellow and pink spots.”

Correction date in the state record: Nov 16, 2023

3270.82(g) Clean and good repair

“The toilet handle in the toddler 2 room bathroom was damaged creating a sharp edge. The pipes under the sink in the toddler 2 room bathroom appeared to be corroded.”

Correction date in the state record: Dec 8, 2023

3270.75(c) Has all items

“The first-aid kit, in Room 101, lacked scissors and soap. The first-aid kit, in Room 104, lacked rubber gloves.”

Correction date in the state record: Nov 15, 2023

3270.69(b) 110º F or less

“The water in the Pre k 4 room sink exceeded 110° F, the water temperature was 113.9° F.”

Correction date in the state record: Nov 22, 2023

3270.66(a) Locked or inaccessible

“There was a backpack in a toddler two-room cubby that contained a Diaper Rash Ointment cream label " keep out of reach of children " accessible to children. There was a backpack in a cubby in the Pre-K 3 room that contained Tylenol and Benadryl accessible to children. There was a Lysol Disinfectant can, located on a metal storage cart in room 104, labeled "Keep out of reach of children," accessible to children. The unlocked office, in the Makers' Space Room, contained: Dynaflex Sealant, 10.1. fl. Oz., Clorox Cleaner Bleach, 24 oz., Pine-Sol, 28 oz. Gorilla Wood Glue, 18 fl. Oz. , Dawn Dishwashing Liquid, 7 fl. oz. label "Keep out of reach of children," and were accessible to children in care. The unlocked storage room, in the Makers' Space Room, contained (6) gallon cans of paint labeled, "Keep out of reach of children," and were accessible to children in care. An open cardboard box with nine (9) paint containers of varying sizes, labeled, "Keep out of reach of children," and were accessible to children in care.”

Correction date in the state record: Nov 14, 2023

3270.65 Protective Outlet Covers 5 yrs. or less

“There were 2 uncovered outlets in Preschool 1 room, 1 uncovered outlet in Pre k 3 room, a large, black outlet, in room 104, on the wall under the pool table cue sticks that did not contain a protective cover, 5 uncovered outlets between the hanging, wall monitors, and 1 uncovered outlet in room 15 accessible to children 5 years of age or younger.”

Correction date in the state record: Nov 17, 2023

3270.32(a)/3270.192(2)(iii) Comply with CPSL/Exp, educ., training at facility

“The file for staff # 1 contained a current mandated reporter training certificate dated 2/27/20 that was not obtained within 60 months of the previous certificate dated 1/5/15. The file for staff # 2 contained a current mandated reporter training certificate dated 3/20/23 that was not obtained within 60 months of the previous certificate dated 2/19/18. The file for staff # 4 contained a current mandated reporter training certificate dated 8/21/22 that was not obtained within 60 months of the previous certificate dated 6/5/17.”

Correction date in the state record: Nov 17, 2023

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

“The file for staff # 6 contained a current State Police clearance dated 6/22/21. Staff #6 began employment prior to 6/22/21. The file for staff # 6 contained a current Child Abuse clearance dated 7/21/21. Staff #6 began employment prior to 7/21/21. The file for staff # 6 contained a current FBI clearance dated 10/25/21. Staff #6 began employment prior to 10/25//21. The file for staff # 6 contained a current NSOR clearance dated 6/23/21. Staff #6 began employment prior to 6/23/21. The file for staff # 7 contained a current State Police clearance dated 9/2/21. Staff #6 began employment prior to 9/2/21. The file for staff # 7 contained a current Child Abuse clearance dated 9/7/21. Staff # 7 began employment prior to 9/7/21. The file for staff # 7 contained a current NSOR clearance dated 9/10/21. Staff # 7 began employment prior to 9/10/21.”

Correction date in the state record: Nov 17, 2023

3270.31(f) Health and Safety Training

“The files for staff # 5 contained a current Pediatric First Aid and Pediatric CPR certificate that was taken after 90 day of initial employment. Staff person(s) shall complete professional development in the topics of 3270.31(f)(1 -- 10) within 90 days of hire. The certificates for staff # 5 is date 8/16/22.. The files for staff # 7 contained a current Pediatric First Aid and Pediatric CPR certificate that was taken after 90 day of initial employment. Staff person(s) shall complete professional development in the topics of 3270.31(f)(1 -- 10) within 90 days of hire. The certificates for staff # 7 is date 1/27/22.”

Correction date in the state record: Nov 17, 2023

3270.27(c) Training regarding plan

“The file for staff #7 contained a current Emergency Plan training dated 8/16/23, that was updated after a year from the previous Emergency Plan training dated 6/6/22.”

Correction date in the state record: Nov 17, 2023

3270.102(a) Clean and good repair

“There was a broken garbage can lid, on the gray, Rubbermaid trash container, located in the playground area, created a scraping/cutting hazard for children in care. There were several green and red sections, of the playground surface, that were deteriorated/peeling/unsecured/peeling, which created tripping and choking hazards for children in care. There was a cracked clear bin in Pre k 3 room.”

Correction date in the state record: Dec 8, 2023

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

“The file for staff # 1 lacked a Child Abuse clearance. The prior Child Abuse clearance was dated 7/9/18.”

Correction date in the state record: Jul 20, 2023

3270.133(7) Medication log

“The operator was not maintaining a medication log for the prescription medications, Epinephrine 0.3 and Albuterol Sulfate inhalers for children #1, 2, and 3.”

Correction date in the state record: Jul 20, 2023

3270.133(3) Name on bottle

“There were two Albuterol Sulfate inhalers that were not label with the names of the children whom the medication was intended for. The medication was intended for child # 2 and 3.”

Correction date in the state record: Jul 20, 2023

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

“The file for staff # 1 lacked a Child Abuse clearance. The prior Child Abuse clearance was dated 7/9/18.”

Correction date in the state record: Jul 20, 2023

3270.133(7) Medication log

“The operator was not maintaining a medication log for the prescription medications, Epinephrine 0.3 and Albuterol Sulfate inhalers for children #1, 2, and 3.”

Correction date in the state record: Jul 20, 2023

3270.133(3) Name on bottle

“There were two Albuterol Sulfate inhalers that were not label with the names of the children whom the medication was intended for. The medication was intended for child # 2 and 3.”

Correction date in the state record: Jul 20, 2023

3270.103 Small Toys and Objects

“The diaper changing pad was observed to be torn exposing the children to foam interior and poses a choking hazard to the children in the room who are still placing objects in their mouths in the Toddler 1 room.”

Correction date in the state record: Dec 9, 2022

3270.106(a) Clean, age appropriate

“The rest equipment in the Toddler 2 room and PreK-5 room was observed to lack labels with the names of specific children in care.”

Correction date in the state record: Nov 28, 2022

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

“The emergency plan for the facility lacked requirements for continuity of 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: Dec 9, 2022

3270.107 Refrigerator

“The refrigerator in the PreK-5 room was observed to lack an operating thermometer.”

Correction date in the state record: Nov 28, 2022

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

“The file for staff person #2 lacked documentation of NSOR clearance results prior to date of hire (See LIS CODE SHEET) required for provisional hiring under CPSL. The files for staff persons #5 and #6 were observed not to contain documentation of application of PA State Police Clearance prior to date of hire (See LIS CODE SHEET) required for provisional hiring under the CPSL”

Correction date in the state record: Nov 28, 2022

3270.76 Building Surfaces

“A piece of metal was observed to be broken off and inside an electrical outlet hole in the Toddler 2 room.”

Correction date in the state record: Nov 30, 2022

3270.66(b) Original container

“Two unlabeled spray bottles of cleaning fluid were observed in a cabinet above the sink in the PreK-3 room. The staff person in the room identified the contents in the bottles as bleach water. Four unlabeled spray bottles of fluids were observed to be stored next to children's food in a low cabinet below the sink in the Toddler 1 room. The staff persons in the room could not confirm the content in each spray bottle.”

Correction date in the state record: Nov 28, 2022

3270.33(a)/3270.192(2)(ii) Each staff person meets quals/Exp, educ., training prior to facility

“The files for staff persons #3 and #4 were observed to lack documentation of verification of child care experience in order to meet staff qualification for the position in which the staff persons are performing.”

Correction date in the state record: Dec 9, 2022

3270.31(f) Health and Safety Training

“Staff person #4 and #7 have not completed the following required pre-service training within 90 days of their date of hire (see LIS code sheet): Health and Safety training.”

Correction date in the state record: Nov 30, 2022

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

“The emergency contact form on file for children #1, #2, #3, #5, #6, #7, #8 and #9 lacked the enrolling parent's work address. The emergency contact form on file for children #1, #2, #3, #4, #5, #6, #7, #8 and #9 lacked the enrolling parent's work telephone number.”

Correction date in the state record: Dec 9, 2022

3270.151(c)(3)/3270.192(3) Exam communicable disease/Health assessment, TB test

“Staff person #4 was observed to have a health assessment on file that displayed the individual has a communicable disease. The file for staff person #4 lacked documentation from the physician on the staff person's conditions and the risk it might pose to others exposed.”

Correction date in the state record: Nov 28, 2022

3270.124(b)(5) Information re: special needs

“The emergency contact forms on file for child #1, #2, #3, #4, #5, #6, #7, #8 and #9 lacked information of the child's special needs, as specified by the child's parent, physician, physician's assistant or CRNP, which is needed for an emergency.”

Correction date in the state record: Dec 9, 2022

3270.135(a)(3) Disposable diapers

“Soiled diapers were observed to be discarded in a trash can that was not a plastic-lined, hands-free covered can in the Toddler 2's bathroom.”

Correction date in the state record: Nov 28, 2022

3270.151(a)/3270.192(3) 12 months prior to service and every 24 months thereafter/Health assessment, TB test

“The file for staff person #1 was observed to have documentation of a health assessment that was not renewed before the expiration date of the most current certification. The health assessments on file for staff #1 are dated 10/16/20 and 10/17/22.”

Correction date in the state record: Nov 28, 2022

3270.151(a)/3270.192(3) 12 months prior to service and every 24 months thereafter/Health assessment, TB test

“The file for staff person #6 lacked documentation of a health assessment conducted within 12 months prior to providing initial service in a child care setting.”

Correction date in the state record: Nov 30, 2022

3270.151(c)(2)/3270.192(3) Mantoux TB/Health assessment, TB test

“The file for staff person #6 lacked documentation of a tuberculosis screening at initial employment (See LIS CODE SHEET).”

Correction date in the state record: Nov 30, 2022

3270.131(a) Health information

“The files for children #2 and #3 lacked an initial health report within 60 days following the first day of attendance at the facility.”

Correction date in the state record: Dec 9, 2022

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

“The file for staff person #5 lacked pediatric first aid and pediatric cardiopulmonary resuscitation (CPR) training within 90 days of hire.”

Correction date in the state record: Nov 28, 2022

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

“The emergency contact form on file for child #7 was observed to lack parental consent for minor first aid.”

Correction date in the state record: Dec 9, 2022

3270.102(a) Clean and good repair

“One clear plastic storage bin and lid containing markers and dry erasers were observed to be cracked in the PreK-3 room exposing the children to rough edges and sharp corners.”

Correction date in the state record: Nov 28, 2022

3270.51 Similar Age Level

“***On 7/19/22, at approximately 3:00 pm, in Preschool Summer Camp A, Staff #1 was observed alone with 14 preschool aged children.”

Correction date in the state record: Nov 14, 2022

3270.51 Similar Age Level

“**On 7/19/22, at approximately 3:00 pm, in Preschool Summer Camp A, Staff #1 was observed alone with 14 preschool aged children.”

Correction date in the state record: Nov 14, 2022

3270.51 Similar Age Level

“*On 7/19/22, at approximately 3:00 pm, in Preschool Summer Camp A, Staff #1 was observed alone with 14 preschool aged children.”

Correction date in the state record: Nov 14, 2022

3270.192(2)(ii) Exp, educ., training prior to facility

“The file for staff person #10, holding the title of AGS, included a bachelor of arts diploma that didn't specify the degree obtained and 2078 hours of verified childcare experience.”

Correction date in the state record: Dec 8, 2021

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

“The file for child #5 did not contain signed parental consent for minor first-aid procedures by staff.”

Correction date in the state record: Jan 31, 2022

3270.176(a) Insured

“Insurance for the vehicle used to transport school-age children was not available at the time of the inspection.”

Correction date in the state record: Jan 31, 2022

3270.175(a) Age appropriate restraints

“There was one car seat observed in the van used to transported school-agers from school to the facility. Based on conversation with the driver of the van and the director, 6 children are transported at a time from 2 different schools. Out of the 12 children, 6 of them are 7 years old or younger.”

Correction date in the state record: Jan 31, 2022

3270.151(c)(2) Mantoux TB

“The file for staff person #4 did not include the results of a TB screening. The file for facility person #5 and staff person #7 and #9 included a health assessment dated after they began working with children.”

Correction date in the state record: Dec 8, 2021

3270.151(b) Conducted by physician, PA or CRNP

“The signature on the health assessment in the file for staff person #9 did not include the individual's professional title.”

Correction date in the state record: Nov 22, 2021

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

“The last two health assessments in the file for staff person #1, #11, #15 and #20 were dated more than 12 months apart. The file for staff person #4 did not include a health assessment. The file for staff person #9 included a health assessment dated after they began working with children. The last health assessment in the file for staff person #20 was dated more than 24 months ago.”

Correction date in the state record: Dec 8, 2021

3270.74 Emergency Numbers Posted

“The telephone number of the nearest hospital, police department, fire department, ambulance and poison control center was not posted in the Pre-K 3 room or in the the preschool 2 room (#321).”

Correction date in the state record: Dec 8, 2021

3270.66(a) Locked or inaccessible

“The maintenance closet was unlocked and slightly ajar, making the 7 cans of paint and the bottle of Krud Kutter graffiti remover spray accessible to the children. All items included instructions to keep out of the reach of children.”

Correction date in the state record: Dec 31, 2021

3270.51 Similar Age Level

“At approximately 11:05 am, staff person #21 was observed standing in the young toddler room, leaving staff person #22 alone and out of ratio with 7 older toddlers in the older toddler room.”

Correction date in the state record: Dec 8, 2021

3270.27(b) Plan reviewed/updated annually

“Based on conversation with the director, the emergency plan was reviewed, but the review was not documented.”

Correction date in the state record: Jan 31, 2022

3270.27(c) Training regarding plan

“The last 2 emergency plan trainings in the file for staff person #1, #16 and #17 were dated more than 12 months apart. The emergency plan training in the file for staff person #4, #5 and #13 was dated beyond their initial employment.”

Correction date in the state record: Nov 19, 2021

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

“The last fire safety training in the file for staff person #1, #16 and #17 was dated more than 12 months ago.”

Correction date in the state record: Jan 31, 2022

3270.32(a)/3270.192(2)(iii) Comply with CPSL/Exp, educ., training at facility

“The mandated reporter training in the file for facility person #13 was presented by a school district and was not one of the acceptable trainings for DHS. The last two mandated reporter trainings in the file for staff person #18 were dated more than 60 months apart.”

Correction date in the state record: Jan 31, 2022

3270.37(c) Aides supervised all times

“On 11/19/21, staff person #12, holding the title and qualifications of an aide, was observed escorting 2 children down the hall alone. On 12/8/21, staff person #12, holding the title and qualifications of aide was observed supervising 5 children outside of the 3rd floor children's bathrooms.”

Correction date in the state record: Dec 8, 2021

3270.36(b)(5) HS/GED + 2 yrs

“The file for staff person #10, holding the title of AGS, included a bachelor of arts diploma that didn't specify the degree obtained and 2078 hours of verified childcare experience.”

Correction date in the state record: Dec 8, 2021

3270.34(a)(6) Staff evaluations

“The last two evaluations in the file for staff person #19 were dated more than 12 months apart.”

Correction date in the state record: Nov 22, 2021

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

“The file for staff person #1, hired seasonally since 2017 included an NSOR certificate dated after 6/17/21. The FBI clearance in the file for facility person #5 was dated after their first day of employment and did not include proof of request of their FBI clearance before they started working at the facility. The file for facility person #13, observed in the childcare office on 11/19/21, did not include proof of request of their state police clearance before their first day of work. There was also no child abuse clearance on file, and the file included only a DOE FBI clearance. The proof of request for the NSOR certificate in the file for staff person #7 was dated after their first day of employment. The FBI clearance in the file for staff person #9 was dated after their first day of employment and there was no proof of request for the clearance dated before they began working with children. The file for staff person #10, observed caring for children on 11/19/21, only included a DOE FBI clearance.”

Correction date in the state record: Dec 8, 2021

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

“The facility's fire detection system is interconnected and there was not proof of purchase.”

Correction date in the state record: Jan 31, 2022

3270.31(h) Health and Safety Training

“The health and safety training in the file for staff person #1, hired in 2017, was dated after 6/17/21. The health and safety training in the file for staff person #4, hired in 2021, was dated beyond their first 90 days working with children. There was no evidence of health and safety training in the file for staff person #6, employed more than 90 days. The health and safety training in the file for staff person #8, hired in 2021, was dated beyond their first 90 days working with children. The health and safety training in the file for staff person #11, hired in 2019, was dated after 6/17/21. There was no evidence of health and safety training in the file for staff person #12, hired in 2020.”

Correction date in the state record: Jan 31, 2022

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

“The first-aid/CPR training in the file for staff person #6, employed more than 90 days, did not specify that the training was "pediatric." The pediatric first-aid/CPR in the file for staff person #7, hired in March 2021, was dated beyond their first 90 days working with children.”

Correction date in the state record: Jan 31, 2022

3270.27(a)(5) Emergency plan

“The facility's emergency plan did not include accommodations for infants, toddlers, children with disabilities, and children with chronic medical conditions.”

Correction date in the state record: Jan 31, 2022

3270.24(f) Director ID

“On 11/22/21, the PA driver's license presented by staff person #14, the director, had expired on 11/20/21.”

Correction date in the state record: Dec 8, 2021

3270.192(5) Two written references

“The file for staff person #3 included only one letter of reference. The file for facility person #13, who works in the childcare facility's office, did not include 2 letters of reference.”

Correction date in the state record: Dec 8, 2021

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

“The verification of experience in the file for staff person #2, holding the title of AGS, was not signed by a representative of the of the experiential entity.”

Correction date in the state record: Dec 8, 2021

3270.131(e)(2)(i) Exemption documentation from parent/guardian

“There was no evidence of a flu shot in the file for child #4, a 5 year-old, and no written statement of exemption by a parent.”

Correction date in the state record: Jan 31, 2022

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

“The emergency contact information in the file for child #4 does not include the addresses for the three release persons.”

Correction date in the state record: Jan 31, 2022

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

“The emergency contact information in the file for child #5 did not include the written parental consent for emergency medical care”

Correction date in the state record: Jan 31, 2022

3270.27(f) Emergency plan

“Based on conversation with the director, they did not send a copy of the emergency plan updates to the county emergency management agency or the local municipality.”

Correction date in the state record: Jan 31, 2022

3270.27(a)(1) Emergency plan

“The facility's emergency plan did not include accommodations for shelter of children during a lock-down.”

Correction date in the state record: Jan 31, 2022

3270.25(a) Availability of certificate of compliance and applicable regulations

“The link to the current regulations was not posted at the time of the inspection. Based on conversation with the director, parents have not been provided with information on how to access the regulations in this chapter electronically.”

Correction date in the state record: Jan 31, 2022

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

“The emergency contact information in the file for child #4 did not include the name and address of the child's physician.”

Correction date in the state record: Jan 31, 2022

3270.123(a)(6) Admission date

“The agreement form in the file for child #2 and #6 did not specify the child's date of admission.”

Correction date in the state record: Jan 31, 2022

3270.123(a)(5) Designated release persons

“The agreement form in the file for child #1 did not specify the persons designated by a parent to whom the child may be released.”

Correction date in the state record: Jan 31, 2022

3270.104(a) Clean, good repair, proper size

“There was a light blue bean bag chair in the younger toddler room.”

Correction date in the state record: Dec 8, 2021

3270.103 Small Toys and Objects

“In the older toddler room, a child was observed carrying the lid from a colored marker, which was less than one inch in diameter. A bin holding markers and their lids were in a bin on a low shelf, making them accessible to the older toddlers. On the apartment sized refrigerator sitting on the floor in the older toddler room, there was a layer of plastic on the top of it and along the left side, making it accessible to the older toddlers in the room. Tiny areas of the plastic were missing or peeling.”

Correction date in the state record: Jan 31, 2022

3270.92(a) No portable space heaters

“There was an operational portable space heater in the office for facility person #5.”

Correction date in the state record: Dec 8, 2021

3270.82(h) Handwashing signs

“On the 3rd floor, there was not a handwashing sign by one of the sinks in the children's bathrooms to left and by one of the sinks in the children's bathrooms to the right.”

Correction date in the state record: Dec 8, 2021

3270.31(e)(4)(i) Age and Training

“The file for staff person #1, employed seasonally since 2017, did not include evidence of pediatric first-aid and CPR.”

Correction date in the state record: Jan 31, 2022

3270.94(a)(7) Participation

“Based on review of the fire drills documented in the previous 12 months and on conversation with the director, all facility persons and children in attendance were not participating in every fire drill. Nine out of the last 12 drills involved only certain classroom staff and children. On the 3 documented drills in which all facility persons participated, the names of the staff were not documented; The log read "All teachers." None of the 12 fire drills specified the hypothetical location of the fire; the log listed the specific classrooms that participated in the drills instead.”

Correction date in the state record: Nov 30, 2021

3270.94(a)(9) Written record

“Based on review of the fire drills documented in the previous 12 months and on conversation with the director, all facility persons and children in attendance were not participating in every fire drill. Nine out of the last 12 drills involved only certain classroom staff and children. On the 3 documented drills in which all facility persons participated, the names of the staff were not documented; The log read "All teachers." None of the 12 fire drills specified the hypothetical location of the fire; the log listed the specific classrooms that participated in the drills instead.”

Correction date in the state record: Oct 26, 2021