Primary Plus, INC.

The facility shall update their admission agreement and submit revised version to the Department by 4/19/2024. The revised admission agreement shall be used moving forward for enrolling parents into both the preschool and infant program. The facility did not specify all of the requirements of this Section as the Admission Agreement was missing (2), (3)(B), (3)(C), (6) and (7), which poses a potential risk to the health, safety, and personal rights of children in care.

The facility shall update their policies page and include all sections indicated that are missing to meet the regulatory requirements. Updated policies to be submitted to the Department by 4/19/2024. The facility did not include all policies required by this Section and during review, LPA observed the policies are missing (1), (2), (5), (6), and (8), which poses a potential risk to the health, safety, and personal rights of children in care. 8 Updated policies shall be added to the admission folder for infant and preschool parents and be available when requested.

Director stated all three faucets have been replaced and are awaiting retesting. Director states she will send updated retesting information to licensing by the due date 10/13/23. After water lead testing was completed, the facility had three faucets G, N, and O located in the preschool with an Action Level Exceedance of 10, 240, and 27, which poses a potential risk to the health, safety, and personal rights of children in care. 8 Director states the water company Enthalpy Analytical has been in contact and have not given at retesting date.

Based on record review, the licensee did not comply with the section cited above in five out of 64 persons which poses a potential health, safety or personal rights risk to persons in care. LPAs observed there were 64 children. Five children were not signed in.